Preterm Labor and Delivery

Preterm Labor and Preterm Labor and DeliveryDelivery

StatisticsStatistics 12.8% of all deliveries in the U.S. in 200612.8% of all deliveries in the U.S. in 2006

These preemies comprise 80% of all These preemies comprise 80% of all perinatal deaths in the U.S.perinatal deaths in the U.S.

Preterm birth is the leading cause of Preterm birth is the leading cause of infant mortality in Ohio.infant mortality in Ohio.

    Among states, we rank 35th in infant Among states, we rank 35th in infant mortality and 31st in prematuritymortality and 31st in prematurity

Economic ImpactEconomic Impact

Average hospital cost for a 25 weeker to Average hospital cost for a 25 weeker to discharge is $203,000discharge is $203,000

32 weeks almost $19,000. more than 38 32 weeks almost $19,000. more than 38 weeksweeks

Even at 36 weeks there is an increased Even at 36 weeks there is an increased cost of $1700 more than delivery at 37 cost of $1700 more than delivery at 37 weeksweeks

Ethnic disparitiesEthnic disparities

17.9% of all black births17.9% of all black births 13.7 of all Native American Indian13.7 of all Native American Indian

CausesCauses

Cause remains greatly unknownCause remains greatly unknown

What we know and what we What we know and what we don’t knowdon’t know

Theories Theories

There is compelling evidence to There is compelling evidence to support four major pathways:support four major pathways:

StressStress Placental abruptionPlacental abruption Infection Infection Uterine distensionUterine distension

Further study needed to Further study needed to determine significance determine significance of:of:

Link to poor dental healthLink to poor dental health Link to intention of pregnancyLink to intention of pregnancy Link to racial discrimination and Link to racial discrimination and

associated stressassociated stress

Epidemiologic ApproachEpidemiologic Approach

Based on placental histology and Based on placental histology and placental microbiologyplacental microbiology

Disorders leading to preterm delivery Disorders leading to preterm delivery can be separated into 2 groups:can be separated into 2 groups:

Epidemiologic ApproachEpidemiologic Approach

1.1. Those associated with intrauterine Those associated with intrauterine inflammation, Chorioamnionitis, inflammation, Chorioamnionitis, placental microbe recoveryplacental microbe recovery

PROMPROM Placental abruptionPlacental abruption Cervical insufficiencyCervical insufficiency Preterm laborPreterm labor

Epidemiologic ApproachEpidemiologic Approach

2.2. Those associated with aberrations of Those associated with aberrations of placentationplacentation

PreeclampsiaPreeclampsia Intrauterine growth restrictionIntrauterine growth restriction

Mcelrath, et al (2008) Pregnancy disorders that lead to delivery before the 28Mcelrath, et al (2008) Pregnancy disorders that lead to delivery before the 28 thth week of week of gestation: An epidemiologic approach to classification. gestation: An epidemiologic approach to classification. American Journal of American Journal of Epidemiology. 168 (9) Epidemiology. 168 (9)

Risk FactorsRisk Factors

History of previous preterm delivery is the History of previous preterm delivery is the #1 risk factor.#1 risk factor.

Previous cervical procedures: cone Previous cervical procedures: cone biopsy and LEEPbiopsy and LEEP

Uterine anomaliesUterine anomalies Multiple gestationMultiple gestation Urinary tract infectionsUrinary tract infections Pregnancy with the past 12 monthsPregnancy with the past 12 months

The Preterm Prediction The Preterm Prediction StudyStudy

Positive Fetal fibronectin and short Positive Fetal fibronectin and short cervical length are good indicators for cervical length are good indicators for predicting preterm deliverypredicting preterm delivery

Newman, Goldenberg, Iams, et al (2008) Preterm prediction study: Comparison of the Cervical Newman, Goldenberg, Iams, et al (2008) Preterm prediction study: Comparison of the Cervical score and Bishop score for prediction of spontaneous preterm delivery. score and Bishop score for prediction of spontaneous preterm delivery. Obstetrics & Obstetrics & Gynecology.Gynecology. 112 (3), 508-515. 112 (3), 508-515.

