Preterm BirthPreterm Labor Interventions Non-pharmacologic therapy of no proven benefit Bed rest,...

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Preterm BirthPreterm Birth

Kym Kym GohnGohn, DO, DO


Leading cause of neonatal mortality in Leading cause of neonatal mortality in

USUS

Accounts for 35% of all U.S. healthcare Accounts for 35% of all U.S. healthcare

spending for infantsspending for infants

Accounts for 10% U.S. healthcare Accounts for 10% U.S. healthcare

spending for all childrenspending for all children

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More than 500,000 live preterm births More than 500,000 live preterm births

annuallyannually

Births <37weeks and >20 weeksBirths <37weeks and >20 weeks

Responsible for 75% of neonatal Responsible for 75% of neonatal

mortalitymortality

Preterm births <32 weeks account for 1Preterm births <32 weeks account for 1--

2% of all deliveries2% of all deliveries


Despite numerous interventions, preterm birth Despite numerous interventions, preterm birth

rate has remained unchanged over the last 40 rate has remained unchanged over the last 40

yearsyears

Most preventative and therapeutic efforts are Most preventative and therapeutic efforts are

ineffectiveineffective

Preterm birth remains the single largest Preterm birth remains the single largest

challenge for obstetricians todaychallenge for obstetricians today

Importance of corticosteroids, GBS prophylaxis, Importance of corticosteroids, GBS prophylaxis,

atraumatic delivery, availability of NICUatraumatic delivery, availability of NICU

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Neonatal mortality rates have decreased in recent Neonatal mortality rates have decreased in recent yearsyears 2020--30% survival at 2230% survival at 22--23 weeks23 weeks

50% survival at 2450% survival at 24--25 weeks25 weeks

90% survival at 2890% survival at 28--29 weeks29 weeks

Short term morbiditiesShort term morbidities RDS, IVH, PVL, NEC, BPD, sepsis, PDARDS, IVH, PVL, NEC, BPD, sepsis, PDA

Long term morbiditiesLong term morbidities Cerebral palsy, mental retardationCerebral palsy, mental retardation

Risk directly related to gestational age Risk directly related to gestational age

CP risk 2/1000 live births overallCP risk 2/1000 live births overall

CP risk 8CP risk 8--10% survivors BW<1000g10% survivors BW<1000g

Preterm LaborPreterm Labor

Regular uterine contractions before 37 Regular uterine contractions before 37 weeks resulting in cervical changeweeks resulting in cervical change

Causes of preterm labor are numerousCauses of preterm labor are numerous

Preterm labor is not the only etiology for Preterm labor is not the only etiology for PTDPTD

Spontaneous PTL Spontaneous PTL --4040--50%50%

Preterm PROM 25Preterm PROM 25--40%40%

Indicated delivery 20Indicated delivery 20--25%25%

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Pathogenesis of Preterm Pathogenesis of Preterm

LaborLabor

Not well understoodNot well understood

Numerous theoriesNumerous theories Progesterone withdrawalProgesterone withdrawal

Oxytocin initiationOxytocin initiation

Premature decidual activationPremature decidual activation

At least 4 potential pathwaysAt least 4 potential pathways InflammationInflammation

Decidual hemorrhageDecidual hemorrhage

Uterine over distentionUterine over distention

Premature activation of normal laborPremature activation of normal labor

Preterm Delivery Risk Preterm Delivery Risk

FactorsFactors

History of prior preterm deliveryHistory of prior preterm delivery 1717--40% recurrence rate40% recurrence rate

The earlier the prior delivery, the greater recurrence riskThe earlier the prior delivery, the greater recurrence risk

African American race 18% risk vs. 8% for Caucasian patientsAfrican American race 18% risk vs. 8% for Caucasian patients

Age <17 or >35Age <17 or >35

Low socioeconomic statusLow socioeconomic status

Tobacco use Tobacco use 25% increased risk preterm birth25% increased risk preterm birth

