Preterm Eylem: Klinik Bulgular, Tanısal Değerlendirme ve İlk Tedavi
Özet
Preterm doğum (PTD), global ölçekte maternal-fetal sağlığı tehdit eden en ciddi obstetrik komplikasyonlardan biridir. Dünya Sağlık Örgütü (WHO)’ne göre her yıl yaklaşık 15 milyon bebek preterm doğmakta olup bu sayı tüm canlı doğumların %11’inden fazlasını oluşturmaktadır. Neonatal mortalitenin birincil nedeni olan PTD, uzun vadeli morbidite, yaşam kalitesinde düşüş ve önemli ekonomik yüklerle ilişkilidir. Bu doğumların yaklaşık 1 milyonu neonatal dönemde yaşamını yitirmekte, sağ kalanların önemli bir kısmı ise ileri yaşlara kadar devam eden medikal ve nörogelişimsel sorunlar yaşamaktadır. Prematüriteye bağlı komplikasyonlar; respiratuvar distres sendromu (RDS), bronkopulmoner displazi (BPD), intraventriküler hemoraji (IVH), nekrotizan enterokolit (NEC) ve periventriküler lökomalazi (PVL) gibi patolojileri içermektedir. Uzun dönem etkiler arasında serebral palsi, duyusal bozukluklar, kognitif gecikme ve okul başarısızlığı öne çıkmaktadır. Preterm doğumun etyopatogenezi multifaktöriyel olup; intrauterin enfeksiyonlar, servikal yetmezlik, uterin distansiyon, plasental disfonksiyon, kısa intergebelik aralığı, yardımcı üreme teknikleri ve olumsuz yaşam tarzı faktörleri belirleyicidir. Klinik tanıda transvajinal ultrasonografi ile servikal uzunluk ölçümü ve fetal fibronektin testi önemlidir. Tedavide amaç doğumu kısa süreliğine ertelemek, fetal maturasyonu desteklemek ve uygun merkeze transfer sağlamaktır. Tokolitik ajanlar, antenatal kortikosteroidler, magnezyum sülfat, antibiyotikler ve progesteron başlıca tedavi yaklaşımlarıdır.
Referanslar
Blencowe H, Cousens S, Oestergaard MZ, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet. 2012;379(9832):2162–2172.
Goldenberg RL, Culhane JF, Iams JD, et al. Epidemiology and causes of preterm birth. Lancet. 2008;371(9606):75–84.
Liu L, Oza S, Hogan D, et al. Global, regional, and national causes of child mortality in 2000–13. Lancet. 2015;385(9966):430–440.
Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet. 2008;371(9608):261–269.
Behrman RE, Butler AS. Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: National Academies Press; 2007.
American College of Obstetricians and Gynecologists. Practice Bulletin No. 171: Management of Preterm Labor. Obstet Gynecol. 2016;128(4):e155–e164.
Romero R, Dey SK, Fisher SJ. Preterm labor: one syndrome, many causes. Science. 2014;345(6198):760–765.
Cervical insufficiency and short cervix. UpToDate. https://www.uptodate.com. Accessed June 2025.
Kovács K, et al. Association between human papillomavirus and preterm delivery: A systematic review. Acta Obstet Gynecol Scand. 2024;103(4):456–463.
Karimi A, Sayehmiri K, Vaismoradi M, et al. Vaginal bleeding in pregnancy and adverse clinical outcomes: a systematic review and meta-analysis. J Obstet Gynaecol. 2024;44(1):2288224.
Nachum Z, et al. Vaginal progesterone for pregnancy prolongation after arrested preterm labor. JAMA Netw Open. 2024;7(7):e2419894.
Norman JE, Shennan AH. Prevention of preterm birth — practice and perspectives. N Engl J Med. 2023;389(8):701–710.
Cobo T, et al. Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomized controlled trial. Lancet. 2012;379(9828):1800–1806.
Conde-Agudelo A, Romero R. Progesterone for the prevention of preterm birth in women with a short cervix. Am J Obstet Gynecol. 2016;214(1):40–59.
Lisonkova S, Hutcheon JA, Joseph KS. Temporal trends in spontaneous and iatrogenic preterm birth in the United States, 2004–2013. Obstet Gynecol. 2016;128(2):241–249.
Romero R, Espinoza J, Kusanovic JP, et al. The preterm parturition syndrome. BJOG. 2006;113(Suppl 3):17–42.
