The threat and causes of preterm birth - symptoms, signs and prevention. Premature birth at different stages of pregnancy, causes, symptoms, threats, treatment

28.07.2019

And carry out the necessary treatment.

Prevention comes down to monitoring a pregnant woman, timely identification of risk groups for preterm birth, diagnosis and treatment of emerging disorders (infections, isthmic-cervical insufficiency (ICN), concomitant extragenital pathology, prevention of placental insufficiency from early pregnancy).

Based on the letter of the Ministry of Health and Social Development of the Russian Federation of December 16, 2011 No. 15-4/10/2-12700 “On the direction of the methodological letter “Premature birth”” prevention of preterm birth is as follows:

Primary prevention

Effective:

limitation of repeated intrauterine manipulations (diagnostic curettage of the uterus during a medical abortion);
informing the public about the increased risk of premature birth of children conceived with the help of assisted reproductive technologies (IVF). Limiting the number of transferred embryos depending on the patient's age and prognosis.

Ineffective:

taking multivitamins before conception and during the first two months of pregnancy.

Secondary prevention

Effective:

introduction of anti-nicotine programs among pregnant women.

Ineffective:

the appointment of protein-energy nutritional supplements during pregnancy;
additional intake of calcium during pregnancy;
additional intake of antioxidants - vitamins C and E;
bed rest;
hydration (enhanced drinking regimen, infusion therapy), used to normalize fetoplacental blood flow to prevent premature birth.

To date controversial as a preventive measure:

use of a cervical pessary;
treatment of periodontal diseases during pregnancy.

Selected methods of prevention in the group of pregnant women at high risk of preterm birth

Stitches on the cervix. It is considered ineffective to suture a short cervix in all pregnant women, except for women at high risk of preterm birth. However, with a cervical length of 15 mm or less, with additional intravaginal administration of progesterone, the frequency of preterm birth decreases.

In twin pregnancy, suturing a shortened cervix, on the contrary, increases the risk of preterm birth.

Appointment of progesterone. Effectively prescribing progesterone in a high-risk group (primarily among women with a history of preterm birth) reduces the risk of recurrent preterm birth by 35%. Studies have shown that weekly injections of this hormone, starting from the 16th to 20th week and continuing until the 36th week, significantly reduce the risk of recurrent preterm birth for women in this situation. It should be noted that progesterone and its derivatives are ineffective in multiple pregnancies.

When prescribing progesterone preparations, the informed consent of the woman is required, since the manufacturing companies, when registering these medicines in the Russian Federation, do not indicate threatening preterm labor and the possibility of using the drugs in the second and third trimesters of pregnancy in the indications for use.

Antibacterial prophylaxis. Identification and treatment of asymptomatic bacteriuria (the presence of bacteria in the urine of more than 10 cfu / ml). Treatment of bacterial vaginosis in pregnant women with a history of preterm delivery. Treatment of bacterial vaginosis and chlamydial infection given before 20 weeks of gestation may reduce the risk of preterm birth.

Premature birth is not good for the baby. If you experience pain in the lower abdomen, tension of the uterus, suspected outpouring of water, you should immediately consult a doctor. Recommendations for hospitalization should be strictly followed.

The earlier a pregnant woman went to the doctor, the earlier complex treatment was started, the more likely it is that it will be possible to prevent premature birth and give birth to a healthy baby.

Yes, in fact, just like the timely ones. A woman may notice the appearance of pulling pains in the lower abdomen and lower back. The pains are sometimes cramping in nature, i.e. we can talk about the beginning contractions. In some cases, childbirth begins with rupture of amniotic fluid or with mucus plug discharge . In any of these cases, urgent hospitalization in the maternity hospital is necessary.

What can cause premature birth?

First of all infection 2 . Normally, the uterine cavity is sterile. Any inflammatory process makes the uterine wall inferior, so the pregnancy continues until the uterine wall can stretch, and then the body tries to get rid of the embryo.

That is why it is not necessary to spare money, time and effort for examination for the presence of infection. Every woman - ideally even before pregnancy - should be examined for the presence of infectious diseases, especially those that are often asymptomatic (carriage of chlamydial, ureaplasma, mycoplasma, toxoplasma infection, herpes simplex virus, cytomegalovirus). Particular attention should be paid to women with a history of chronic and acute inflammation of the uterine appendages and endometrium (the mucous membrane of the uterine body), intrauterine interventions (abortions, diagnostic curettage), as well as cases of spontaneous abortion. In the presence of an inflammatory process, it naturally needs to be cured. The drugs and procedures selected by the doctor will help to expel the infection from the body even before conception. If for some reason the necessary tests were not made before conception, then when diagnosing pregnancy, you should definitely undergo an appropriate medical examination, and you should not neglect regular examinations in the future. The sooner the presence of microbes in the body of a woman that can cause premature birth or potentially harmful to the fetus, so much the better. Modern medicine has a significant arsenal of tools to reduce the risk of miscarriage and infection of the fetus.

The second most common cause of preterm labor is isthmic-cervical insufficiency , ICI (isthmus - "isthmus", the place of transition of the uterine body to the cervix, cervix - "womb"), that is, the inferiority of the muscular layer of the cervix, which during a normal pregnancy plays the role of a kind of sphincter (retaining ring) that does not allow the embryo " leave the uterine cavity. ICI is congenital (very rare) and acquired. What can cause the development of ICI? The reasons are quite banal: trauma to the isthmus and cervix during abortions, especially when terminating the first pregnancy, deep ruptures of the cervix in previous births (this can happen, for example, during childbirth with a large fetus, the imposition of obstetric forceps), gross forced expansion of the cervical canal during diagnostic manipulations in the uterine cavity (hysteroscopy, i.e. examination of the uterine cavity with a special device - a hysteroscope; curettage of the endometrium), that is, any injury to the muscular layer of the cervix.

Very often, ICI is formed with hyperandrogenism - an increased content of male sex hormones in the blood, which are produced in the adrenal glands of the mother, and later in the fetus.

Infections and isthmic-cervical insufficiency are the main, but not the only factors causing premature birth. Often to premature birth lead endocrinopathy - minor violations of the function of the endocrine glands - the thyroid gland, adrenal glands, ovaries, pituitary gland (with gross violations, women, as a rule, cannot become pregnant on their own at all).

Also premature birth may occur when hyperdistension of the uterus caused by multiple pregnancy, polyhydramnios, large fetus.

hard physical work , chronic stressful situation at work or at home, any acute infectious disease (influenza, acute respiratory infections, tonsillitis, pyelonephritis, especially with fever, etc.) can also provoke an abortion.

What to do if preterm labor begins?

With the appearance of alarming symptoms: abdominal pain, leakage of amniotic fluid, urgent hospitalization is necessary. Only in a hospital can doctors choose the right tactics for each specific case.

Before the arrival of the ambulance team, you can drink 2 tablets of no-shpa or, if the woman is taking ginipral, an additional tablet of this drug.