Poor or excessive weight gain/low BMIPoor or excessive weight gain/low BMI

Abnormalities of AFV/Abnormalities of AFV/oligooligo or polyor poly

Multiple gestation, Multiple gestation, previaprevia, abruption, abruption Twins 36 wks, triplets 33 weeks, quads 31 weeksTwins 36 wks, triplets 33 weeks, quads 31 weeks

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Preterm Labor Preterm Labor

InterventionsInterventions

NonNon--pharmacologic therapy of no proven pharmacologic therapy of no proven

benefitbenefit

Bed rest, hydration, pelvic restBed rest, hydration, pelvic rest

Tocolytic therapy may, at best, transiently Tocolytic therapy may, at best, transiently

delay deliverydelay delivery

Magnesium sulfate, calcium channel blockers, Magnesium sulfate, calcium channel blockers,

indomethacin, atosiban, beta mimetics, nitroglycerinindomethacin, atosiban, beta mimetics, nitroglycerin

Antibiotic therapy trials have shown mixed Antibiotic therapy trials have shown mixed

resultsresults

Preterm Labor Preterm Labor

InterventionsInterventions

Single most beneficial intervention is Single most beneficial intervention is

administration of corticosteroids for women at administration of corticosteroids for women at

risk for delivery between 24 and 34 weeks risk for delivery between 24 and 34 weeks

gestationgestation

Decreased risk neonatal mortality, RDS, IVH, NECDecreased risk neonatal mortality, RDS, IVH, NEC

Betamethasone 12mg IM q 24 hours x 2 dosesBetamethasone 12mg IM q 24 hours x 2 doses

Dexamethasone 6mg IV q 6 hours x 4 dosesDexamethasone 6mg IV q 6 hours x 4 doses

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Predicting Preterm Labor: Predicting Preterm Labor:

Cervical LengthCervical Length

Median length is 35mmMedian length is 35mm

Range 25Range 25--45mm45mm

Risk of preterm birth inversely related to CLRisk of preterm birth inversely related to CL

<25mm at 22<25mm at 22--24 weeks24 weeks

6x increase risk of delivery <35 weeks6x increase risk of delivery <35 weeks

In symptomatic patient, CL >30mm reliably In symptomatic patient, CL >30mm reliably

excludes diagnosis of preterm laborexcludes diagnosis of preterm labor


Fetal FibronectinFetal Fibronectin

Extracellular matrix proteinExtracellular matrix protein

Attaches fetal membranes to deciduaAttaches fetal membranes to decidua

Normally present in cervicoNormally present in cervico--vaginal vaginal secretionssecretions

Before 16Before 16--18 weeks18 weeks

End of normal pregnancyEnd of normal pregnancy

Not normally present between 22Not normally present between 22--37 37 weeksweeks

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Presence of fFN after 22 weeks is a Presence of fFN after 22 weeks is a

marker of disruption of decidualmarker of disruption of decidual--chorionic chorionic

interfaceinterface

Positive Positive fFNfFN



Markedly increased risk of delivery within 7Markedly increased risk of delivery within 7--

14 days of test14 days of test



Positive predictive value of delivery within Positive predictive value of delivery within

14 days <20%14 days <20%

Most important clinical characteristic of Most important clinical characteristic of

fFN is negative predictive valuefFN is negative predictive value

In a symptomatic patient with negative In a symptomatic patient with negative

fFN, risk of delivery within 7fFN, risk of delivery within 7--14 days is 14 days is

<1%<1%

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Current strategies lead to 40% false Current strategies lead to 40% false

positive diagnosis of preterm laborpositive diagnosis of preterm labor

fFNfFN perhaps most helpful when:perhaps most helpful when:

