DR G MUNISWARAN,

MFM SPECIALIST , OBSTETRICIAN & GYNAECOLOGIST,

MBBS(UM), MOBGYN(UM), MRCOG(UK), MFM (MAL/UK)

MATERNITY HOSPITAL KUALA LUMPUR

Care Bundles:

Preterm labour

Declaration

No conflict of interest

Impact

An estimated 15 million babies are born prematurely yearly

Increase in incidence - 5% to 18% between countries.

Racial and ethnic inequalities

Deaths from preterm birth complications - leading cause of under-5

mortality The unfinished agenda of preterm

births

The Lancet 12 November 2016

Significance

Most common cause of hospital admissions

Significant neonatal morbidity

Burden of disease enormous - USD 51,000 per premature

infant

Level III

Goldenberg RL, Culhane JF, Iams JD, Romero R.

Epidemiology and causes of preterm birth. Lancet 2008

Prevention

Teenage pregnancy

Nutrition & well-being

Spacing

Improvedantenatal

care

Modificationsof risk factors

Tobacco & substance

misuse

Prevention

Cervical screening

ProgesteroneAsymptomatic

bacteuria

Rescue

Cerclage

Cervical pessary

Universal screening

Transvaginal cervical length screening 19–23 6/7 weeks

Length of significance 25mm

FIGO Best practice in maternal–fetal medicine☆ International

Journal of Gynecology and Obstetrics 128 (2015) 80–82

SMFM Consult

Practicality? Cost effectiveness in resource limited countries?

Universal screening in

Malaysia?

Urine C&S at booking ??

Inconclusive evidence from Cochrane…

Smaill FM. Cochrane database. 2015

Progesterones

Progesterones for women with preterm or shortened cervix

Phase III trials and meta-analysis

Dodd JM, Cochrane database 2013FIGO Best practice in maternal–fetal medicine☆ International

Journal of Gynecology and Obstetrics 128 (2015) 80–82

RCT – benefits yet to be proven

Progesterones

Cervix<25mm

Significant risk Cerclage

No significantrisk

Vaginalprogesterone

Preterm labour and birth NICE guideline Published: 20

November 2015 nice.org.uk/guidance/ng25

Rescue cerclage

Consider between 16+0 and 27+6 weeks of pregnancy with a dilated cervix

and unruptured fetal membranes

Preterm labour and birth NICE guideline Published: 20

November 2015 nice.org.uk/guidance/ng25

Cervical pessary

Care bundles

Diagnosis Tocolysis Corticosteroids

Fetal neuroprotection

PPROMMode of delivery

Diagnosis

Challenges

Less than 10% of women with clinical diagnosis deliver within 7days of

presentation

30% resolve spontaneously

50% of hospitalized patients delivery at term

Fuchs IB et al. Sonographic cervical length in singleton pregnancies with intact membranes

presenting with threatened preterm labor. Ultrasound Obstet Gynecol 2004;24:554–7.

Level II-3

Contractions but no cervical

change..

Only 18% delivered before 37weeks and within 2weeks

Iams JD, Romero R. Preterm birth. In: Gabbe SG, Niebyl JR, Simpson JL,

editors. Obstetrics: normal and problem pregnancies. 5th ed.

Philadelphia (PA): Churchill Livingstone Elsevier; 2007. p. 668–712.

Level III

Threatened preterm labour – care

bundle

History

Secondary test

Examination

Cervical length

15mm

Quantitative fetal fibronectin

<10 or > 200ng/ml

Care bundle

If pregnancy is beyond 30weeks, consider performing cervical

length.

No interventions if cervix > 15mm

Preterm labour and birth NICE guideline Published: 20

November 2015 nice.org.uk/guidance/ng25

Additional test?

Fetal fibronection - Quantitative & qualitative

Ness A et l. Does knowledge of cervical length and fetal

fibronectin affect management of women with threatened

preterm labor? A randomized trial. Am J Obstet Gynecol

2007;197:426.e1–7.

Level II-2

Quantitative fetal

fibronection

American Journal of Obstetrics & Gynecology FEB 2013

ACOG 2015 May;125(5):1168-76.

Tocolysis

Optimal patients for

intervention

Delay in delivery by 48 hours will be beneficial

Common drugs for

tocolysis

Tocolysis

Nidefipine – 1st line ( off license use)

Atosiban – less maternal side effects

Not more superior than nifedipine or betamimetics

Vicki Flenady. Cochrane Database. 2014

Progesterones for acute

tocolysis

No evidence of benefits

Lin-Lin Su. Cochrane Database. 2014

Corticosteroids

Corticosteroids

Single course - 24-34 weeks

Most efficacious 2-7days of delivery

Reduction in neonatal death, RDS, IVH, NEC & need for

mechanical ventilation

Number needed to treat increases after 34weeks

Devender Roberts. Cochrane Database March 2017

Corticosteroids dosage

Bethamethasone

IM 12mg OD x 2days

Dexamethasone

IM 6mg QID x 2 days

No benefits of “accelerated dosing” or repeat doses

ACOG. 2016

Cochrane database. 2013.

BMJ 2016;355:i5044 | doi: 10.1136/bmj.i5044

Lee et al.NICHD. Pediatrics 2008;121:289–96

Rescue dose

Repeat IM 12mg if given 14days later from initial dose

Reduction in RDS, need for surfactant and composite morbidity

No difference in long term outcomes

Garite TJ, Obstetrix Collaborative Research Network

Am J Obstet Gynecol 2009;200:248.e1–9

2015 Crowther Cochrane meta-analysis

Fetal

neuroprotection

Magnesium sulphate for fetal

neuroprotection

Up till 31 weeks plus 6 days

Continue tocolysis despite on magnesium sulphate

Dose 4g IV over 30minutes & 1g/hour

Minimum duration – 4 hours

Discontinue after 24 hours

Insufficient evidence for repeat doses

Nguyen T-MN. Cochrane database 2013.

SOGC 2011

PPROM

PPROM

Most sensitive diagnosis – per speculum examination

if pooling of amniotic fluid is not observed, consider performing an

insulin-like growth factor binding protein-1 test or placental alpha-

microglobulin-1 test of vaginal fluid.

Antibiotics

Do not rely on single test of CRP or raised WBC to make a decision

Mode of

delivery

Mode of delivery for preterm singletons

Caesarean section conferred no benefits in singleton

pregnancies

Breech – individualized management

Avoid ventouse < 34weeks

Zarko Alfirevic. Cochrane Database. 2013

Not recommended

Prophylactic &Repeat steroids

Antibiotics for intact

membranes

Prolonged tocolysis

Non pharmacological

measures

Future

PAMG – 1 – placental alpha microglubilin 1 (Partosure)

Vyacheslav Bolotskikh J. Obstet. Gynaecol. Res. 2017

ACOG 2014. DOI: http://dx.doi.org/10.1016/j.ajog.2014.10.174J Perinatal Med. 2014 Jul;42(4):473-7. doi: 10.1515/jpm-2013-0234.

Care bundle for preterm

labour

IM 6mg Dexa 6 hourly x 2 days if delivery within 7

days

MgSo4

before 32 weeks

( 4 hours)

Delay delivery for 48 hours (nifedipine)

Use cervical length or

quantitative fibronectin

Progesterones & cerclage has a

role in preventionEES for PPROM

17th November

References

ACOG practice bulletin. Number 171, October 2016

Cochrane database 2013

FIGO Best practice in maternal–fetal medicine☆ International Journal of Gynecology and Obstetrics 128 (2015) 80–82

Preterm labour and birth NICE guideline Published: 20 November 2015 nice.org.uk/guidance/ng25

THANK

YOU