As a rule, in a hospital, they try to keep the pregnancy, because every day spent in the womb increases the child's chances of survival.

What do doctors do to stop preterm labor?

At premature start of contractions first of all, prescribe tocolytic (that is, reducing the tone of the uterus) drugs - partusisten, ginipral. First, these drugs are administered intravenously, and when contractions stop, a transition to tablet forms is possible. These medicines are usually taken until 37 weeks of pregnancy. Magnesium sulphate, a 10% solution of ethyl alcohol and some other drugs are also used as agents that reduce the tone of the uterus.

At the second stage of treatment, they try to eliminate the very cause premature birth. When an infection is detected, antibacterial drugs are prescribed (depending on the type of infection), sedative (that is, soothing) therapy - in order to break the vicious circle: the objective factors that increase the tone of the uterus are added to the fear of losing a child, which, in turn, further increases the tone uterus.

With the development of ICI for up to 28 weeks of pregnancy, “stretching” sutures are applied to the cervix, which prevent the fetal egg from “falling out” of the uterus. Sutures are placed under short-term intravenous anesthesia, while drugs are used that have a minimal effect on the child.

For a period of more than 28 weeks, with an inferior cervix, a special supporting Golgi ring is inserted into the vagina: it, without narrowing the cervix, holds the presenting part of the fetus, not allowing it to put pressure on the cervix. At the same time, if the contractions have stopped, further opening of the cervix does not occur.

The complex of treatment always includes the hormonal drug dexamethasone (microdoses of this hormone are prescribed, so that side effects are practically excluded). Its purpose is not to prevent premature birth, but to stimulate the “maturation” of the lungs in a child (so that he is able to breathe on his own, if he is still born prematurely).

A woman must necessarily observe bed rest, and in a hospital. In nutrition, it is better to avoid irritating, spicy, fatty, indigestible foods.

The situation is more complicated with premature rupture of amniotic fluid. At a gestational age of up to 34 weeks, if it was possible to suppress labor, the condition of the woman and the fetus is normal, there is no increase in body temperature, there are no inflammatory changes in the blood, it is possible to maintain and prolong pregnancy with the obligatory prescription of antibacterial drugs to prevent infectious complications. (The fact is that the discharge of water indicates a violation of the integrity of the fetal bladder. This means that the vagina is now communicating with the uterine cavity, that is, the path of infection is open, and taking antibacterial drugs is a vital measure.)

Do doctors always try to stop preterm labor?

No not always.

There are situations that require early delivery due to the threatening condition of the woman. In severe forms of late toxicosis (preeclampsia), chronic diseases of internal organs, doctors often causepremature birth to save the life of both mother and fetus.

For a period of more than 34 weeks, with the outflow of water, pregnancy is also not preserved, but they try to very gently and carefully carry out childbirth.

What happens to a woman after a premature birth?

The course of the postpartum period 3 at premature birth, as a rule, is no different from that after timely delivery. It happens that a woman is detained in a maternity hospital longer than the prescribed period, but in most cases this is due to the condition of the child, and not the woman herself.

All women after premature birth it is desirable to undergo a comprehensive examination, including tests for the presence of infectious diseases and the carriage of infectious agents, a study of hormonal status. With ICI, it is necessary to perform hysterosalpingography (X-ray examination of the uterus and fallopian tubes after the introduction of a radiopaque substance into their cavities); in case of severe somatic diseases - to be examined by the relevant specialists. Naturally, if violations are detected, you need to undergo a course of treatment.

During subsequent pregnancies, hospitalization in the maternity hospital at the so-called "critical times" is desirable. The greatest concern is the timing of the termination of a previous pregnancy. In addition, the following are considered critical periods: the first 2-3 weeks (fixation of the fetal egg in the uterine mucosa); 4-12 weeks (formation of the placenta); 18-22 weeks (intense increase in the volume of the uterus); days corresponding to menstruation.

What happens to the baby after a premature birth? 4

At present, it is possible to nurse children whose birth weight is more than 1 kilogram, but, unfortunately, such small children survive only in 50% of cases. Sometimes children with a body weight of 500 to 1000 grams are nursed, but this happens extremely rarely, in addition, this is a very, very expensive process. Children born with a weight of more than 1500 grams are easier for pediatricians to nurse, since all their organs are more “mature”.

At the second stage of nursing, premature babies are often sent to children's hospitals.

1 Preterm birth is usually reported after 28 weeks of gestation. Spontaneous termination of pregnancy in the period from conception to 28 weeks is called spontaneous abortion (miscarriage). For details on the threat of abortion, see: A. Koroleva, "The threat of abortion" / No. 1-2001.
2 For more on infectious diseases, see: Zh. Mirzoyan; S. Gonchar.
3 On the course of the postpartum period, see the article by N. Brovkina "The Fourth Trimester" in this issue of the journal.
4 The subject of this article is preterm birth, so the nursing of premature babies is devoted to just a few lines here. Detailed material on the methods of nursing premature and underweight babies will be published in one of the next issues of our journal.

Timely, or urgent (on time) delivery is the physiological completed process of pregnancy. Complications of preterm birth are directly related to the term of the latter and largely determine the necessary measures for this complex medical and social problem.

It consists in nursing premature newborns, measures to improve their later life, as well as in additional socio-economic costs. Therefore, the most difficult and most important question is “how to prevent preterm birth”.

Definition and features of the flow

Accepted abroad and in Russia, the terms of birth, which are considered premature, differ, which is the reason for the difference in statistics. According to the recommendations of the World Health Organization, preterm births are considered if they occur between 22 and 37 weeks of gestation, or on the 154-259th day, with a fetal weight of 500 to 2,500 g and a body length of at least 25 cm.

In the Russian Federation in 1992, terms were adopted - 28-37 weeks, or on the 196-259th day, and spontaneous interruption at 22-27 weeks is a separate category that is not classified as childbirth.

This difference is due to the fact that for nursing newborns from 22 weeks old with a body weight of 500 to 1,000 g, highly qualified and experienced neonatologists are needed, as well as special highly sensitive ventilators and other advanced equipment. All this is available in specialized specialized neonatal centers in Russia, but is not available in ordinary maternity hospitals.

With multiple pregnancy, births from 22 to 35 weeks of pregnancy are considered premature. Since the body weight of each of them is lower than in a singleton pregnancy, early birth is more dangerous for them. However, most babies born at 28 weeks of gestation or later can be successfully nursed.

Among all births, preterm births account for 6 to 10%, of which 5 to 7% - at 22-28 weeks, from 33 to 42% - at 29-34 weeks and 50-60% - at 34-37 weeks . The incidence and mortality rate of premature babies in the perinatal period is 30-70%.

What are the features and why is preterm birth dangerous?

