Introduction and management of Preterm Birth

1. MESYUARAT PEMANTAPAN
PERKHIDMATAN O&G KKM BAGI
PENCEGAHAN
KELAHIRAN BAYI PRAMATANG :
NATIONAL TRAINING OF
TRAINERS

2. INTRODUCTION
WHO SDG Target 3.2: By 2030, end preventable deaths of
newborns and children under 5 years of age.
Our aim: Reduction of preventable under 5 mortality by
30% in the year 2030 (target set by KKM)
Child Health 2021-2030, MOH, 2021

3. Malaysia achievement in 2016:
neonatal mortality rate of 4.2/1000 live births and
under-5 mortality rates of 8.4/1000 live births.
But the rates have plateaued since then

4. UNDER 5 MORTALITY
REVIEW 2016 SPECIAL REPORT
Conditions originating in
PERINATAL period is the
highest leading cause of
death for under 5
children.
Prematurity,
45.20%
Asphyxia,
28.80%
Infection,
17.90%
Under-5 Mortality Review 2016: Looking into The Preventable Deaths MOH/K/ASA/119.22(RR)

5. Guideline on Prevention and
Management of Preterm Birth
According to the Malaysia National Neonatal Registry 2016, among preterm
babies, 23.3% were born below 32 weeks, and 25.5% were ≤1500g
birthweight.
The survival rates of babies born below 26 weeks were much lower as
compared to babies born between 28 to 32 weeks (<50% versus 80 to 90%).
77.3% of premature babies <32 weeks suffered at least one major morbidity.

6. 55.9% (1011/1809) of all deaths were in the prematurity group.
Most of the deaths were not preventable, 67.2% (679/1011).
Majority of the preventable deaths occurred in hospital setting.
Mainly occurred in infants with birth weight 1500g and less
(44.1%); and premature less than 28 weeks (54.5%).
66.9% death occurred in the first week of life, 24.1% were late
neonatal death and 9.0% died after 28 days of life until less than
1 year old.

7. Causes of death secondary to
prematurity was nosocomial
infection at 22.0% (73/332)
followed by respiratory distress
syndrome, 16.9% (56/332),
palliative comfort care group,
14.6% (48/332), and congenital
infection, 11.4% (38/332).
Majority of deaths in palliative
comfort care group occurred in
smaller babies 1000 grams and
less; and at extreme gestation of
less than 28 weeks.
T
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9.
The immediate cause of death secondary to prematurity was nosocomial infection at 22.0% (73/ 332)
ollowed by respiratory distress syndrome, 1
6.9% (56/ 332), palliative comfort care group, 1
4.6% (48/ 332),
nd congenital infection, 1
1
.4%(38/ 332). (Table 4.3)
* Palliative comfort care refers to “no active care” was given to the premature babies.
Figure 4.4: Preventable Deaths in Prematurity for Certain Conditions Originating in the
Perinatal Period, Malaysia, 2016
Overall Causes of Death in Prematurity
Causes of Death in Prematurity
Frequency
300
250
200
1
50
1
00
50
0
Causes of death prematurity
Nosocomial
infection
RDS
Palliative
Comfort
Care
Congenital
infection
Hypoxia
NEC
Others
Unknown
Severe
IVH
Preventable
Not preventable
Undetermined
73
25
1
0
56
1
40
1
9
48
1
88
1
4
38
53
1
2
26
24
7
23
1
4
4
1
8
43
6
24
50
1
9
26
46
5

8. Only 26.5% (88/332) antenatal mothers in the preventable death category
were documented to have received corticosteroid therapy, 7.3% (124/332)
did not have documentation.
Malaysian Neonatal Registry (NNR) 2016 reported 74.5% of mothers who
were less than 32 weeks’ gestation received antenatal corticosteroids.
Maternal medical and obstetric risk factors were found in more than half,
58.4% (429/735) in the preventable deaths group.

9. OUTLINE
DEFINITION
SCREENING
PREVENTION
TREATMENT

10. DEFINITION OF PRETERM BIRTH
Preterm birth is defined as a birth that occurs between 22
weeks and before completed 37 weeks of gestation.
It is further classified into:
a. Extremely preterm (<28 weeks);
b. Very preterm (28 to <32 weeks); and
c. Moderate to late preterm (32 to <37 weeks).

11. CLASSIFICATION
The focus of this guidelines is on
spontaneous preterm birth for
singleton pregnancies.
The management of medically-
indicated / iatrogenic preterm
birth and preterm birth related to
multiple pregnancies is beyond
the scope of this guideline.

12. RISK FACTORS
Previous
spontane
ous
preterm
birth
Short
cervix
(<25mm)
Previous
cervical
surgery/t
rauma
Smoking
during
pregnanc
y
Bacteriur
ia /
urinary
tract
infection
(UTI)
Genital
tract
infection
during
pregnanc
y
Low
body
mass
index
(BMI)
Teenage
pregnanc
y
Uterine
anomaly
Multiple
pregnanc
y

13. OBJECTIVE
a. General objective
◦ i. To establish a guideline which aims to reduce the rates of spontaneous preterm
birth.
b. Specific objectives
◦ i. To develop a screening procedure to identify pregnant women at risk of
preterm birth.
◦ ii. To ensure health care providers can recognize preterm labour to enable them
to commence appropriate management.
◦ iii. To guide the use of progesterone supplementation and cervical cerclage for
preventing preterm birth in singleton pregnancies.

