Certain pregnancy conditions, such as preeclampsia, multiple gestations, placenta previa, and others may necessitate an early delivery (1). When standards of care for the timing and management of early delivery are followed, a preterm birth can help prevent birth injuries and brain damage in the baby. An obstetrician must take a thorough history of the mother as soon as pregnancy is confirmed. If her history or a current condition makes the pregnancy high-risk, she should be referred to a maternal-fetal specialist and her prenatal testing should occur more frequently than normal.
On our page, The Importance of a Planned, Early Delivery for High-Risk Pregnancy, we discuss pregnancy complications that require an early delivery and at what gestational ages delivery should occur. In this article, we take a more in-depth look at maternal and obstetrical issues that are an indication for preterm delivery.
The importance of the womb, the placenta, and the umbilical cord
The fetus develops inside the womb (uterus) during pregnancy and is surrounded by amniotic fluid. The placenta, which is attached to the inside of the womb, helps bring oxygen and nutrients to the fetus from the mother and removes waste. Oxygen and nutrient-rich blood travels through vessels that run between the uterus and placenta, and this blood is delivered to the baby through the umbilical cord, which arises from the placenta. Conditions that affect the uterus, placenta, umbilical cord, and amniotic fluid can cause birth injuries that result in the baby having hypoxic ischemic encephalopathy (HIE), infection, sepsis, meningitis, brain damage, seizures, cerebral palsy, and other lifelong conditions.
Described below are some maternal issues that can affect the environment of the unborn baby and thus require early delivery.
Hypertension and preeclampsia
High blood pressure (hypertension) during pregnancy can prevent the placenta from getting enough blood, which means the baby will receive less oxygen and nutrients. Preeclampsia is a more severe form of hypertension, and Preeclampsia occurs when the mother has high blood pressure that has been diagnosed after 20 weeks of gestation along with dysfunction in some major organs (2).
High blood pressure and preeclampsia increase a baby’s risk of having the following conditions:
- Poor fetal growth
- Intrauterine (fetal) growth restriction (IUGR/FGR)
- Placental abruption
- Premature birth
Preeclampsia poses the additional risks of the mother having kidney failure, a hypertensive crisis, HELLP syndrome, and eclampsia (seizures) (2). These conditions are life-threatening for the baby.
The conditions caused by mismanaged hypertension and preeclampsia can result in the baby having birth injuries such as hypoxic-ischemic encephalopathy (HIE) and cerebral palsy. In order to prevent brain damage in the baby, certain circumstances require early delivery.
If long-term (chronic) maternal hypertension is not being treated with medication, delivery should occur by 38 – 39 weeks. If additional complicating issues are present, such as IUGR/FGR, preeclampsia, etc., an earlier delivery may be indicated.
Chronic maternal hypertension controlled with medication requires delivery by 37 – 39 weeks. If there are additional complicating issues, such as IUGR/FGR, preeclampsia, etc.,
delivery may need to occur at an earlier date.
Chronic maternal hypertension that is difficult to control (requires frequent medication adjustments) necessitates a delivery by 36 – 37 weeks. If additional complicating
issues exist, such as IUGR/FGR, preeclampsia, etc., an earlier delivery may be indicated.
Gestational hypertension (hypertension that begins during pregnancy) necessitates a delivery by 37 – 38 weeks.
Severe preeclampsia requires that delivery take place as soon as the mother is diagnosed, as long as the pregnancy is at 34 weeks or later. If additional complicating issues exist, such as IUGR/FGR, an earlier delivery may be indicated.
Mild preeclampsia means that the baby should be delivered by 37 weeks. If there are additional complicating issues, such as IUGR/FGR, delivery may need to occur at an earlier date.
Approximately 2– 5 % of pregnant women have gestational diabetes (3). Diabetes can cause numerous medical problems, including blood vessel problems, excessive glucose being carried to the baby, and a lack of oxygen in the baby’s brain (hypoxia). Complications associated with gestational diabetes & pregestational diabetes include the following:
- A large for gestational age (LGA) baby and macrosomia, which increases the baby’s risk of having forceps and vacuum extractors used during delivery, shoulder dystocia, brachial plexus injuries, Erb’s palsy and being non-vigorous at birth
- Fetal hypoxia
- Insufficient fetal growth
- Maternal hypertension
- Reduced uteroplacental perfusion (RUPP), which is a condition that decreases blood flow between the mother and fetus
- Preterm delivery (if mother is obese)
- Neonatal hypoglycemia
- Hyperbilirubinemia (prolonged jaundice)
- Respiratory distress
- Cardiomyopathy (baby has a large heart)
- Hypocalcemia, hypomagnesemia, polycythemia
In order to prevent the baby from having brain damage, early delivery is indicated in certain circumstances.