They are characterized by:

the onset (a significant number of them - about 40%) of premature discharge of water;
the development of abnormal labor activity;
an increase in duration or, conversely, rapid or rapid childbirth;
the occurrence of fetal asphyxia or hypoxia of varying degrees;
bleeding in the afterbirth and early postpartum periods;
frequent infectious complications.

Classification and consequences

There is no generally accepted unified classification. According to a letter from the Ministry of Health of the Russian Federation, preterm births, in accordance with gestational age, are recommended to be divided into:

very early

Frequency 5%, occur after 27 weeks + 6 days. At the same time, newborns are characterized by deep prematurity, body weight below 1,000 g, and severe immaturity of the lungs, although in some cases, prevention of respiratory distress syndrome is effective.

The survival prognosis for these children is extremely poor, and mortality and morbidity rates are as high as possible. Surviving premature babies born at 24 weeks of gestation and even later, very often subsequently remain disabled due to persistent physical and mental disabilities.

Early

Frequency (15%) - 28-30 weeks + 6 days. Prematurity of such children is regarded as "severe". Characteristic for them are body weight less than 1,500 gr. and immature lung tissue, the accelerated development of which can be achieved with the use of glucocorticosteroid drugs (Dexamethasone) and drugs that stimulate the formation of surfactant - a biologically active substance that covers the epithelium of the mucous membrane of the alveoli and does not allow their walls to subside.

The severity of the condition of children born at the 30th week of pregnancy is much less pronounced than in those who were born earlier, and approaches the average degree.

Premature

Frequency (20%) - 31-33 weeks + 6 days. The survival rate of children born at 32 weeks of gestation is very high and averages 95%. The degree of their prematurity is regarded as medium. However, they are very prone to infectious diseases, since the laying and formation of the fetal immune system at these times is just beginning.

late premature

Frequency (70%) - 34-36 weeks + 6 days. By this time, the lung tissue of the fetus is practically formed and there is no need to stimulate its maturation. In addition, these children have significantly lower susceptibility to infectious agents, compared with newborns of the previous group, and drug prolongation of pregnancy does not have a significant effect on the causes of death.

According to the totality of signs and the nature of the occurrence, they distinguish:

Spontaneous preterm birth (70-80%), of which 40 to 50% occur with regular labor activity with a preserved fetal bladder and 25-40% with amniotic fluid discharge in the absence of regular labor activity.
Induced, or artificial preterm birth (20-30%), carried out according to certain medical indications.

Indications for artificial preterm birth and their stimulation

Indications for induction may be associated with pathology in the body of the mother and/or fetus. In the first case it is:

severe decompensated endogenous (of organs or systems) diseases that threaten a woman's life;
severe in the form of severe preeclampsia and / or eclampsia;
pathology of the hepatic function, accompanied by a violation of the flow of bile (intrahepatic cholestasis of pregnant women);
complication of pregnancy in the form of HELLP-syndrome (erythrocyte hemolysis in combination with a low platelet count in the blood and increased activity of liver enzymes) and some others.

Fetal indications are:

progression of deterioration, despite the measures taken;
malformations incompatible with life;
intrauterine death.

For these purposes, drugs are used that stimulate the "ripening" of the cervix, increase the tone and contractile activity of the uterus. These drugs include mifepristone in combination with misoprostol, oxytocin, dinoprostone, and dinoprost. They are introduced into the vagina, into the cervix, intraamniotically, intravenously in large doses and according to the developed schemes.

An attempt to self-induce at home can lead to extremely serious complications, often resulting in death even when emergency medical care is provided.

Possible Complications

Prematurity of childbirth by parturients is often the cause of certain complications that develop in them much more often than urgent ones. These complications include:

massive bleeding due to its presentation or dense increment;
ruptures of the cervix and perineal tissues due to their unpreparedness for the passage of the fetus during rapid labor;
infection of the birth canal with the development of septic conditions; development of coagulopathic conditions during prolonged labor, etc.

Hypogalactia is associated with the unpreparedness of the woman's body at this time, complications during pregnancy and childbirth, a weak sucking reflex in an immature newborn and forced late attachment to the mother's breast.

But the greatest threat of premature birth is for the health and life of the child. Survival in perinatal centers among children born before 23 weeks of gestation is only 20%, at 26 weeks - already 60% and at 27-28 weeks - up to 80%.

On the basis of survival and depending on body weight, children are divided into categories:

I - body weight is low (1500-25000 g). Children of this category survive more often, by about 3 years they reach the level of development of their peers and then continue to develop in accordance with accepted age indicators.
II - body weight is very low (1000-1500 g). Approximately 50% of these children are not amenable to nursing, while the rest often develop persistent organ or systemic disorders.
III - body weight is extremely low (500-1,000 g). In specialized neonatal centers, some of these children manage to get out, but almost always they have persistent disorders of the function of the central nervous system, respiratory organs, digestion, and genitourinary system.

However, criteria such as gestational age, weight and height do not always correspond to the maturity of the fetus. So, for example, among children weighing 2,500 gr. from 18 to 30% are full-term, and with a weight of 3,000 gr. - 4 to 8% are premature.

Therefore, when determining maturity, the proportionality of the physique, the condition of the bones of the skull, the nature of the distribution and density of growth of vellus hair, the color and thickness of the skin, the severity of the subcutaneous fat layer, the location of the umbilical ring, the degree of development of the external genital organs of the child, etc. are also taken into account.

Causes of preterm birth and risk factors

Among specialists there is no single and clear idea of the mechanisms of development of this disorder. Most of them consider hormonal disorders, chronic infectious processes and neoplasms of the internal genital organs, as well as disorders in the blood coagulation system to be the main causes.

The main mechanisms of pathology are associated with:

An increase in the release of specific informational protein molecules into the blood during infectious processes in a woman's body.
The development of coagulopathic processes (blood clotting disorders), which are the cause of microthrombosis in the placenta with its subsequent premature detachment.
An increase in the content and activation of the oxytocin receptor system in the muscular layer of the uterus. This contributes to the increase and its contractile activity due to the opening of calcium channels in muscle cells and the entry of calcium ions into them.
Premature rupture of the membranes due to infection of the lower parts of the fetal bladder, which usually occurs with isthmic-cervical insufficiency.

Risk factors

Multiple contributing factors are usually considered as the causes of pregnancy disorders. What can cause preterm labor? All risk factors can be conventionally grouped into 4 groups.

Complications during this pregnancy:

infection of the vagina and cervix;
bleeding from the uterus;
severe gestosis occurring with edema, high blood pressure and proteinuria (protein in the urine);
sensitization by the Rh factor;
antiphospholipid syndrome;
polyhydramnios and multiple pregnancy;
pelvic presentation of the fetus;
placenta previa or its premature detachment;
pathology, including asymptomatic, urinary tract;
prematurely "ripe" for childbirth the cervix;
premature violation of the integrity of the membranes and outpouring of water;
malformations of the fetus.