Symptoms occur between 24Symptoms occur between 24--34 weeks34 weeks

Intact membranesIntact membranes

Cervix <3cmCervix <3cm

fFNfFN results available within few hoursresults available within few hours


CL and fFNCL and fFN

Routine screening of low risk, Routine screening of low risk,

asymptomatic patients not indicatedasymptomatic patients not indicated

For some atFor some at--risk patients, screening may risk patients, screening may

avert interventions that are unnecessary avert interventions that are unnecessary

or ineffectiveor ineffective

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CL and fFN CL and fFN

Clinical value of CL and fFN rests Clinical value of CL and fFN rests

primarily on negative testsprimarily on negative tests

Management of patients with positive tests Management of patients with positive tests

remains uncertainremains uncertain

In asymptomatic, low risk patients, In asymptomatic, low risk patients,

positive predictive value for preterm birth positive predictive value for preterm birth

<35 weeks with positive fFN and CL <35 weeks with positive fFN and CL

<25mm was only 50%<25mm was only 50%

Preventing Preterm BirthPreventing Preterm Birth

Focus on risk reduction and early detectionFocus on risk reduction and early detection

Risk reduction trials not effectiveRisk reduction trials not effective

Early detection approachesEarly detection approaches

Patient educationPatient education

Surveillance for cervical changeSurveillance for cervical change

Home uterine activity monitoringHome uterine activity monitoring

Early detection strategies have not consistently Early detection strategies have not consistently

reduced rates of preterm birthreduced rates of preterm birth

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Preterm Labor TherapyPreterm Labor Therapy

No evidence that bedrest worksNo evidence that bedrest works

In twins, may be harmfulIn twins, may be harmful

Oral/IV hydration not effectiveOral/IV hydration not effective

Parenteral sedation also does not reduce Parenteral sedation also does not reduce

risk of preterm birthrisk of preterm birth

Preterm Labor Therapy: 17 Preterm Labor Therapy: 17

alphaalpha--hydroxyprogesterone hydroxyprogesterone

caproate caproate

Preterm labor prophylaxisPreterm labor prophylaxis

Prospective trials from 1980’s Prospective trials from 1980’s

demonstrated efficacydemonstrated efficacy

Not employed as acute therapyNot employed as acute therapy

Not widely adopted in practiceNot widely adopted in practice

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Preterm Labor Therapy: Preterm Labor Therapy:

17P17P

Prospective, randomized, double blinded Prospective, randomized, double blinded

placebo controlled trial in NEJM 2003placebo controlled trial in NEJM 2003

Women between 16Women between 16--20 weeks with 20 weeks with

history of prior preterm birthhistory of prior preterm birth

Patients received 250mg 17P weekly Patients received 250mg 17P weekly

until 36 weeksuntil 36 weeks

Preterm Labor Therapy: Preterm Labor Therapy:

17P17P

Patients had significantly reduced risk of Patients had significantly reduced risk of

preterm birth at <37, <35 and <32 weekspreterm birth at <37, <35 and <32 weeks

Neonatal outcomes also significantly Neonatal outcomes also significantly

improved with reduced risk of NEC, IVH improved with reduced risk of NEC, IVH

and oxygen therapy durationand oxygen therapy duration

Risk of preterm birth still ranged from 11Risk of preterm birth still ranged from 11--

36%36%

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ProgesteroneProgesterone

Literature review 2000Literature review 2000--20082008

History of prior spontaneous preterm birthHistory of prior spontaneous preterm birth Weekly IM 17P initiated at 16Weekly IM 17P initiated at 16--20 weeks or 100mg vaginal 20 weeks or 100mg vaginal

suppository beginning <24 weekssuppository beginning <24 weeks

CL <15mmCL <15mm 200 mg vaginal suppository200 mg vaginal suppository

TwinsTwins--not indicated unless history of prior SPTBnot indicated unless history of prior SPTB--250mg IM injection 17P weekly or CL <15mm, 200mg 250mg IM injection 17P weekly or CL <15mm, 200mg vaginal suppository dailyvaginal suppository daily