Bio-Chemical predictorsBio-Chemical predictors

Fetal Fibronectin is a glycoproteinFetal Fibronectin is a glycoprotein Should not be detectable between 22-35 Should not be detectable between 22-35

weeks gestationweeks gestation

Negative Fetal Negative Fetal FibronectinFibronectin

Negative Ffn results are most usefulNegative Ffn results are most useful 99.2% negative predictive value99.2% negative predictive value Highly unlikely that preterm labor will Highly unlikely that preterm labor will

occur within 14 days.occur within 14 days.

Positive Fetal FibronectinPositive Fetal Fibronectin

Positive predictive value: not so goodPositive predictive value: not so good Only 65% with positive Ffn will have a Only 65% with positive Ffn will have a

preterm deliverypreterm delivery

Collecting Ffn specimen Collecting Ffn specimen

For Accurate Patient ResultsFor Accurate Patient Results For accurate patient results, please ensure that For accurate patient results, please ensure that

you follow these specimen collection instructions.you follow these specimen collection instructions. The specimen should be collected prior to a The specimen should be collected prior to a

digital cervical exam, collection of culture digital cervical exam, collection of culture specimens, or vaginal probe ultrasound exams. specimens, or vaginal probe ultrasound exams.

Do not contaminate the swab or specimen with Do not contaminate the swab or specimen with lubricants, soaps, disinfectants, or creams. lubricants, soaps, disinfectants, or creams.

Do not collect specimen if patients have had Do not collect specimen if patients have had sexual intercourse within 24 hours prior to sexual intercourse within 24 hours prior to sampling; moderate or gross vaginal bleeding; sampling; moderate or gross vaginal bleeding; advanced cervical dilation (3 cm or greater); advanced cervical dilation (3 cm or greater); rupture of membranes; gestational age <22 rupture of membranes; gestational age <22 weeks or >35 weeks; or suspected or known weeks or >35 weeks; or suspected or known placental abruption or placenta previa.placental abruption or placenta previa.

Biophysical PredictorsBiophysical Predictors

Cervical length less than 20 mm per Cervical length less than 20 mm per transvaginal ultrasoundtransvaginal ultrasound

Cervical score less than 1.5 per digital Cervical score less than 1.5 per digital cervical examcervical exam

Cervical score = Cervical length (cm) Cervical score = Cervical length (cm) minus Cervical Dilation (cm) at the minus Cervical Dilation (cm) at the internal osinternal os

Cervical scoreCervical score

Uses digital cervical examination for Uses digital cervical examination for measurementmeasurement

Eliminates cost and logistical difficulties Eliminates cost and logistical difficulties of serial transvaginal ultrasoundof serial transvaginal ultrasound

ACOG DiagnosisACOG Diagnosis

Regular contractions that occur before 37 Regular contractions that occur before 37 weeks gestation and are associated with weeks gestation and are associated with changes in the cervix.changes in the cervix.

(No proven cause/effect)(No proven cause/effect)

How to manageHow to manage HydrationHydration Bed restBed rest

Little evidence to demonstrate Little evidence to demonstrate effectivenesseffectiveness

Pharmacologic Pharmacologic managementmanagement

Tocolytics have failed to demonstrate Tocolytics have failed to demonstrate effectiveness in preventing preterm laboreffectiveness in preventing preterm labor

Some delay delivery for 48 hours Some delay delivery for 48 hours Buying steroid timeBuying steroid time

Beta-adrenergicsBeta-adrenergics- - terbutaline and ritodrineterbutaline and ritodrine

Beta-adrenergicsBeta-adrenergics- - terbutaline and ritodrineterbutaline and ritodrine Stimulate beta2-adrenergic receptors relaxing Stimulate beta2-adrenergic receptors relaxing

smooth musclesmooth muscle Not shown to reduce preterm birthNot shown to reduce preterm birth Substantial maternal adverse effects: Substantial maternal adverse effects:

bronchospasm, HTN, arrhythmias, pulmonary bronchospasm, HTN, arrhythmias, pulmonary edema, hyperglycemia, seizuresedema, hyperglycemia, seizures

