1. Preterm Labor and Delivery

2. Statistics 12.8% of all deliveries in the U.S. in 2006
These preemies comprise 80% of all perinatal deaths in the U.S.
Preterm birth is the leading cause of infant mortality in Ohio.
  Among states, we rank 35th in infant mortality and 31st in prematurity

3. Economic Impact
Average hospital cost for a 25 weeker to discharge is $203,000
32 weeks almost $19,000. more than 38 weeks
Even at 36 weeks there is an increased cost of $1700 more than delivery at 37 weeks

4. Ethnic disparities 17.9% of all black births
13.7 of all Native American Indian

5. Causes Cause remains greatly unknown
What we know and what we don’t know

6. Theories There is compelling evidence to support four major pathways:
Stress
Placental abruption
Infection
Uterine distension

7. Further study needed to determine significance of:
Link to poor dental health
Link to intention of pregnancy
Link to racial discrimination and associated stress

8. Epidemiologic Approach
Based on placental histology and placental microbiology
Disorders leading to preterm delivery can be separated into 2 groups:

9. Epidemiologic Approach
Those associated with intrauterine inflammation, Chorioamnionitis, placental microbe recovery
PROM
Placental abruption
Cervical insufficiency
Preterm labor

10. Epidemiologic Approach
Those associated with aberrations of placentation
Preeclampsia
Intrauterine growth restriction
Mcelrath, et al (2008) Pregnancy disorders that lead to delivery before the 28th week of gestation: An epidemiologic approach to classification. American Journal of Epidemiology. 168 (9)

11. Risk Factors
History of previous preterm delivery is the #1 risk factor.
Previous cervical procedures: cone biopsy and LEEP
Uterine anomalies
Multiple gestation
Urinary tract infections
Pregnancy with the past 12 months

12. The Preterm Prediction Study
Positive Fetal fibronectin and short cervical length are good indicators for predicting preterm delivery
Newman, Goldenberg, Iams, et al (2008) Preterm prediction study: Comparison of the Cervical score and Bishop score for prediction of spontaneous preterm delivery. Obstetrics & Gynecology. 112 (3),

13. Bio-Chemical predictors
Fetal Fibronectin is a glycoprotein
Should not be detectable between weeks gestation

14. Negative Fetal Fibronectin
Negative Ffn results are most useful
99.2% negative predictive value
Highly unlikely that preterm labor will occur within 14 days.

15. Positive Fetal Fibronectin
Positive predictive value: not so good
Only 65% with positive Ffn will have a preterm delivery

16. Collecting Ffn specimen

17. For Accurate Patient Results
For accurate patient results, please ensure that you follow these specimen collection instructions.
The specimen should be collected prior to a digital cervical exam, collection of culture specimens, or vaginal probe ultrasound exams.
Do not contaminate the swab or specimen with lubricants, soaps, disinfectants, or creams.
Do not collect specimen if patients have had sexual intercourse within 24 hours prior to sampling; moderate or gross vaginal bleeding; advanced cervical dilation (3 cm or greater); rupture of membranes; gestational age <22 weeks or >35 weeks; or suspected or known placental abruption or placenta previa.

18. Biophysical Predictors
Cervical length less than 20 mm per transvaginal ultrasound
Cervical score less than 1.5 per digital cervical exam
Cervical score = Cervical length (cm) minus Cervical Dilation (cm) at the internal os

19. Cervical score Uses digital cervical examination for measurement
Eliminates cost and logistical difficulties of serial transvaginal ultrasound

21. ACOG Diagnosis
Regular contractions that occur before 37 weeks gestation and are associated with changes in the cervix.
(No proven cause/effect)

22. How to manage Hydration Bed rest
Little evidence to demonstrate effectiveness

23. Pharmacologic management
Tocolytics have failed to demonstrate effectiveness in preventing preterm labor
Some delay delivery for 48 hours
Buying steroid time

24. Beta-adrenergics- terbutaline and ritodrine
Stimulate beta2-adrenergic receptors relaxing smooth muscle
Not shown to reduce preterm birth
Substantial maternal adverse effects: bronchospasm, HTN, arrhythmias, pulmonary edema, hyperglycemia, seizures
Neonatal effects: fetal tachycardia, neonatal hypoglycemia (reactive)

25. Calcium Channel blockers- Nifedipine
Inhibits Calcium ion influx into smooth muscle:
Demonstrates effectiveness in delaying delivery
Does not prevent preterm delivery
Adverse reactions: CHF, pulmonary edema, arrhythmia, severe hypotension
Common S/E: headache, dizziness, flushing, fatigue, weakness, transient hypotension