Associated common diseases:

acute infectious diseases during pregnancy, including intestinal ones, especially those occurring with a high temperature;
the presence in the body of chronic foci of infection (chronic tonsillitis, rhinosinusitis, periodontitis, etc.);
heavy physical exertion, injuries and surgical interventions during pregnancy;
arterial hypertension and cardiovascular insufficiency;
severe forms of diabetes;
renal pathology.

Burdened obstetric and gynecological history:

menstrual irregularities;
anomalies in the development of internal genital organs and the presence of benign tumors of the uterus;
conization or amputation of the cervix, isthmic-cervical insufficiency;
pregnancy after premature birth;
four or more births;
two or more medical or one or more recent miscarriages;
pregnancy as a result of the use of assisted reproductive technologies.

Socio-biological:

age - less than 18 years (due to insufficient maturity of the reproductive system) and more than 34 years (due to acquired chronic diseases);
unfavorable socio-economic living conditions;
frequent stressful conditions and negative emotional and mental stress;
nicotine, alcohol, drug intoxication.

Can sex cause preterm labor?

In the last stages of pregnancy, excessively active sexual relations can provoke a contraction of the smooth muscle fibers of the cervix and its expansion, leading to an increase in uterine tone. This can cause damage and premature rupture of the membranes in the region of the lower pole of the fetal bladder, infection, leakage or discharge of amniotic fluid and stimulation of labor.

Do Bucospan suppositories cause premature birth?

Bucospan is an antispasmodic drug, that is, it relieves spasm of smooth muscles. During pregnancy, it, like other antispasmodics, is sometimes prescribed to reduce the tone of the myometrium in case of a threatened miscarriage and in some other cases. In the normal course of pregnancy, theoretically, it can contribute to the opening of the cervix and provoke the onset of labor, especially in the presence of isthmic-cervical insufficiency. However, there are no reliable descriptions of such an effect of the drug.

Prematurity is considered a multifactorial disorder. The more combinations of causative factors are detected in a woman, the higher the likelihood of pregnancy failure, and such a patient should be included in the risk group.

Clinical signs

Due to the unpreparedness (immaturity) of the cervix, there is a risk of abnormal development of labor, as a result of which the whole process becomes protracted. In addition, 40% of such births proceed without any precursors and begin with prenatal rupture of amniotic fluid. However, in most cases, the symptoms of preterm labor are practically no different from those at term.

Depending on the clinical course, such births are divided into:

Threatening.
Beginning (for up to 34 weeks).
Started.

Due to the absence of specific symptoms, the threat of preterm birth often presents certain difficulties in terms of diagnosis. It mainly shows up:

increased tone and excitability of the uterus during its palpation;
complaints of a pregnant woman about increased discomfort or the appearance of moderate pains in the lower abdomen of a pulling or cramping nature, on “menstrual-like” pains in the lumbar region; in some cases, there may be no complaints;
subjective and objective increase in the activity of fetal movement or, conversely, the cessation of its activity;
a feeling of fullness or pressure in the vagina, frequent urge to urinate, and sometimes to defecate, which is associated with a low location and pressure on the internal tissues of the presenting part of the fetus.

In addition, in the case of premature rupture of the membranes, the woman in labor complains of a liquid discharge from the vagina. The consequence of abundant outflow of amniotic fluid is a decrease in the volume of the abdomen and a decrease in intrauterine pressure. At the same time, body temperature often rises, which is accompanied by chills, sometimes pronounced. This indicates the rapid development of inflammation of the membranes (chorioamnionitis).

Diagnosis of the threat is carried out on the basis of the above signs and is refined by vaginal examination, tonusometry, external multichannel hysterography and ultrasound in dynamics.

During vaginal examination, there are no changes in the cervix, it is formed, has a length of about 1.5-2 cm, its external os is closed or, if childbirth is repeated, it passes the tip of the finger (up to 1 cm). The presenting part of the fetus, pressed against the entrance to the small pelvis, can also be determined. The data of instrumental studies indicate an increase in the tone of the myometrium.

How to understand that premature birth has begun?

Their onset is characterized by severe cramping pains in the lower abdomen or regular contractions, confirmed by hysterography. During vaginal examination, a shortened and softened or (often) smoothed cervix is determined and the opening of its external os in dynamics up to 3 cm. Palpation and ultrasound reveal the deployment of the lower uterine segment.

Signs of the onset of childbirth:

Regular labor activity (regular contractions) with an interval between them of about 10-15 minutes.
Departure of amniotic fluid.
Slight, spotting bloody discharge.
During vaginal examination, the fetal presenting part is determined at the entrance to the small pelvis.
The dynamic opening of the external cervical os is more than 3-4 cm.

Management of preterm birth

Management tactics can be conservative-expectant or active. Her choice is due to the following main factors:

The condition of a woman.
Terms of pregnancy.
The presence and severity of bleeding.
The clinical course of childbirth (threatening, beginning or begun) and their severity.
The state of the fetus.
The degree of neck opening.
The state of the fetal bladder.
The presence of symptoms of infection.

Expectant tactics

If pain occurs in the lower abdomen and lumbar region, it is necessary to call an ambulance for the purpose of hospitalizing the pregnant woman. First aid to her is to provide physical and psycho-emotional rest - bed rest, a psychologically calming effect, taking an infusion or tincture of motherwort and hawthorn, a decoction or extract of valerian root, antispasmodic drugs (No-shpa, Drotaverine, Papaverine) in tablets, intramuscularly or in the form candles.

Conservative treatment of the threat of preterm birth in a hospital setting

The purpose of the therapeutic effect is to prolong pregnancy. Management consists of:

threat treatment;
prevention of fetal asphyxia;
prevention of infectious complications based on measurements of body temperature, blood tests and studies of smears and microflora of the cervical canal.

When a woman is threatened, bed rest is prescribed, conditions are created for physical and emotional rest, light sedative and antispasmodic drugs inside, intramuscularly, in the form of rectal suppositories, magnesian iontophoresis, acupuncture, electrorelaxation therapy.

Use of tocolytics

If necessary, tocolytic agents are used. There are tocolytics with a different mechanism for suppressing the contractile activity of the uterus. These include:

beta-adrenomimetic drugs that help reduce the content of calcium ions in cells (Ritodrin, Terbutaline, Ginipral); they are used orally or intravenously;
magnesium sulfate (intravenous drip), which reduces the contractility and excitability of the myometrium, also by reducing the concentration of calcium ions in the cell cytoplasm;
non-steroidal anti-inflammatory drugs (Indomethacin rectally), which are inhibitors of prostaglandin synthesis; their use is recommended after the 32nd week of pregnancy (to avoid complications).

Nifedipine also belongs to tocolytic drugs that block the entry of calcium into the cell. During studies of the effect of Nifedipine with the threat of preterm labor, good results were obtained in terms of suppression of uterine contractility, in which it is comparable or even superior to beta-agonists (Ritodrine and others), and the absence of an adverse effect on the fetus. The drug makes it possible to increase the gestational age up to 1 week. However, when using it, care must be taken, since the drug can lead to hypotension, especially orthostatic.

