1. 조산 및 지연임신

2. Survival Rate by Birthweight

3. Probability of Mortality by Gestational Age

4. Percent Mortality by Birthweight

5. Causes of Preterm Birth
Medical and obstetrical complication
Threatened abortion
Lifestyle factors
Genetic factors
Amniotic fluid infection

6. Causes of Preterm Birth
Medical and obstetrical complication
Placental hemorrhage
Preeclampsia
Cervical incompetence
Uterine anomaly
Hydramnios
Trauma

7. Causes of Preterm Birth
Lifestyle factors
Alcohol
Smoking
Cocaine
Young maternal age
Poverty
Short stature
Occupational factors

8. Causes of Preterm Birth
Amniotic fluid infection
Pathogenesis
Bacterial products
 monocytes, macrophage
 Cytokines  Arachidonic acid
 Prostaglandins
 Uterine contractions

9. Causes of Preterm Birth
Amniotic fluid infection
Diagnosis
Amniocentesis
Bacterial culture & Gram stain
Amniotic fluid WBC
Low glucose
Cytokines

10. Identification of Women at Risk
Risk scoring system
Prior preterm birth
Cervical dilatation
Signs and symptoms
Fetal fibronectin
Ambulatory uterine contraction testing
Salivary estriol

11. Identification of Women at Risk
Risk Scoring System
Scores of 1 through 10
Socioeconomic status
Reproductive history
Daily habits
Current pregnancy complications
Scores of 10 or more  high risk

12. Identification of Women at Risk
Prior preterm birth
First birth Second birth Next birth preterm(%)
Term
Preterm
Term Preterm
Preterm Preterm

13. Identification of Women at Risk
Cervical dilatation
Asymptomatic dilatation
USG measurement of cervical length
Knowledge of antenatal cervical dilatation
Did not affect outcome
Prenatal cervical exam
Neither beneficial nor harmful

14. Identification of Women at Risk
Signs and Symptoms
Painful or painless uterine contractions
Pelvic pressure symptoms
Menstrual-like cramps
Watery or bloody vaginal discharge
Pain in the low back
 Late warning sign of preterm birth

15. Identification of Women at Risk
Fetal fibronectin
Glycoprotein
Cervicovaginal secretion
Negative results are more meaningful
Effective predictor

16. Identification of Women at Risk
Ambulatory uterine contraction testing
Ineffective in prevention of preterm birth
Salivary estriol
Under investigation

17. Diagnosis of Preterm Labor
Herron's criteria
Regular uterine contraction
after 20 weeks or before 37 weeks
5 to 8 minutes apart or less
With one or more of following
Progressive change in the cervix
Cervical dilatation of 1 cm or more
Cervical effacement of 80% or more

18. Antepartum Management
Preterm ruptured membranes
Preterm labor with intact membranes

19. Preterm Ruptured Membranes
Natural history
75% already in labor
10% spontaneous labor within 48 hours
7%  delivery delayed 48 hours or more
Appeared to benefit from delayed delivery,
no neonatal death occurred
Time period from rupture to delivery
Inversely proportional to gestational age

20. Preterm Ruptured Membranes
Complication
Cord prolapse
Fetal infection
Chorioamnionitis
Abruptio placentae

21. Preterm Ruptured Membranes
Expectant management
Active interventions did not improve perinatal outcomes
May have aggravated infection-related complications
Ampicillin plus corticosteroids were beneficial because of less respiratory disease
Neonatal survival was not affected by any intervention

22. Preterm Ruptured Membranes
Overt chorioamnionitis
Chorioamnionitis가 진단되면 가능한 한 질식분만을 통한 신속한 분만을 시도한다.
Fever is the only reliable indicator
Infants born to women with chorioamnionitis had increased mortality and morbidity

23. Preterm Ruptured Membranes
Antimicrobial therapy
Fewer RDS, necrotising enterocolitis
Longer latency
Prolonged therapy
May cause superinfection
Pseudomonas aeruginosa

24. Preterm labor with intact membranes
Same with PROM
Antimicrobial therapy
조기진통이 이미 생긴 경우,
cytokine cascade를 막기에는 너무 늦다.
Glucocorticoid therapy
Betamethasone 12 mg IM in two doses 24 hours apart
Dexamethasone 5 mg IM every 12 hours for 4 doses, repeated every 7 days

25. Methods to Inhibit Preterm Labor
Bed rest
Hydration and sedation
Beta-adrenergic receptor agonist
Magnesium sulfate
Prostaglandin inhibitors
Calcium channel-blocking drugs
Nitric oxide donor
Oxytocin antagonist

26. Methods to Inhibit Preterm Labor
Bed rest
Hydration and sedation
Beta-adrenergic receptor agonist
Ritodrine (Yutopar)
Terbutaline

27. Methods to Inhibit Preterm Labor
Beta-adrenergic receptor agonist
Ritodrine (Yutopar)
Intravenous
Side effects
Maternal tachycardia, hypotension, apprehension, chest tightness,
pulmonary edema
Hyperglycemia, hyperinsulinemia, hypokalemia, lactic acidosis

28. Methods to Inhibit Preterm Labor
Beta-adrenergic receptor agonist
Terbutaline
Not so effective

29. Methods to Inhibit Preterm Labor
Magnesium sulfate
4 g loading dose, 2 g/hr continuous infusion
Complications
Pulmonary edema
Respiratory depression
Cardiac arrest
Profound muscular paralysis
Profound hypotension

30. Methods to Inhibit Preterm Labor
Prostaglandin inhibitors
Aspirin, indomethacin, sulindac, naproxen
Closure of ductus arteriosus, necrotising enterocolitis, intracranial hemorrhage

31. Methods to Inhibit Preterm Labor
Calcium channel-blocking drugs
Nifedipine
Decrease vascular resistence
Maternal hypotension
Decreased uteroplacental perfusion
Combination of nifedipine and magnesium for tocolysis is potentially dangerous

32. Methods to Inhibit Preterm Labor
Nitric oxide donor
Nitroglycerin
Severe hypotension
Oxytocin antagonist
Atosiban
FDA approval  denied

33. Intrapartum Management
Continuous electronic monitoring
Prevention of neonatal Group B Streptococcal infection
Penicillin G or ampicillin
Every 6 hours until delivery
Neonatal resuscitation

34. Postterm Pregnancy Definition ACOG (1997)
42 completed weeks (294 days) or more

35. Gestational Age at Birth

36. Perinatal Mortality in Late Pregnancy

37. Pathophysiology Postmaturity syndrome
Unique and characteristic appearance
Wrinkled skin
Long and thin body
Open-eyed, unusually alert, old and worried-looking
Long nail
Growth - not restricted

38. Pathophysiology High rate of mortality and morbidity
Pregnancy hypertension
Prolonged labor with CPD
Unexplained anoxia
Malformation
Primary adrenal hypoplasia
Anencephaly

39. Pathophysiology Fetal distress and oligohydramnios Oligohydramnios
 cord compression
 fetal distress
Fetal release of meconium into already reduced amniotic fluid
Thick, viscous meconium
 meconium aspiration syndrome

40. Pathophysiology Increased perinatal risk Meconium stain
Labor induction
Cesarean delivery
Macrosomia
Shoulder dystocia
Meconium aspiration

41. Postmaturity Syndrome

42. Intrapartum management
Continuous electronic monitoring
Meconium passage
Suction the pharynx as soon as the head is delivered
Trachea should be aspirated as soon as possible after delivery
Consider cesarean section when delivery is remote