Early delivery for babies affected by pregestational and gestational diabetes
In the case of diabetes that the mother had prior to becoming pregnant (pregestational) that are well-controlled, late preterm birth or early term birth is not necessarily
recommended. However, if additional complicating issues exist, such as IUGR/FGR, preeclampsia, etc., an earlier delivery may be indicated.
Pregestational diabetes that is poorly controlled requires that delivery take place by 34 – 39 weeks, with specific timing individualized to the mother’s situation. If there are additional complicating issues, such as IUGR/FGR, preeclampsia, etc., an earlier delivery may be indicated.
In cases of gestational diabetes that are well-controlled with diet or medication, late preterm birth or early term birth may not be recommended. However, if additional complicating issues exist, such as IUGR/FGR, preeclampsia, etc., a delivery prior to term may be indicated.
Gestational diabetes that is poorly controlled on medication requires that delivery take place by 34 – 39 weeks, with specific timing individualized to the mother’s situation. If there are additional complicating issues, such as IUGR/FGR, preeclampsia, etc., an earlier delivery may be indicated.
Preterm labor and premature rupture of the membranes (PROM)
Premature rupture of the membranes (PROM) occurs when the amniotic sac ruptures (“water breaks”) before labor begins. Expectant management is when the mother and baby are closely monitored and delivery is allowed to occur “naturally.” The amniotic fluid serves as a protective layer for the baby, so the loss of amniotic fluid can put the baby at risk. An infection that travels to the baby when the membranes rupture can cause the baby to have sepsis, meningitis, HIE, and cerebral palsy. Chorioamnionitis (infection of the amniotic fluid and fetal membranes) and umbilical cord compression are very serious conditions associated with preterm labor and PROM (4). Umbilical cord compression can cause birth asphyxia, HIE and cerebral palsy.
Due to the potential for severe harm if the baby has a compressed cord or gets an infection, expectant management is typically not recommended when late-preterm labor or early-term PROM occur. Experts recommend that obstetricians promptly deliver babies when preterm PROM occurs at or after 34 weeks. Listed below are specific guidelines for preterm labor and PROM.
In cases where the mother had a previous spontaneous preterm birth and is currently experiencing preterm PROM,the baby can be delivered by a gestational age of 34 weeks or older. If there are additional complicating issues, such as IUGR/FGR, preeclampsia, etc., an earlier delivery may be indicated.
In cases when the mother had a previous spontaneous preterm birth and is currently experiencing active preterm labor, delivery is necessary if there is progressive labor or an additional maternal of fetal indication. If additional complicating issues exist, such as IUGR/FGR, preeclampsia, etc., an earlier delivery may be indicated.
The benefits of planned early delivery
When preterm birth is about to occur, obstetricians must make every effort to prevent associated problems, such as respiratory distress, sepsis, brain bleeds, and periventricular leukomalacia (PVL). When a baby is at or less than 34 weeks of gestation and the obstetrician is planning a preterm delivery, a steroid such as betamethasone should be given in-utero. Betamethasone has been shown to reduce the incidence and severity of respiratory distress syndrome (RDS), intraventricular hemorrhages (brain bleeds), sepsis, and PVL. Steroids such as betamethasone help the baby’s lungs and numerous tissues throughout the body mature.
Another in-utero medication that should be given when preterm birth is about to occur is called magnesium sulfate. This drug helps protect the baby’s brain. Premature babies are at an increased risk for brain injury and cerebral palsy, and magnesium sulfate reduces the risk of the baby having cerebral palsy and other major movement disabilities.
Magnesium sulfate has been suspected to protect the baby’s brain by the following mechanisms (5):
- It increases blood flow in the baby’s brain
- It reduces the damaging molecules that are released when a brain insult, such as birth asphyxia, causes brain inflammation
- It has antioxidant effects
- It reduces a process called neuronal excitability, which is damaging to the brain and occurs when the brain experiences an insult
- It stabilizes membranes in the brain
Magnesium sulfate is given approximately 24 hours before preterm delivery and it is administered when the baby is between 24 and 32 weeks of gestation. It can be given to women with preterm PROM, preterm labor with intact membranes, and indicated preterm delivery.
An early scheduled delivery can be crucial in preventing birth injuries such as HIE, brain damage, and cerebral palsy. Early delivery allows the baby to be delivered before an underlying condition worsens or causes secondary complications. In addition, planned deliveries enable in-utero drugs to be given and important medical treatments such as blood transfusions to be readily available. Planning can also be crucial in ensuring the presence of enough staff and medical equipment to properly care for the mother and baby.
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