Iams JD, Goldenberg RL, Meis PJ, et al. The length of the cervix and the risk of spontaneous premature delivery. N Engl J Med. 1996;334(9):567–572.
Honest H, Bachmann LM, Gupta JK, et al. Accuracy of cervicovaginal fetal fibronectin test in predicting risk of spontaneous preterm birth. BMJ. 2002;325(7359):301.
Romo A, Carceller R, Tobajas J. Intrauterine growth retardation (IUGR): epidemiology and etiology. Pediatr Endocrinol Rev. 2009;6(Suppl 3):332–336.
Menon R, Fortunato SJ. Infection and the role of inflammation in preterm premature rupture of the membranes. Best Pract Res Clin Obstet Gynaecol. 2007;21(3):467–478.
Hassan SS, Romero R, Hendler I, et al. A sonographic short cervix as the only clinical manifestation of intra-amniotic infection. J Perinat Med. 2006;34(1):13–19.
Spong CY. Prediction and prevention of recurrent spontaneous preterm birth. Obstet Gynecol. 2007;110(2 Pt 1):405–415.
Keirse MJ. Uterine activity and the onset of labor. In: Studd J (ed.) Progress in Obstetrics and Gynaecology. Edinburgh: Churchill Livingstone; 1983. p. 205–222.
Leitich H, Brunbauer M, Kaider A, et al. Cervical length and dilatation of the internal cervical os detected by vaginal ultrasonography as markers for preterm delivery. Ultrasound Obstet Gynecol. 1999;13(2):114–117.
O'Brien JM, Adair CD, Lewis DF, et al. Progesterone vaginal gel for the reduction of recurrent preterm birth. Am J Obstet Gynecol. 2007;197(4):366.e1–366.e6.
Berghella V, Odibo AO, To MS, et al. Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data. Obstet Gynecol. 2005;106(1):181–189.
Norman JE, Shennan AH, Bennett PR, et al. Trial of progesterone to prevent spontaneous preterm birth in twin pregnancy. N Engl J Med. 2022;387(20):1854–1865.
Alfirevic Z, Stampalija T, Medley N. Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy. Cochrane Database Syst Rev. 2017;6:CD008991.
Goya M, Pratcorona L, Merced C, et al. Cervical pessary in pregnant women with a short cervix. Lancet. 2012;379(9828):1800–1806.
Norman JE, Marlow N, Messow CM, et al. Vaginal progesterone prophylaxis for preterm birth (OPPTIMUM study). Lancet. 2016;387(10033):2106–2116.
Ciavattini A, Delli Carpini G, Marinelli T, et al. Cervical length screening as a part of routine obstetric evaluation. Am J Obstet Gynecol. 2021;224(2):138–149.
Shennan A, Brewin J, Martin J, et al. The UK Preterm Clinical Network consensus statement. BJOG. 2020;127(3):284–288.
WHO. Born Too Soon: The Global Action Report on Preterm Birth. Geneva: World Health Organization; 2012.
Esplin MS, Elovitz MA, Iams JD, et al. Predictive accuracy of serial cervical lengths and fFN levels. Am J Obstet Gynecol. 2017;216(5):e1–e13.
Arias F, Daftary SN, Bhide AG. Practical Guide to High-Risk Pregnancy and Delivery. 4th ed. New Delhi: Elsevier; 2015.
March of Dimes, PMNCH, Save the Children, WHO. Born Too Soon. Geneva: WHO; 2012.
Barros FC, Bhutta ZA, Batra M, et al. Global report on preterm birth and stillbirth. BMC Pregnancy Childbirth. 2010;10(Suppl 1):S1.
Elovitz MA, Gajer P, Riis V, et al. Cervicovaginal microbiota and local immune response modulate the risk. Nat Commun. 2019;10(1):1305.
Reddy UM, Laughon SK, Sun L, et al. Preterm birth reduction through education and lifestyle interventions. Am J Obstet Gynecol. 2015;213(3):345.e1–345.e8.
Gyamfi-Bannerman C, Thom EA, Blackwell SC, et al. Antenatal betamethasone for late preterm delivery. N Engl J Med. 2016;374(14):1311–1320.
Chawanpaiboon S, Vogel JP, Moller AB, et al. Preterm birth levels in 2014: global estimates. Lancet Glob Health. 2019;7(1):e37–e46.