As a rule, treatment begins with the appointment of beta-agonists or magnesium sulfate. In case of their ineffectiveness, non-steroidal anti-inflammatory drugs and calcium antagonists are prescribed. The combination of tocolytic agents with each other is used only for periods up to 28 weeks and with the opening of the external cervical os of more than 2 cm. Further use of tocolytics according to a certain scheme as maintenance therapy is possible.

The use of gestagens, glucocorticosteroids

Progestogens (progesterone), which include Utrozhestan, have a high degree of effectiveness in order to stop or prevent preterm labor. Its combination with beta-agonists allows you to reduce the dosage of the latter. Utrozhestan is recommended to be used with caution, due to its property to increase the sensitivity of the uterus of a pregnant woman to the bacterial flora.

In addition, antibiotic therapy and therapeutic suturing of the cervix are often indicated. To prevent the development of RDS (respiratory distress syndrome) in the fetus, glucocorticosteroids are used. The consensus conference, held in August 2000, recognized the most effective and recommended for use intramuscular administration of Dexamethasone for periods of 24 to 34 weeks twice (12 mg twice within 1 day) or four times (6 mg four times also during 1 day).

In exceptional cases, after careful observation, treatment is carried out on an outpatient basis (at home).

Contraindications to expectant management

Absolute contraindications to the conservative tactics of managing the threat of preterm birth are:

Pregnancy of 36 weeks or more.
Oblique, transverse arrangement of the fetus.
Foot presentation in combination with a central rupture of the fetal bladder and an open cervical canal.
Signs of intrauterine infection.

Relative contraindications:

pregnancy 34-35 weeks;
foot presentation of the fetus in combination with a high rupture of the fetal bladder and a closed cervical canal;
criminal (outside a medical institution) intervention in the uterine cavity for the purpose of terminating a pregnancy, but in the absence of obvious infection;
multiple pregnancy, nephropathy, severe extragenital (comorbid) pathology in a woman;
the presence of pathogenic microorganisms in the vagina or the third degree of purity;
the presence of leukocytosis in the blood with a shift to the left under the condition of normal body temperature.

With relative contraindications, with the threat of preterm birth, preventive measures for fetal hypoxia, antibiotic therapy (if indicated), therapy for the underlying pathology and preparation for childbirth are carried out. In the absence of their onset within 5 days, they are stimulated by intravenous prostaglandins or Oxytocin drip under the control of cardiotocography. Active management is necessary when:

Suspicions of the presence of anomalies of fetal development.
Complications of pregnancy in the form of severe preeclampsia, not amenable to correction.
Severe somatic pathology in a woman in labor.
Outpouring of water and the absence of a fetal bladder.
Having regular contractions.
Threats of intrauterine fetal asphyxia.
The presence of symptoms of infection.

Active management of preterm labor

The first stage of labor is characterized by a high degree of mobilization of the adaptive mechanisms of the body of the pregnant woman and the placental-fetal system. Their gradual depletion sometimes leads to a rapid change in the obstetric situation, disruption of the fetal life support systems and the development of its hypoxia. In this regard, it is necessary to carry out constant cardiomonitoring and carry out an individual decision on the implementation of appropriate preventive (every 2 hours) and therapeutic measures.

After opening the cervix up to 3 cm, the use of epidural analgesia is recommended. It helps to reduce or eliminate pain, expand the cervical canal, relax the muscles of the pelvic floor in the second period (exile period), improve blood microcirculation in the tissues of the mother and fetus, and also reduces the likelihood of developing discoordination uterine contractions and increased blood pressure. In addition, epidural analgesia, unlike anesthesia with Promedol, does not cause respiratory depression in the newborn.

In the event of a threat of rapid or rapid labor, the contractile function of the uterus is corrected by intravenous drip of Partusisten. It is administered at a certain rate over 10 minutes with a gradual dose reduction until the required frequency and regularity of contractions are established, the external os opens up to 8 cm and the fetal head advances into the narrow part of the pelvic cavity.

The second period is characterized by a high degree of risk of injury (mainly craniocerebral) of the fetus. Therefore, during the period of exile, protection of the perineum of the woman in labor to prevent ruptures is not carried out. In order to stretch the soft tissues of the pelvic floor and facilitate the passage of the fetus, the obstetrician-gynecologist with his fingers stretches the skin and muscles from the side of the vagina towards the ischial tuberosities. If necessary, the perineum is incised.

In preterm birth, the indications for resolution by caesarean section are:

Severe form of preeclampsia (preeclampsia and eclampsia).
Placental presentation.
Premature detachment with a normal location of the placenta.
A transversely located fetus or complications that have arisen in the case of its breech presentation.
A burdened obstetric history in a woman due to miscarriage, the birth of a dead fetus.

Prevention of preterm birth

There are no clinically acceptable preventive diagnostic methods that allow predicting preterm labor in the long term (over 3 weeks).

Tests

To date, the generally accepted and most informative test is for preterm birth, based on the determination of fibronectin glycoprotein in the cervical mucus after 20 weeks. The latter is found in significant quantities in the cells of the membranes of the fetus and amniotic fluid.

The detection of fibronectin in the cervical mucus indicates the appearance of amniotic fluid in it and is considered as a precursor. The highest (up to 71%) testing sensitivity is two weeks before preterm birth. Three weeks before them, the information content of the test is about 59%, and at gestational ages up to 37 weeks - no more than 52%. This test can only be performed in a medical facility.

There is also a fairly informative test for the determination of premature violations of the membranes of the fetus in the conditions of the antenatal clinic. For self-determination of amniotic fluid in the vaginal discharge, a test pad is offered - “FRAUTEST amnio”. However, diagnosis with this test is unreliable.

Transvaginal ultrasound

Another relatively informative study is an echographic dynamic determination of the neck length using a transvaginal sensor of an ultrasound device. If the length of the neck exceeds 3 cm, then the probability of childbirth in the coming weeks does not exceed 1%.

Other preventive measures

Preventive measures even before pregnancy include informing women about risk factors, minimizing any manipulation of the internal genital organs, smoking cessation and unmotivated intake of pharmaceutical vitamin preparations before and within 2 months after conception. Reception during pregnancy by women at risk of progesterone derivatives, antibiotics and other antibacterial drugs as prescribed by a gynecologist, antibiotic therapy according to indications, etc.

The technique of suturing with a shortened neck has an ambiguous preventive effect. In some cases, an obstetric pessary is used alone or in addition to cervical sutures. It is installed in the vagina and is a ring. This ring, in case of a threat of preterm labor, should provide additional support, due to which pressure on the lower uterine segment is reduced and an obstacle is created for opening the external os and rupturing the membranes of the fetus. However, most experts are skeptical about the effectiveness of this medical device.