Arrested preterm laborArrested preterm labor 400mg daily vaginal suppository or 341mg IM twice weekly400mg daily vaginal suppository or 341mg IM twice weekly

Tocolytic TherapyTocolytic Therapy--

RitodrineRitodrine

Only medication approved by FDA for Only medication approved by FDA for treatment of preterm labortreatment of preterm labor

Delays delivery 24Delays delivery 24--48 hours48 hours

Beta agonist side effectsBeta agonist side effects Pulmonary edema, myocardial ischemia, Pulmonary edema, myocardial ischemia,

arrhythmia, hyperglycemia, maternal death, fetal arrhythmia, hyperglycemia, maternal death, fetal cardiac effectscardiac effects

Due to maternal/fetal complications: cost and Due to maternal/fetal complications: cost and limited evidence of improved outcomes, limited evidence of improved outcomes, ritodrine currently not widely usedritodrine currently not widely used

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Tocolytic Therapy: Tocolytic Therapy:

TerbutalineTerbutaline

Most commonly used beta mimeticMost commonly used beta mimetic

Administered via oral, IV or Administered via oral, IV or subcutaneous routessubcutaneous routes

Like ritodrine, delays delivery but has not Like ritodrine, delays delivery but has not been demonstrated to reduce rate of been demonstrated to reduce rate of preterm birthpreterm birth

Subcutaneous terbutaline pump has not Subcutaneous terbutaline pump has not been shown to be effectivebeen shown to be effective


Magnesium SulfateMagnesium Sulfate

First described as tocolytic 1977First described as tocolytic 1977

Initial bolus 4Initial bolus 4--6 grams over 30 minutes6 grams over 30 minutes Maintenance infusion 1Maintenance infusion 1--3 grams/hour3 grams/hour

Common SE: nausea, flushing, lethargy, Common SE: nausea, flushing, lethargy, blurred visionblurred vision

Deep tendon reflexes lost >12mg/dLDeep tendon reflexes lost >12mg/dL Respiratory depression >14mg/dLRespiratory depression >14mg/dL

Cardiac arrest >18mg/dLCardiac arrest >18mg/dL

Reversal with 1 gram calcium gluconateReversal with 1 gram calcium gluconate

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Magnesium SulfateMagnesium Sulfate

Absolute contraindications: myasthenia Absolute contraindications: myasthenia

gravis, heart blockgravis, heart block

Relative contraindications: renal disease, Relative contraindications: renal disease,

recent MI, concurrent calcium channel recent MI, concurrent calcium channel

blockersblockers

Pulmonary edema occurs 1%Pulmonary edema occurs 1%

Monitoring I/O is essentialMonitoring I/O is essential


IndomethacinIndomethacin

Prostaglandin synthetase inhibitorProstaglandin synthetase inhibitor

First prospective trial 1980First prospective trial 1980

Similar efficacy to other agentsSimilar efficacy to other agents

Few maternal side effectsFew maternal side effects

Administered orally/rectallyAdministered orally/rectally

5050--100mg loading dose100mg loading dose

Followed by total 24 hour dose <200mgFollowed by total 24 hour dose <200mg

Duration of therapy 24Duration of therapy 24--48 hours48 hours

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Tocolytic TherapyTocolytic Therapy--

IndomethacinIndomethacin

Potential severe fetal effectsPotential severe fetal effects

Decreased urine outputDecreased urine output

OligohydramniosOligohydramnios

Constriction of ductus arteriosusConstriction of ductus arteriosus

Due to risks of long term therapyDue to risks of long term therapy

Limit duration to <48 hoursLimit duration to <48 hours

Limit use to <30Limit use to <30--32 weeks32 weeks

Often employed as second line agentOften employed as second line agent


Calcium Channel BlockersCalcium Channel Blockers

Nifedipine most widely studiedNifedipine most widely studied


Loading dose of 20mg orallyLoading dose of 20mg orally Followed with 10Followed with 10--20 mg q 620 mg q 6--8 hours8 hours