26. Prostaglandin antagonists- Indocin
NSAID: exact action unknown, but reduces prostaglandin synthesis
Second line drug in pregnancy less than 32 weeks.
May increase risk of serious and potentially fatal CV thrombotic events
Serious GI events including bleeding

27. Indocin- fetal adverse side effects
Contraindicated after 32 weeks
Can cause premature closure of the ductus arteriosis in the fetus
Increase risk of necrotizing enterocolitis in the premature neonate
Increase risk of Periventricular leukomalacia (form of brain injury that can lead to CP)

28. Magnesium Sulfate CNS depressant
Serious reactions: cardiovascular collapse, respiratory paralysis, hypothermia, depressed cardiac function and pulmonary edema
Common S/E: depressed DTR, hypotension, flushing, drowsiness, visual changes
*Important to maintain urinary output to prevent toxicity
Little evidence exist to support its use as a tocolytic

29. Magnesium sulfate may decrease risk of IVH
Preliminary studies suggests antepartum administration of Magnesium sulfate may have a neuroprotective effect on premature neonates.
Decreasing the number and severity of intraventricular hemorrhage in preterm neonates and thereby reducing CP
Further research needed

30. When is tocolysis contraindicated?
Presence of infection- chorioamnionitis
Suspected placental abruption
Pregnancy Induced Hypertension

31. Antibiotics
May be indicated in PTL to treat infection as a causative factor.
Bacteruria
PROM
* Should not use tocolytics in the presence of infection

32. Management Goals Focus is on early identification and prevention
Administration of corticosteroids to enhance fetal lung maturity
And delivery in a site capable of caring for the special needs of the premature neonate

33. Fetal Lung Maturity Corticosteroids
Typically Betamethasone 12 mg IM dose x 2.
12 mg then repeat in 24 hours
Make sure neonatal knows: dates important

34. Prevention 17 P Alpha Hydroxy-Progesterone Caproate
There is sufficient evidence to support the administration of progesterone 17 P (injectable form) women with singleton pregnancy and:
a history of preterm birth (< 37 weeks) due to spontaneous onset of labor or SROM
Women with short cervix

35. 17 P
Weekly injections start between weeks and continue until 37 weeks.
Reduced the risk of recurrent preterm birth by as much as 33% over the control group
(March of Dimes)

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

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

38. Warning Signs More than 6 UC’s per hour
Tightening or “balling up” of abdomen (Avoid terminology like “Braxton-Hicks”)
Menstrual-like cramps
Back-pain
Pelvic pressure
Intestinal cramps, gas pains, flu
Increase or change in vaginal discharge
General feeling that something is not right

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

40. Health Promotion while pregnant
Good nutrition
Prenatal vitamins-folic acid
Adequate weight gain
Exercise
Decreasing stress
Avoid occupational exposures
Treatment for sub-clinical infections

41. Prevention Stress the importance of regular prenatal visits
Refer to appropriate provider and regional perinatal center based on risk of preterm birth

42. Prevention
Stress reduction: coping skills, social networking, case management, referral services (nutrition, counseling, housing issues)
Psychological support: nurse/patient relationship, group work, home visits, telephone counseling

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

44. Timing of elective delivery
Late preterm ( 34 0/ /7 weeks gestation)
Early term (37 0/7-38 6/7 weeks gestation)

45. Standards, Guidelines, and Recommendations
Avoid elective induction of labor and elective cesarean birth before 39 weeks of gestation (ACOG, 1999)
Assess fetal lung maturity if there is any question of gestational age before 39 weeks of gestation prior to elective or repeat cesarean birth (AAP & ACOG, 2002)

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

48. Patient Education resources
March of Dimes
AWHONN

49. What about the post-partum period?
Women treated with bed rest experienced cardiopulmonary and musculoskeletal deconditioning
muscle atrophy, muscle soreness of back, legs and knees
Shortness of breath on exertion
Difficulties with gait, negotiating stairs, and transferring to chair
Depression
Financial difficulties (loss of income/insurance)

50. Maternal complications
Breastfeeding problems/Enhance milk production/ early breast pump
Interrupted process of bonding
Stress/Anxiety/feeling hopeless
Sequelae of extended bed rest
Disruption of family unit
Post-partum depression

51. Neonatal complications
Respiratory issues
Difficulty coordinating suck and swallow = breastfeeding problems
Delayed bonding

52. Neonatal complications
Serious long-term disabilities including:
Cerebral palsy
Blindness
Deafness
Other chronic medical, behavioral , and cognitive problems well into school age

53. What can we do?
Early breast pump and contact with Lactation consultant
Introduce and encourage skin-to-skin (kangaroo care) when able
Educate, Educate, Educate!!

54. Breastfeeding VON data Benefits of EBM Special needs for preemies
Do not hesitate to suggest EBM even if mom was planning to bottle feed