Neonatal effects: fetal tachycardia, neonatal Neonatal effects: fetal tachycardia, neonatal hypoglycemia (reactive)hypoglycemia (reactive)

Calcium Channel blockers- Calcium Channel blockers- NifedipineNifedipine

Calcium Channel blockers- NifedipineCalcium Channel blockers- Nifedipine Inhibits Calcium ion influx into smooth Inhibits Calcium ion influx into smooth

muscle: muscle: Demonstrates effectiveness in delaying Demonstrates effectiveness in delaying

deliverydelivery Does not prevent preterm deliveryDoes not prevent preterm delivery Adverse reactions: CHF, pulmonary edema, Adverse reactions: CHF, pulmonary edema,

arrhythmia, severe hypotensionarrhythmia, severe hypotension Common S/E: headache, dizziness, Common S/E: headache, dizziness,

flushing, fatigue, weakness, transient flushing, fatigue, weakness, transient hypotensionhypotension

Prostaglandin Prostaglandin antagonists- Indocinantagonists- Indocin

Prostaglandin antagonists- IndocinProstaglandin antagonists- Indocin NSAID: exact action unknown, but NSAID: exact action unknown, but

reduces prostaglandin synthesisreduces prostaglandin synthesis Second line drug in pregnancy less than Second line drug in pregnancy less than

32 weeks.32 weeks. May increase risk of serious and May increase risk of serious and

potentially fatal CV thrombotic eventspotentially fatal CV thrombotic events Serious GI events including bleedingSerious GI events including bleeding

Indocin- fetal adverse Indocin- fetal adverse side effectsside effects

Contraindicated after 32 weeksContraindicated after 32 weeks Can cause premature closure of the Can cause premature closure of the

ductus arteriosis in the fetusductus arteriosis in the fetus Increase risk of necrotizing enterocolitis Increase risk of necrotizing enterocolitis

in the premature neonatein the premature neonate Increase risk of Periventricular Increase risk of Periventricular

leukomalacia (form of brain injury that leukomalacia (form of brain injury that can lead to CP)can lead to CP)

Magnesium SulfateMagnesium Sulfate

CNS depressantCNS depressant Serious reactions: cardiovascular collapse, Serious reactions: cardiovascular collapse,

respiratory paralysis, hypothermia, depressed respiratory paralysis, hypothermia, depressed cardiac function and pulmonary edemacardiac function and pulmonary edema

Common S/E: depressed DTR, hypotension, Common S/E: depressed DTR, hypotension, flushing, drowsiness, visual changesflushing, drowsiness, visual changes

*Important to maintain urinary output to prevent *Important to maintain urinary output to prevent toxicitytoxicity

Little evidence exist to support its use as a Little evidence exist to support its use as a tocolytictocolytic

Magnesium sulfate may Magnesium sulfate may decrease risk of IVH decrease risk of IVH

Preliminary studies suggests antepartum Preliminary studies suggests antepartum administration of Magnesium sulfate may administration of Magnesium sulfate may have a neuroprotective effect on have a neuroprotective effect on premature neonates.premature neonates.

Decreasing the number and severity of Decreasing the number and severity of intraventricular hemorrhage in preterm intraventricular hemorrhage in preterm neonates and thereby reducing CPneonates and thereby reducing CP

Further research neededFurther research needed

When is tocolysis When is tocolysis contraindicated?contraindicated?

Presence of infection- chorioamnionitis Presence of infection- chorioamnionitis Suspected placental abruptionSuspected placental abruption Pregnancy Induced HypertensionPregnancy Induced Hypertension

AntibioticsAntibiotics

May be indicated in PTL to treat infection May be indicated in PTL to treat infection as a causative factor.as a causative factor.