Sublingual route hazardousSublingual route hazardous Risk of acute/severe hypotensionRisk of acute/severe hypotension

Recent systematic review and metaanalysisRecent systematic review and metaanalysis Significant reduction in PTD within 7 days vs. B agonistsSignificant reduction in PTD within 7 days vs. B agonists

No difference efficacy/adverse outcomes vs. Magnesium No difference efficacy/adverse outcomes vs. Magnesium sulfatesulfate

Fewer maternal SE vs. Mag sulfate and B agonistsFewer maternal SE vs. Mag sulfate and B agonists

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Tocolytic TherapyTocolytic Therapy--Other Other

AgentsAgents

Oxytocin antagonistsOxytocin antagonists

Atosiban not available in U.S.Atosiban not available in U.S.

May delay delivery 24May delay delivery 24--48 hours48 hours

Nitric oxide donorsNitric oxide donors

Nitroglycerine/glycerol trinitrateNitroglycerine/glycerol trinitrate


Profound/severe hemodynamic effectsProfound/severe hemodynamic effects

Experimental usage only at this timeExperimental usage only at this time


SummarySummary

Frequently unnecessaryFrequently unnecessary

Often ineffectiveOften ineffective

Potentially harmfulPotentially harmful

Delays delivery to allow steroid Delays delivery to allow steroid

administrationadministration

Typically not employed after 34 weeksTypically not employed after 34 weeks

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Antibiotic Therapy: Antibiotic Therapy:

SummarySummary

Currently, treatment of patients with Currently, treatment of patients with

intact membranes in preterm labor with intact membranes in preterm labor with

antibiotics for the purpose of preventing antibiotics for the purpose of preventing

preterm birth is not recommendedpreterm birth is not recommended

Patients in preterm labor should receive Patients in preterm labor should receive

GBS prophylaxis unless proven GBS GBS prophylaxis unless proven GBS

negativenegative

Antibiotic TherapyAntibiotic Therapy

ACOG Committee OpinionACOG Committee Opinion

“The utility of antibiotics to prolong pregnancy “The utility of antibiotics to prolong pregnancy

and reduce neonatal mortality in women with and reduce neonatal mortality in women with

preterm labor and intact membranes has been preterm labor and intact membranes has been

evaluated in numerous randomized clinical evaluated in numerous randomized clinical

trials. Antibiotic use intended only for trials. Antibiotic use intended only for

pregnancy prolongation in women with preterm pregnancy prolongation in women with preterm

labor with intact membranes does not have labor with intact membranes does not have

shortshort--term neonatal benefits and may be term neonatal benefits and may be

associated with longassociated with long--term harm.”term harm.”

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Corticosteroid TherapyCorticosteroid Therapy

Single most effective intervention to Single most effective intervention to

improve neonatal outcomeimprove neonatal outcome

Administered between 24Administered between 24--34 weeks34 weeks

Repetitive dosing not indicatedRepetitive dosing not indicated

First line agent: betamethasoneFirst line agent: betamethasone

Alternative agent: dexamethasoneAlternative agent: dexamethasone

May be less effective reducing IVH/PVLMay be less effective reducing IVH/PVL

Corticosteroid Therapy Corticosteroid Therapy

Rescue CourseRescue Course--ACOG 2011ACOG 2011

A single rescue course of antenatal A single rescue course of antenatal corticosteroids may be considered if the corticosteroids may be considered if the antecedent treatment was given more than 2 antecedent treatment was given more than 2 weeks prior, the gestational age is less than 32 weeks prior, the gestational age is less than 32 6/7 weeks, and the women are judged by the 6/7 weeks, and the women are judged by the clinician to be likely to give birth within the next clinician to be likely to give birth within the next week. However, regularly scheduled repeat week. However, regularly scheduled repeat courses or multiple courses (more than 2) are courses or multiple courses (more than 2) are not recommended. Further research regarding not recommended. Further research regarding the risks and benefits, optimal dose, and timing the risks and benefits, optimal dose, and timing of a single rescue course of steroid treatment of a single rescue course of steroid treatment is needed.is needed.