The main role in addressing the issues of prevention of pathology and its complications belongs to the antenatal clinic. Its staff is engaged in the identification of women with risk factors, dynamic monitoring of them, developing an individual plan of preventive measures, hospitalization in the department of pathology of pregnant women for examination and individual adequate treatment.

Awareness of women about the pathology allows them to use the recommendations of a specialist even at the stage of preparation for conception, and during pregnancy - to seek medical help in time. The deep knowledge of doctors and their ability to correctly analyze possible causes and risks make it possible to avoid unreasonable prescribing of drugs, which often lead to side effects and complications, as well as to reduce the frequency and severe consequences of this pathology.

1. General recommendations. Prescribe tocolytic therapy. In addition, if the probability of maintaining a pregnancy is low and the risk of having a very premature baby is high, drugs are prescribed that accelerate the maturation of the fetal lungs. There are reports that the efficacy of tocolytic therapy is enhanced by empiric antimicrobial therapy. After 34 weeks of pregnancy, tocolytic agents are not prescribed, since children are born viable, and the risk of complications of tocolytic therapy far outweighs the benefits of its use.

2. Tocolytic drugs - a group of drugs with different mechanisms of action that suppress the contractile activity of the uterus. These include beta-agonists, magnesium sulfate, NSAIDs (inhibit prostaglandin synthesis) and calcium antagonists. Of all the drugs, only the beta-agonist ritodrine is approved by the FDA as a tocolytic agent. However, in the United States, magnesium sulfate and terbutaline are widely used in addition to ritodrine. There are also reports of the use of indomethacin and nifedipine as tocolytic agents, but there is little experience with their use in obstetrics.

Tocolytic agents in most cases are prescribed as monotherapy. It is necessary to stop or significantly reduce the contractile activity of the uterus. Treatment usually begins with beta-agonists (ritodrine or terbutaline) or magnesium sulfate. If the drug is ineffective at the maximum dose, it is replaced by another with a different mechanism of action. The effectiveness of the second drug is observed in 10-20% of cases.

a. Beta adrenostimulants. For tocolytic therapy, ritodrine, terbutaline, hexoprenaline, isoxsuprine and salbutamol are used. Although only ritodrine is FDA-approved for tocolytic therapy, terbutaline is widely used in the US. Beta-agonists cause an increase in the concentration of cAMP, followed by a decrease in the concentration of calcium ions in the cytoplasm. As a result, the activity of myosin light chain kinase decreases and myometrial contractility decreases.

1) Side effects of beta-agonists include tachycardia, dyspnea, chest pain, as well as hyperglycemia and hypokalemia.

2) Contraindications - ischemic heart disease and other heart diseases that can worsen against the background of tachycardia, thyrotoxicosis, arterial hypertension. A relative contraindication is diabetes mellitus. The use of beta-agonists in this disease is allowed only with careful monitoring of plasma glucose levels. With hyperglycemia, increase the dose of insulin.

3) Doses and application. In the treatment of beta-adrenergic stimulants, ARDS may develop. Causes are most likely related to the infection and not to the tocolytic agents themselves. However, fluid intake is limited to 100 ml/h during tocolytic therapy. There are reports that hypotonic solutions should be used to prevent ARDS.

a) Ritodrine is administered orally or intravenously. For a quick cessation of contractions, intravenous administration is recommended. In / in ritodrine is administered in 5% glucose at a rate of 0.05-0.1 mg / min. The rate of administration is increased every 15-30 minutes by 0.05 mg / min until the contractions stop. After the cessation of contractions, treatment is continued for another 12-24 hours. The rate of administration should not exceed 0.35 mg / min. With the manifestation of side effects of the drug, it is reduced. If chest pain occurs, the administration of the drug is suspended and an ECG is performed. If the heart rate exceeds 130 min-1, the dose of ritodrine is reduced. Inside, ritodrine is first prescribed at a dose of 10 mg every 2 hours, and then at 10-20 mg every 4-6 hours.

b) Terbutaline is used both for the treatment and prevention of preterm labor. For prophylactic purposes, terbutaline is usually prescribed orally, and to stop labor - in / in. It should be emphasized that terbutaline is less effective than ritodrine in stopping labor. Some authors recommend subcutaneous administration of terbutaline using an infusion pump at 0.25 mg every hour until contractions stop. Then the drug is administered orally at a dose of 2.5-5.0 mg every 4-6 hours. During treatment, it is monitored that the heart rate in a pregnant woman does not exceed 130 min-1. Some authors recommend adjusting the dose of terbutaline so that the heart rate exceeds the baseline by no more than 20–25%.

b. Magnesium sulfate

1) The mechanism of tocolytic action has not been precisely established. It is known that magnesium sulfate reduces the excitability and contractility of the myometrium by reducing the concentration of calcium ions in the cytoplasm of muscle cells.

2) Doses and administration

a) Contraindications include intracardiac conduction disorders, myasthenia gravis and severe heart failure. Relative contraindication - chronic renal failure, since the drug is excreted mainly by the kidneys. When treating with magnesium sulfate, respiratory depression is possible - during treatment, the breathing of the pregnant woman is carefully monitored. This is especially important when prescribing narcotic analgesics, sedatives and other drugs that depress respiration.

b) The introduction of the drug. 4-6 g of magnesium sulfate is dissolved in 100 ml of saline and injected intravenously for 30-45 minutes, after which they switch to continuous intravenous administration at a rate of 2-4 g/h until the contractions cease or significantly slow down. Sometimes after the cessation of labor, slight contractions of the uterus continue. In this case, a vaginal examination is regularly performed. If cervical dilatation continues, increase the dose or prescribe another tocolytic agent.

c) The therapeutic concentration of the drug in serum is 5.5-7.5 mg%. To achieve it, in most cases it is sufficient to introduce magnesium sulfate at a rate of 3-4 g/h. Signs of overdose - inhibition of tendon reflexes and respiration. Inhibition of tendon reflexes occurs at a concentration of magnesium in the serum of 7-10 mg%, respiratory depression - at a concentration above 12 mg%.

d) If treatment is ineffective or high doses of magnesium sulfate are required, determine the concentration of magnesium in the serum. If it is below therapeutic (due to the rapid excretion of magnesium by the kidneys), an increase in the dose is acceptable. If no effect is observed at the therapeutic concentration of magnesium in the serum, another drug is prescribed (simultaneously with magnesium sulfate or instead of it).

e) If a pregnant woman has chronic renal failure, the dose of magnesium sulfate is reduced. Serum magnesium levels are closely monitored during treatment.