Eschenbach DA. Treating spontaneous preterm labor. N Engl J Med. 2005;352(6):593–595.
Papageorghiou AT, Ohuma EO, Gravett MG, et al. International standards for fundal height. Lancet. 2018;392(10159):1619–1629.
Liggins GC, Howie RN. A controlled trial of antepartum glucocorticoid. Pediatrics. 1972;50(4):515–525.
Miller J, Turan S, Baschat AA, et al. Fetal assessment in preterm labor: Doppler and ultrasound. Prenat Diagn. 2013;33(10):912–919.
Rouse DJ, Owen J, Goldenberg RL, et al. Vaginal fetal fibronectin testing. Obstet Gynecol. 1999;93(3):439–444.
Ethun CG, Johnson J, Grant J. Socioeconomic determinants of preterm birth. J Matern Fetal Neonatal Med. 2017;30(17):2094–2098.
Keelan JA, Blumenstein M, Helliwell RJ, et al. Cytokines, prostaglandins and parturition. Reproduction. 2003;125(4):425–435.
Dodd JM, Flenady V, Cincotta R, et al. Progesterone for preventing preterm birth. Cochrane Database Syst Rev. 2006;1:CD004947.
Simhan HN, Canavan TP. Preterm premature rupture of membranes: diagnosis and management. Lancet. 2005;366(9484):687–697.
Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 26th ed. New York: McGraw-Hill; 2022.
Roberts D, Brown J, Medley N, et al. Antenatal corticosteroids for fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev. 2017;3:CD004454.
Villar J, Papageorghiou AT, Knight HE, et al. The preterm birth syndrome: a prototype phenotypic classification. Am J Obstet Gynecol. 2012;206(2):119–123.
Yost NP, Cox SM. Infection and preterm labor. Clin Obstet Gynecol. 2000;43(4):759–767.
Daskalakis G, Papantoniou N, Mesogitis S, et al. Management of preterm labor. Arch Gynecol Obstet. 2003;268(3):179–185.
Vincenzo B, Luigi D, Stefania T, et al. Cervical funneling and risk of preterm delivery. Eur J Obstet Gynecol Reprod Biol. 2006;129(2):125–129.
Garite TJ, Freeman RK, Linzey EM, et al. Management of threatened preterm labor: current concepts. Clin Perinatol. 1995;22(4):843–857.
Parry S, Strauss JF. Premature rupture of the fetal membranes. N Engl J Med. 1998;338(10):663–670.
Hauth JC, Goldenberg RL, Andrews WW, et al. The effect of bacterial vaginosis on preterm birth. Am J Obstet Gynecol. 1995;173(4):1231–1235.
Sheehan HL, Lynch JB. Pathology of the Placenta. Edinburgh: Churchill Livingstone; 1973.
Mercer BM, Goldenberg RL, Meis PJ, et al. The NICHD MFMU network randomized clinical trial of antibiotics for PPROM. Am J Obstet Gynecol. 1997;177(3):587–595.
Yamasmit W, Chaithongwongwatthana S. Erythromycin for prolongation of pregnancy after PPROM. Cochrane Database Syst Rev. 2012;11:CD001058.
Cnattingius S, Reilly M. Short interpregnancy interval and preterm birth. BMJ. 2008;337:a1994.
DeFranco EA, Newman RB, Muglia LJ, et al. A short interpregnancy interval increases the risk for preterm birth. Am J Obstet Gynecol. 2007;197(3):257.e1–257.e6.
Lo JO, Shaffer BL, Allen AJ, et al. Effect of magnesium sulfate on maternal outcomes in preeclampsia. BJOG. 2014;121(8):904–910.
National Institute for Health and Care Excellence (NICE). Preterm labour and birth. Clinical guideline [NG25]. London: NICE; 2015.
Kashanian M, Baradaran H, Shabandoust S. Comparison between vaginal progesterone and cervical pessary for preventing preterm birth. J Obstet Gynaecol Res. 2015;41(3):428–433.
Tita AT, Andrews WW. Diagnosis and management of clinical chorioamnionitis. Clin Perinatol. 2010;37(2):339–354.
Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network. Preterm Birth Research. Bethesda: NIH; 2020.
Barros FC, Bhutta ZA, Batra M, et al. Global report on preterm birth and stillbirth: the imperative to address this global crisis. BMC Pregnancy Childbirth. 2010;10(Suppl 1):S1.