BacteruriaBacteruria PROMPROM

* Should not use tocolytics in the * Should not use tocolytics in the presence of infectionpresence of infection

Management GoalsManagement Goals

Focus is on early identification and Focus is on early identification and preventionprevention

Administration of corticosteroids to Administration of corticosteroids to enhance fetal lung maturityenhance fetal lung maturity

And delivery in a site capable of caring And delivery in a site capable of caring for the special needs of the premature for the special needs of the premature neonateneonate

Fetal Lung MaturityFetal Lung Maturity

CorticosteroidsCorticosteroids Typically Betamethasone 12 mg IM dose Typically Betamethasone 12 mg IM dose

x 2. x 2. 12 mg then repeat in 24 hours12 mg then repeat in 24 hours Make sure neonatal knows: dates Make sure neonatal knows: dates

importantimportant

PreventionPrevention

17 P Alpha Hydroxy-Progesterone Caproate17 P Alpha Hydroxy-Progesterone Caproate

There is sufficient evidence to support the There is sufficient evidence to support the administration of progesterone 17 P (injectable administration of progesterone 17 P (injectable form) women with singleton pregnancy and:form) women with singleton pregnancy and:

a history of preterm birth (< 37 weeks) due to a history of preterm birth (< 37 weeks) due to spontaneous onset of labor or SROMspontaneous onset of labor or SROM

Women with short cervixWomen with short cervix

17 P17 P

Weekly injections start between 16-20 Weekly injections start between 16-20 weeks and continue until 37 weeks.weeks and continue until 37 weeks.

Reduced the risk of recurrent preterm Reduced the risk of recurrent preterm birth by as much as 33% over the control birth by as much as 33% over the control groupgroup

(March of Dimes)(March of Dimes)

Ongoing studies underway with regards Ongoing studies underway with regards to multiple gestations and progesterone to multiple gestations and progesterone vaginal cream vaginal cream

PreventionPrevention

Education:Education: Information about Information about pre-maturity, signs/symptoms, pre-maturity, signs/symptoms, fetal development, hydration, fetal development, hydration, public awarenesspublic awareness

Warning SignsWarning Signs More than 6 UC’s per hourMore than 6 UC’s per hour Tightening or “balling up” of abdomen Tightening or “balling up” of abdomen

(Avoid terminology like “Braxton-Hicks”)(Avoid terminology like “Braxton-Hicks”) Menstrual-like crampsMenstrual-like cramps Back-painBack-pain Pelvic pressurePelvic pressure Intestinal cramps, gas pains, fluIntestinal cramps, gas pains, flu Increase or change in vaginal dischargeIncrease or change in vaginal discharge General feeling that something is not General feeling that something is not

rightright

PreventionPrevention

Preconception health:Preconception health: smoking smoking cessation #1, substance abuse, cessation #1, substance abuse, nutrition, folic acid, managing nutrition, folic acid, managing chronic illness ie: Diabetes, HTN, chronic illness ie: Diabetes, HTN, obesity, asthmaobesity, asthma

Health Promotion while Health Promotion while pregnantpregnant

Good nutritionGood nutrition Prenatal vitamins-folic acid Prenatal vitamins-folic acid Adequate weight gainAdequate weight gain ExerciseExercise Decreasing stressDecreasing stress Avoid occupational exposuresAvoid occupational exposures Treatment for sub-clinical infectionsTreatment for sub-clinical infections

PreventionPrevention

Stress the importance of regular Stress the importance of regular prenatal visitsprenatal visits

Refer to appropriate provider and Refer to appropriate provider and regional perinatal center based regional perinatal center based on risk of preterm birthon risk of preterm birth

PreventionPrevention

Stress reduction:Stress reduction: coping skills, social coping skills, social networking, case management, referral networking, case management, referral services (nutrition, counseling, housing services (nutrition, counseling, housing issues)issues)

Psychological support:Psychological support: nurse/patient nurse/patient relationship, group work, home visits, relationship, group work, home visits, telephone counselingtelephone counseling

Iatrogenic prematurityIatrogenic prematurity

Iatrogenic disorder-Iatrogenic disorder- An abnormal An abnormal mental or physical condition induced mental or physical condition induced in a patient by effects of treatment by in a patient by effects of treatment by a physician or surgeon. Term implies a physician or surgeon. Term implies that such effects could have been that such effects could have been avoided by proper and judicious care avoided by proper and judicious care on the part of the physician.on the part of the physician.