3) Side effects are observed less frequently than in the treatment of other tocolytic agents. Hot flashes (usually at the beginning of treatment), palpitations, headache, and dry mouth are possible. Diplopia and disturbance of accommodation are sometimes observed. When prescribing magnesium sulfate after massive infusion therapy or beta-agonists, pulmonary edema is possible.

a) An overdose of magnesium sulfate is quite common. It is manifested by respiratory depression and a drop in muscle tone. To eliminate symptoms, calcium gluconate is administered intravenously slowly. With significant respiratory depression, mechanical ventilation may be required.

v. NSAIDs are considered effective tocolytic agents. They can cause transient oligohydramnios, but within 1-2 days after discontinuation of the drug, the volume of amniotic fluid returns to normal. NSAIDs have also been reported to cause narrowing of the ductus arteriosus in the fetus. The risk of this complication is highest when taking drugs before the 32nd week of pregnancy. 24 hours after discontinuation of the drug, the patency of the arterial duct is completely restored.

1) The choice of drug. NSAIDs are used in case of inefficiency or contraindications to the use of other tocolytic agents. Before starting treatment, the pregnant woman is warned about the risk of narrowing of the arterial duct in the fetus and the possibility of other methods of treatment is discussed.

2) Contraindications include allergy to salicylates, aspirin-induced asthma, hemostasis disorders, and severe CKD and liver failure. Relative contraindication - peptic ulcer.

3) Indomethacin is well absorbed when taken orally and rectally. Due to the fact that with regular labor, the evacuation of the contents of the stomach is slowed down, indomethacin is best administered rectally. Initially, 100 mg is administered, and then 50 mg every 8 hours for 48 hours. Since the visualization of the arterial duct with ultrasound is difficult, continuous CTG is performed for early diagnosis of its narrowing in the fetus. The volume of amniotic fluid is determined daily. If oligohydramnios is suspected, indomethacin is discontinued.

4) Side effects are rare. There are reports that NSAIDs increase the risk of postpartum hemorrhage. In this regard, at a gestational age of more than 32 weeks, NSAIDs are contraindicated.

d. Calcium antagonists disrupt the penetration of calcium ions into the cell, thus reducing the contractility of myometrial cells. Prospective studies of the calcium antagonist nifedipine have shown that it does not adversely affect the fetus and approaches ritodrine in efficacy. The drug is prescribed at a dose of 10 mg, usually under the tongue. Nifedipine is taken repeatedly at the same dose every 15-20 minutes until the contractions stop (no more than 3 doses). After the cessation of contractions, nifedipine is prescribed 10 mg every 6 hours for several days.

Additional recommendations. Despite the widespread use of various tocolytic agents, the prevalence of preterm birth in Western countries has not changed. The reason for this is probably the late diagnosis of preterm birth.

1. Monotherapy. The following order of prescription is recommended. Treatment begins with beta-agonists or magnesium sulfate. If neither is effective, NSAIDs or calcium antagonists are prescribed. Despite reports of the effectiveness of tocolytic agents of these groups, none of them has been studied enough to become the drug of choice.

2. Combined therapy with tocolytic agents is indicated only in the most extreme cases, for example, at a gestational age of up to 28-30 weeks with ineffectiveness of monotherapy and cervical dilatation by more than 2-3 cm. fetal lungs and significantly reduce the risk of neonatal death. It has been shown that each additional day of intrauterine stay at 25-28 weeks of gestation significantly increases the viability of the newborn. With the simultaneous appointment of several tocolytic agents, the woman is explained in detail the likely consequences, as well as the possibility of other methods of treatment.

The ineffectiveness of tocolytic agents is often due to infection. With chorioamnionitis, tocolytic therapy is contraindicated. For other infections, such as pyelonephritis, tocolytic therapy is acceptable, but it increases the risk of ARDS. For the prevention of ARDS, the intake and administration of liquids is limited (up to 100 ml / h). When treated with corticosteroids for 24-36 hours, leukocytosis up to 30,000 µl-1 can be observed with a shift of the leukocyte formula to the left. If the level of leukocytes is more than 30,000 µl-1, infection is excluded.

a. There is no ideal combination of tocolytic agents. The combination of indomethacin with magnesium sulfate or ritodrine is most effective. The use of ritodrine in combination with magnesium sulfate has also been reported, but the effectiveness of this regimen was practically the same as that of using each drug separately. Calcium antagonists are not recommended to be combined with other drugs.

b. The simultaneous administration of three tocolytic agents is not recommended, since this significantly increases the risk of complications without increasing the effectiveness of treatment.

3. ARDS is a common complication of tocolytic therapy. It was previously thought to be due to the use of corticosteroids to accelerate the maturation of the fetal lungs, but research has shown that infection is the main cause of ARDS in preterm birth. Prevention includes fluid restriction. The total fluid intake (orally and intravenously) should not exceed 100–125 ml/h or approximately 2.0–2.5 l/day. When treating with tocolytic agents for infusion therapy, 5% glucose or 0.25% NaCl is used.

4. Accelerating the maturation of the lungs of the fetus

a. Corticosteroids. In 1994, the US National Institutes of Health recommended corticosteroids to accelerate fetal lung maturation in threatened preterm labor before the 34th week of pregnancy. The mechanism of action of corticosteroids in this case is not exactly established. Perhaps they activate enzymes involved in the synthesis of surfactant, or stimulate the release of surfactant from type II alveolocytes. Corticosteroids have been found to be most effective at 30-34 weeks of gestation. Among newborns, the greatest effect of treatment was noted in black girls, and the smallest - in white boys. After 34 weeks of pregnancy, corticosteroids are ineffective. Usually betamethasone 12 mg orally every 12 to 24 hours (total dose 24 mg) or dexamethasone 5 mg orally every 6 hours (total dose 20 mg). Treatment begins 24-48 hours before delivery.

b. Other methods. The development and maturation of the fetal lungs is quite complex. Studies have shown that T4 and prolactin play an important role in this process. Betamethasone plus protirelin has been found to be more effective in preventing hyaline membrane disease than betamethasone alone. Although such a regimen is not yet widely used, if the risk of having a very preterm baby is high, its appointment is acceptable.

5. Antimicrobial therapy. Infection is considered one of the main causes of premature birth. According to studies, antimicrobial therapy significantly increases the effectiveness of preterm birth prevention. However, due to the high cost and complexity of the mass examination of pregnant women, this method has not found wide application. In addition, there is evidence of the ineffectiveness of ampicillin in combination with erythromycin in the premature onset of labor. Some authors reported on the effective use of prophylactic antimicrobial therapy in pregnant women with unexplained causes of premature onset of labor. After taking the material from the cervical canal for sowing, in this case, ampicillin is prescribed, 2 g intravenously 4 times a day. Treatment is continued for 48 hours and if the culture is negative, the antibiotic is discontinued. In case of allergy to penicillins, cephalosporins acting on Streptococcus agalactiae are prescribed. According to other authors, ampicillin is ineffective in the premature onset of labor.

6. Hemorrhage in the ventricles of the brain occurs more often in children born before the 32-34th week of pregnancy. Prevention includes the introduction of phytomenadione, 10 mg IM, to the woman in labor.