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Preterm Birth: Delivery Preterm Birth: Delivery

IssuesIssues

Virtually all preterm breech birth infants Virtually all preterm breech birth infants

delivered via cesarean sectiondelivered via cesarean section

Limit traumatic/hypoxemic injuryLimit traumatic/hypoxemic injury

Preterm vertex infants delivered via Preterm vertex infants delivered via

cesarean section for same indications as cesarean section for same indications as

term infantsterm infants

Preterm Birth: Delivery Preterm Birth: Delivery

IssuesIssues

Currently, offer cesarean birth for fetal Currently, offer cesarean birth for fetal

indications at about 24 weeksindications at about 24 weeks

Extensive counselling is criticalExtensive counselling is critical

Pay particular attention to avoiding Pay particular attention to avoiding

traumatic deliverytraumatic delivery

Risks of vacuum extractionRisks of vacuum extraction

Intact membranes may protectIntact membranes may protect

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Care for Women with Prior Care for Women with Prior


Cervical ripening and decidual activation is keyCervical ripening and decidual activation is key

Progesterone impacts inflammationProgesterone impacts inflammation--driven driven processprocess

Cerclage may benefit some patients by Cerclage may benefit some patients by preventing membrane prolapse and bacterial preventing membrane prolapse and bacterial infectioninfection

Process starts before 20 weeks in many Process starts before 20 weeks in many womenwomen

Effective interventionEffective intervention Smoking cessation, screen/treat asymptomatic Smoking cessation, screen/treat asymptomatic

bacteriuria, progesterone, steroidsbacteriuria, progesterone, steroids

Preterm Birth: SummaryPreterm Birth: Summary

Effective interventionsEffective interventions

Delivery at a site with available NICUDelivery at a site with available NICU

Corticosteroid administrationCorticosteroid administration

GBS prophylaxisGBS prophylaxis

Avoid trauma/hypoxemiaAvoid trauma/hypoxemia

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Premature Rupture of Premature Rupture of

MembranesMembranes

PROMPROM

Ruptured membranes prior to laborRuptured membranes prior to labor

Preterm PROMPreterm PROM

Ruptured membranes prior to 37 weeksRuptured membranes prior to 37 weeks

Keys to appropriate managementKeys to appropriate management

Accurate gestational age assessmentAccurate gestational age assessment

Maternal & fetal assessmentMaternal & fetal assessment

PROM EtiologyPROM Etiology

Intraamniotic Intraamniotic

infectioninfection

Low socioeconomic Low socioeconomic

statusstatus

Low BMILow BMI

Preterm CTXPreterm CTX

Cigarette smokingCigarette smoking

Uterine Uterine

overdistentionoverdistention

Short CLShort CL

CerclageCerclage

Cervical conizationCervical conization

History prior PTDHistory prior PTD

AmniocentesisAmniocentesis

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PROM after 2PROM after 2ndnd

Trimester Trimester

AmniocentesisAmniocentesis

Outcome better than after spontaneous Outcome better than after spontaneous

preterm PROMpreterm PROM

Risk is 1Risk is 1--1.2%1.2%

Attributable risk of pregnancy loss 0.06%Attributable risk of pregnancy loss 0.06%

Typical clinical course is resealing with Typical clinical course is resealing with

restoration of normal amniotic fluid restoration of normal amniotic fluid

volumevolume

PROM DiagnosisPROM Diagnosis

History and PhysicalHistory and Physical

Speculum examSpeculum exam

Digital exam ifDigital exam if Active laborActive labor

Imminent delivery Imminent delivery

Confirmed by visualization of fluid per osConfirmed by visualization of fluid per os