Timing of elective Timing of elective deliverydelivery

Late pretermLate preterm ( 34 0/7- 36 6/7 ( 34 0/7- 36 6/7 weeks gestation)weeks gestation)

Early termEarly term (37 0/7-38 6/7 weeks (37 0/7-38 6/7 weeks gestation)gestation)

Standards, Guidelines, Standards, Guidelines, and Recommendationsand Recommendations

Avoid elective induction of labor and Avoid elective induction of labor and elective cesarean birth before 39 weeks elective cesarean birth before 39 weeks of gestation (ACOG, 1999)of gestation (ACOG, 1999)

Assess fetal lung maturity if there is any Assess fetal lung maturity if there is any question of gestational age before 39 question of gestational age before 39 weeks of gestation prior to elective or weeks of gestation prior to elective or repeat cesarean birth (AAP & ACOG, repeat cesarean birth (AAP & ACOG, 2002)2002)

OPQC- Ohio Perinatal OPQC- Ohio Perinatal Quality CollaborativeQuality Collaborative

The mission of OPQC (Ohio Perinatal Quality The mission of OPQC (Ohio Perinatal Quality Collaborative) is to decrease preterm birth and Collaborative) is to decrease preterm birth and associated infant morbidities in the State of associated infant morbidities in the State of Ohio. The AIM this year is to reduce by 60% Ohio. The AIM this year is to reduce by 60% the number of women in Ohio of 36.0 to 38.6 the number of women in Ohio of 36.0 to 38.6 weeks gestation for whom initiation of labor or weeks gestation for whom initiation of labor or cesarean section is done in absence of cesarean section is done in absence of appropriate medical or obstetric indication. appropriate medical or obstetric indication.

Patient Education Patient Education resourcesresources

March of DimesMarch of Dimes AWHONNAWHONN

What about the post-What about the post-partum period?partum period?

Women treated with Women treated with bed restbed rest experienced experienced cardiopulmonary and musculoskeletal cardiopulmonary and musculoskeletal deconditioningdeconditioning

muscle atrophy, muscle soreness of back, legs muscle atrophy, muscle soreness of back, legs and kneesand knees

Shortness of breath on exertionShortness of breath on exertion Difficulties with gait, negotiating stairs, and Difficulties with gait, negotiating stairs, and

transferring to chairtransferring to chair DepressionDepression Financial difficulties (loss of income/insurance)Financial difficulties (loss of income/insurance)

Maternal complicationsMaternal complications

Breastfeeding problems/Enhance milk Breastfeeding problems/Enhance milk production/ early breast pumpproduction/ early breast pump

Interrupted process of bondingInterrupted process of bonding Stress/Anxiety/feeling hopelessStress/Anxiety/feeling hopeless Sequelae of extended bed restSequelae of extended bed rest Disruption of family unitDisruption of family unit Post-partum depressionPost-partum depression

Neonatal complicationsNeonatal complications

Respiratory issuesRespiratory issues

Difficulty coordinating suck and swallow Difficulty coordinating suck and swallow = breastfeeding problems= breastfeeding problems

Delayed bondingDelayed bonding

Neonatal complicationsNeonatal complications

Serious long-term disabilities including:Serious long-term disabilities including: Cerebral palsyCerebral palsy BlindnessBlindness DeafnessDeafness Other chronic medical, behavioral , and Other chronic medical, behavioral , and

cognitive problems well into school agecognitive problems well into school age

What can we do?What can we do?

Early breast pump and contact with Early breast pump and contact with Lactation consultantLactation consultant

Introduce and encourage skin-to-skin Introduce and encourage skin-to-skin (kangaroo care) when able(kangaroo care) when able

Educate, Educate, Educate!!Educate, Educate, Educate!!

BreastfeedingBreastfeeding

VON dataVON data Benefits of EBMBenefits of EBM Special needs for preemiesSpecial needs for preemies Do not hesitate to suggest EBM even if Do not hesitate to suggest EBM even if

mom was planning to bottle feedmom was planning to bottle feed