Supportive tocolytic therapy. After the cessation of regular contractions, tocolytic therapy is continued for 12-24 hours at a minimum dose sufficient to maintain normal uterine tone. After that, they switch to maintenance treatment. It was noted that maintenance tocolytic therapy did not prolong pregnancy (pregnancy was extended by 36 days against the background of placebo, and by 34 days when ritodrine was taken orally), but it prevented the recurrence of preterm labor. Currently, different schemes of maintenance tocolytic therapy are used. However, prospective studies of the effectiveness of this treatment method have not been conducted.

1. Beta-agonists. Apply ritodrine, 10-20 mg orally every 4-6 hours, or terbutaline, 2.5-5.0 mg orally every 4-6 hours. Beta-agonists cause tachycardia, so the pregnant woman should determine the heart rate before each dose. If the heart rate is greater than 115 min-1, the drug should be postponed. Terbutaline may impair glucose tolerance. Pregnant women taking beta-adrenergic stimulants for a long time are required to conduct a one-hour oral glucose tolerance test with 50 g of glucose. For maintenance tocolytic therapy, oral magnesium gluconate and s / c administration of terbutaline using an infusion pump are also used.

2. Magnesium gluconate, according to studies by Martin et al., when administered at a dose of 1 g orally every 2-4 hours, is not inferior in effectiveness to ritodrine and causes side effects somewhat less frequently. With prolonged use, inhibition of PTH secretion and a decrease in serum calcium levels are possible. How much the latter affects the contractile activity of the uterus remains unclear.

Description:

Termination of pregnancy between the 21st and 37th week is considered a preterm birth. In this case, a viable, but premature baby is born. Up to 25% of women do not carry a pregnancy, of these cases, 5-10% are premature births.

Premature births are dangerous for the mother and fetus, as they cause severe complications (perinatal morbidity and mortality, internal hemorrhages, etc.)

Symptoms:

A woman may notice the appearance of pulling pains in the lower abdomen and lower back. The pains are sometimes cramping in nature, i.e. we can talk about the beginning of the fights. In some cases, childbirth begins with the outflow of amniotic fluid or with the discharge of the mucous plug. In any of these cases, urgent hospitalization in the maternity hospital is necessary.

Causes of occurrence:

First of all, infection. Normally, the uterine cavity is sterile. Any inflammatory process makes the uterine wall inferior, so the pregnancy continues until the uterine wall can stretch, and then the body tries to get rid of the embryo.

That is why it is not necessary to spare money, time and effort for examination for the presence of infection. Every woman - ideally even before pregnancy - should be examined for infectious diseases, especially those that are often asymptomatic (carriage of chlamydial, ureaplasma, mycoplasma, toxoplasma infection, herpes simplex virus, cytomegalovirus). Particular attention should be paid to women with a history of chronic and acute inflammation of the uterine appendages and endometrium (the mucous membrane of the uterine body), intrauterine interventions (abortions, diagnostic curettage), as well as cases of spontaneous abortion. In the presence of an inflammatory process, it naturally needs to be cured. The drugs and procedures selected by the doctor will help to expel the infection from the body even before conception. If for some reason the necessary tests were not made before conception, then when diagnosing pregnancy, you should definitely undergo an appropriate medical examination, and you should not neglect regular examinations in the future. The sooner the presence in the body of a woman of microbes that can cause premature birth or potentially dangerous to the fetus is detected, the better. Modern medicine has a significant arsenal of tools to reduce the risk and infection of the fetus.
The second common cause of preterm birth is, ICI (isthmus - "isthmus", the place where the body of the uterus passes into the cervix, cervix - "womb"), that is, the inferiority of the muscle layer of the cervix, which during a normal pregnancy plays the role of a kind of sphincter (retaining ring ), which does not allow the embryo to "leave" the uterine cavity. ICI is congenital (very rare) and acquired. What can cause the development of ICI? The reasons are quite banal: trauma to the isthmus and cervix during abortions, especially when terminating the first pregnancy, deep ruptures of the cervix in previous births (this can happen, for example, during childbirth with a large fetus, the imposition of obstetric forceps), gross forced expansion of the cervical canal during diagnostic manipulations in the uterine cavity (hysteroscopy, i.e. examination of the uterine cavity with a special device - a hysteroscope; curettage of the endometrium), that is, any injury to the muscular layer of the cervix.

Very often, ICI is formed with hyperandrogenism - an increased content of male sex hormones in the blood, which are produced in the adrenal glands of the mother, and later in the fetus.

Infections and isthmic-cervical insufficiency are the main, but not the only factors that cause preterm birth. Often, endocrinopathies lead to premature birth - mild dysfunctions of the endocrine glands - the thyroid gland, adrenal glands, ovaries, pituitary gland (with gross violations, women, as a rule, cannot become pregnant on their own at all).

Also, premature birth can occur with overstretching of the uterus caused by multiple pregnancy, polyhydramnios, large fetus.

Heavy physical work, chronic stressful situation at work or at home, any acute infectious disease (flu, acute respiratory infections, tonsillitis, especially with fever, etc.) can also provoke an abortion.

Treatment:

For treatment appoint:

With the premature onset of contractions, first of all, tocolytic (that is, reducing the tone of the uterus) drugs are prescribed - partusisten, ginipral. First, these drugs are administered intravenously, and when contractions stop, a transition to tablet forms is possible. These medicines are usually taken until 37 weeks of pregnancy. Magnesium sulphate, a 10% solution of ethyl alcohol and some other drugs are also used as agents that reduce the tone of the uterus.

At the second stage of treatment, they try to eliminate the very cause of premature birth. When an infection is detected, antibacterial drugs are prescribed (depending on the type of infection), sedative (that is, soothing) therapy - in order to break the vicious circle: in addition to the objective factors that increase the tone of the uterus, the fear of losing a child is added, which, in turn, further increases the tone uterus.

With the development of ICI for up to 28 weeks of pregnancy, “tightening” sutures are applied to the cervix, which prevent the fetal egg from “falling out” of the uterus. Sutures are placed under short-term intravenous anesthesia, while drugs are used that have a minimal effect on the child.

The complex of treatment always includes the hormonal drug dexamethasone (microdoses of this hormone are prescribed, so that side effects are practically excluded). Its action is not aimed at preventing premature birth, but at stimulating the “maturation” of the lungs in a child (so that he is able to breathe on his own if he is still born prematurely).

A woman must necessarily observe bed rest, and in a hospital. In nutrition, it is better to avoid irritating, spicy, fatty, indigestible foods.

More difficult is the situation with premature rupture of amniotic fluid. At a gestational age of up to 34 weeks, if it was possible to suppress labor, the condition of the woman and the fetus is normal, there is no increase in body temperature, there are no inflammatory changes in the blood, it is possible to maintain and prolong pregnancy with the obligatory prescription of antibacterial drugs to prevent infectious complications. (The fact is that the discharge of water indicates a violation of the integrity of the fetal bladder. This means that the vagina is now communicating with the uterine cavity, that is, the path of infection is open, and taking antibacterial drugs is a vital measure.)