14. Management
of Preterm
Labour
•A CLINICAL DIAGNOSIS:
• a. Regular uterine contractions of 2 in every 10 minutes
(Creasy and Herron criteria); and
• b. had a speculum or vaginal examination that reveals os
dilation and cervical effacement.
•IF UNCERTAIN, TESTS CAN BE OFFERED TO PREDICT THE
LIKELIHOOD OF PRETERM BIRTH WITHIN 48 HOURS
(CHOOSE ONLY ONE):
• a. Measuring cervical length by a transvaginal ultrasound
using the cut-off length of ≤15 mm for the diagnosis of
preterm labour; or
• b. Biomarker such as fetal fibronectin, placental alpha
microglobulin-1 and Phosphorylated insulin-like growth
factor-binding protein (IGFBP)-1 as predictor of preterm
delivery with a good negative predictive value of
between 89-97% for delivery within 7-14days.

15. INVESTIGATIONS
a. Vagino-
rectal swab.
b. MSU FEME
and C&S.
c.
Cardiotocogra
ph.
d. Ultrasound
assessment.
(Note: It’s
important to
exclude gross
fetal anomaly)

16. TOCOLYSIS
• May use if occurs between 24 weeks and 35 weeks 6 days of
pregnancy.
• It can delay delivery by 48 hours to allow the completion of a course
of antenatal corticosteroids and in-utero transfer.
Contraindications for tocolysis:
a. Antepartum haemorrhage.
b. Clinical features of infection.
c. Non-reassuring fetal heart rate.

17. TOCOLYTIC
AGENT
OPTIONS
Nifedipine
Maternal hypotension,
dizziness, tachycardia.
Oxytocin receptor
antagonists, such as
Atosiban
Nausea, side effects are
usually mild
Terbutaline
(Bricanyl).
Tachycardia,
hypotension,
hyperglycaemia,
pulmonary edema
Magnesium
sulphate
Flushing, respiratory
depression, cardiac
arrest
NOTE: May use S/C Terbutaline 0.25mg stat
for tocolysis to allow in-utero transfer from
district hospitals or periphery health clinics

18. ANTENATAL CORTICOSTEROIDS:
IM Dexamethasone 6mg 12-hourly for 4 doses; or 12mg 24-hourly for 2 doses* or 12mg 12-hourly x 2 doses**
•Give between 24 weeks and 35 weeks 6 days of
pregnancy who have preterm labour and/or PPROM.
•It’s associated with a reduction in neonatal death,
respiratory distress syndrome (RDS), intraventricular
haemorrhage, necrotising enterocolitis and the need
for mechanical ventilation.
•Perform blood sugar monitoring to anticipate steroids-
induced hyperglycaemia, and consider additional insulin
for diabetic mothers who receive antenatal
corticosteroids.
•A repeat course (rescue) of antenatal corticosteroids can
be given to:
a. Women who are ≤34 weeks 6 days of gestation with
an imminent risk of preterm delivery, if the initial
course was given more than seven (7) days.
b. The number of rescue corticosteroid courses
should be limited to a maximum of two (2).
Rescue antenatal corticosteroids improve the short-
term outcome by reducing the rate of RDS, the need
for surfactant and composite morbidity, though there
is no difference in long-term outcome
•There is a concern about the association of repeat
corticosteroids with a reduction of birth weight, length,
and head circumference, usually associated with a
higher number of repeated courses of corticosteroids.
•Thus, repeat antenatal corticosteroids should be used
with caution.
*Liggins Institute, 2015. Antenatal Corticosteroids Given to Women Prior to Birth tin Improve Fetal, Infant, Child and Adult Health. New Zealand and Australian Clinical Practice Guidelines 2015
**Sukarna N, et al 2021. Glycemic control following two regimens of antenatal corticosteroids in mild gestational diabetes: a RCT, Archieves of Gynecology and Obstetrics, 304, pages345–353

20. Study cohorts: GDM on MNT / diet control

21. •MgSO4 has a modest neuroprotective effect and is currently recommended for use in preterm
deliveries below 30 weeks of gestation or can be considered between 30 weeks and 33 weeks
6 days of gestation.
• If given to women at risk of preterm birth substantially reduced the risk of cerebral palsy and
the rate of substantial gross motor dysfunction in their child.
•The regimes of MgSO4 are:
a. Specialist hospitals: A 4g intravenous bolus over 15 minutes, followed by an intravenous
infusion of 1g per hour until the birth or for 24 hours (whichever is sooner).
b. District hospitals & peripheral health clinics: A 10g intramuscular bolus (5gm + 1 ml of
lignocaine 2% each buttock), followed by 5g + 1 ml of lignocaine 2% in alternate buttocks 4
hourly until the birth or for 24 hours (whichever is sooner).
MgSO4 FOR FETAL NEUROPROTECTION

22. •Monitor signs and symptoms of
MgSO4 toxicity (hourly respiratory
rate, urine output, deep patellar
tendon reflexes).
•Consider reducing the dose of
MgSO4 if the patient develops
oliguria or has renal impairment.
MgSO4 FOR FETAL NEUROPROTECTION

23. INTRAPARTUM ANTIBIOTICS
To start antibiotics if a patient progresses into preterm labour
regardless of the status of GBS (refer to local guidelines for
intrapartum antibiotics for GBS).

24. TAKE HOME MESSAGE
•Referral pathway from periphery health clinic to O&G Specialist Clinic by doing
thorough risk assessment.
•Screening tool include history taking, infection screening cervical length
measurement in high-risk pregnant women.
•Preventive measures include two important therapy : progesterone and/ or
cervical cerclage.
•Management of preterm labour include tocolysis, antenatal corticosteroids,
Magnesium sulphate for neuroprotection and intrapartum antibiotics.
•This guideline should offer auditable indicators to create an impactful health
program.

25. THANK YOU
Original presented by Dr. Nur Afidah Mat Yusof at National ToT, 30-31 Oct 2023
Edited by Dr. Emily Christine D’Silva & Dr. Carol Lim, December 2023