FerningFerning

Vaginal secretion pH assessmentVaginal secretion pH assessment Basic if amniotic fluidBasic if amniotic fluid

False positive with blood, semen, BVFalse positive with blood, semen, BV

Ultrasound for amniotic fluid volumeUltrasound for amniotic fluid volume Instillation indigo carmine dyeInstillation indigo carmine dye

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Initial ManagementInitial Management

Confirm gestational age, presentation, fetal statusConfirm gestational age, presentation, fetal status

Delivery indicated regardless of gestational ageDelivery indicated regardless of gestational age Evident intrauterine infectionEvident intrauterine infection

AbruptionAbruption

Fetal compromiseFetal compromise

PROM at termPROM at term Labor inductionLabor induction

GBS prophylaxis based on culture/risk factorsGBS prophylaxis based on culture/risk factors

Decreased risk chorioamnionitis, postpartum endometritis, Decreased risk chorioamnionitis, postpartum endometritis, neonatal antibiotic therapyneonatal antibiotic therapy

Expectant Management Expectant Management


Delivery at or beyond 34 weeksDelivery at or beyond 34 weeks

2424--33 weeks, manage expectantly33 weeks, manage expectantly

Modified bed restModified bed rest

Frequent maternal/fetal surveillanceFrequent maternal/fetal surveillance

Daily fetal testingDaily fetal testing

Maternal fever, tachycardia, uterine tendernessMaternal fever, tachycardia, uterine tenderness

Specific recommendations for or against Specific recommendations for or against

tocolysis with preterm PROM cannot be madetocolysis with preterm PROM cannot be made

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Corticosteroid administrationCorticosteroid administration

Single course for patients 24Single course for patients 24--32 weeks32 weeks

Reduced risk RDS, IVH, NEC, mortalityReduced risk RDS, IVH, NEC, mortality



Adjunctive antibiotic therapyAdjunctive antibiotic therapy Widely studied and debatedWidely studied and debated

NICHDNICHD--MFMU Research Network 1997MFMU Research Network 1997 IV ampicillin/erythromycin 48 hoursIV ampicillin/erythromycin 48 hours

Followed by oral amoxicillin/erythromycin 5 daysFollowed by oral amoxicillin/erythromycin 5 days

Decreased risk chorioamnionitis, increased latencyDecreased risk chorioamnionitis, increased latency

Reduced risk RDS, NEC, and PDAReduced risk RDS, NEC, and PDA

Intrapartum GBS prophylaxis indicated regardless of Intrapartum GBS prophylaxis indicated regardless of prior antibiotic therapyprior antibiotic therapy

Oral erythromycin/extended spectrum ampicillinOral erythromycin/extended spectrum ampicillin--clavulanic acid not beneficialclavulanic acid not beneficial

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After viability, safety of expectant After viability, safety of expectant management at home not establishedmanagement at home not established

No controlled studies have found No controlled studies have found cerclage retention after PROM to cerclage retention after PROM to improve outcomeimprove outcome

With active HSV, expectant management With active HSV, expectant management with antiviral therapy may be preferablewith antiviral therapy may be preferable

Need to balance against risk of prematurityNeed to balance against risk of prematurity


Preterm PROM before Preterm PROM before

ViabilityViability

No evidence based guidelinesNo evidence based guidelines

Initial period of inpatient monitoringInitial period of inpatient monitoring

Bedrest/pelvic rest possibly aid resealingBedrest/pelvic rest possibly aid resealing

Early identification of infection or abruptionEarly identification of infection or abruption

Monitor temperatures at homeMonitor temperatures at home

Readmit to hospital at viabilityReadmit to hospital at viability

Expectant management with corticosteroidsExpectant management with corticosteroids

Preterm BirthPreterm Labor Interventions Non-pharmacologic therapy of no proven benefit Bed rest,...

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