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Preterm Labor Prevention Guide for High-Risk Patients

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Preterm Labor Prevention and Treatment Kerry Watrin MD August 2 nd 2007
Objectives: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Definitions/ Epidemiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Race/Ethnicity and Prematurity 2000to 2002 1.5% 10.7% White 1.4% 10.2% Asian 1.7% 11.4% Hispanic 2.0% 12.9% Native American 4.1% 17.6% Black 1.9% 11.9% All US < 32wk US < 37wk Race/Ethnicity
Preterm Birth Causes Multifactorial ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case #1 ,[object Object],[object Object],[object Object],[object Object]
Case #1 Preterm Labor Precautions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Prematurity Risk Factors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Cervical Incompetence Risks ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Prematurity Interventions: Lifestyle ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Expected pregnancy weight gain 15+ lbs > 29 Obese 15-25 lbs 26-29 High 25-35 lbs 19.8-26 Normal 28-40 lbs <19.8 Low Recommended wt gain BMI Kg/m2 Wt/ht category
Prematurity Interventions: Medical ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Asymptomatic Bacteriuria ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Bacterial Vaginosis: Clue cell
Bacterial Vaginosis ,[object Object],[object Object],[object Object],[object Object],[object Object]
Bacterial Vaginosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Bacterial Vaginitis Metronidazole potential harm ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Bacterial Vaginitis Clindamycin ,[object Object],[object Object]
Prevention with Progesterone ,[object Object],[object Object],[object Object],[object Object],[object Object]
Preterm outcomes and Progesterone NNT Relative Risk Placebo N=153 Progest N=306 7 0.66 (.51-.87) 62 41.1% 82 27.2% LBW < 2500 gm 12 0.58 (.37-.91) 30 19.6% 35 11.4% Delivery < 32 wk 10 0.67 (.48-.93) 47 30.7% 63 20.6% Delivery < 35 wk 5 0.66 (.54-.81) 84 54.9% 111 36.3% Delivery < 37 wk
Progesterone Outcomes ,[object Object],[object Object],[object Object],[object Object]
Progesterone Meta-analysis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ACOG and Progesterone ,[object Object]
Preterm Birth Risk Stratification ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Markers for Prematurity ,[object Object],[object Object],[object Object],[object Object]
Most Potent Predictive Markers For Preterm Birth < 32 weeks ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Other Markers of Preterm Birth < 32 weeks ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Fetal Fibronectin ,[object Object],[object Object],[object Object],[object Object],[object Object]
Fetal Fibronectin ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Fetal Fibronectin ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case #2 Low Risk no prior PTB at 25 weeks ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Transvaginal Cervical Length ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Rate of Preterm Birth <35 weeks by Cervical Length at 24 weeks 34 % < 13 mm 20 % <20 mm 8 %  25 mm Rate Delivery Length
Ultrasound Cervical Length Prediction of PTB < 35 weeks 17.2% 96.6% 94.5% 25.4% Funneling At 24 wk 17.8% 97% 92.2% 37.3% 25mm 24 weeks 16.7% 97.6% 94.7% 31.3% 20 mm 28 weeks 25.7% 96.7% 97% 23% 20mm 24 weeks PPV NPV Specificity Sensitivity Finding
Cervical Length Caveats ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Cerclage and Short Cervix ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Role of US and Cerclage High risk with 3 prior midterm losses ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],ACOG Practice Bulletin #48, Nov 2003
Short Cervix and Vaginal Progesterone ,[object Object],[object Object],[object Object],[object Object]
Contractions and Bishops Score And birth before 35 weeks ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Threatened Preterm Labor ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Idiopathic Preterm Contractions in Triage ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Contractions what to do? 4 (7%) 4 (6%) 5 (9%) PTB < 34 wks $687 $966 $717 Mean cost < 24 hours 5 (8%) 8 (13%) 7 (13%) admitted 8 (13%) 8 (13%) 10 (18%) More tocolysis 79% 57% 64% Triage < 4hrs 4.1  5.1 hrs 6.0  5.7 hrs 5.2  5.1 hrs Mean time to discharge Terbutaline x1, n=61 Hydration N=62 Observation N=56
Case #2 now with contractions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case #2, Threatened PTL in High Risk (contracts, +FFN, short cervix) ,[object Object],[object Object],[object Object],[object Object],[object Object]
The Recommendations MMWR, Vol 51 (RR-11)
CDC GBS algorithm for Threatened Preterm Delivery ,[object Object],[object Object],[object Object],[object Object],[object Object]
Agents for intrapartum prophylaxis ,[object Object],[object Object],[object Object],[object Object],[object Object]
Antenatal Steroids ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Antenatal Steroids ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Repeat courses of Antenatal Steroids ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Tocolytics: Ca Channel Blockers: dihydropryridines ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Tocolytics: Magnesium Sulfate ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Tocolytics:  - mimetics ,[object Object],[object Object],[object Object],[object Object],[object Object]
Tocolytics:  - mimetics ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
COX Inhibitors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Tocolytics: ACOG 5/2003 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Tocolytics Uncontrolled thyroid or Diabetes Cardiac arrhythmia 0.25mg SQ q 20min-3hr Hold if P>120 ,[object Object],[object Object],Myasthenia gravis Also using Calcium channel Blocker 4-6 gm IV bolus in 20 min, then 2-3gm/hr Mag Sulfate Renal failure, Active Ulcer Coagulation disorders NSAID asthma trigger 50 rectal, 50-100 mg PO, then 25-50 orally q6 x 48 hrs NSAID Indomethacin (<32 weeks) Maternal hypotension Also using Magnesium 30-40 mg load PO 10-20 q 4-6hrs CCB Nifedipine Contra- indication Dose and Route Agent
Case #3, PPROM ,[object Object],[object Object],[object Object]
Incidence and Natural Hx ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PROM Risks ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnosis ,[object Object],[object Object],[object Object],[object Object]
Diagnosis ,[object Object],[object Object],[object Object],[object Object]
Sterile Speculum ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Assessment of Fetal Lung Maturity ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Expectant vs Intervene ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Antibiotics for Preterm PROM ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
4/07 ACOG PPROM ,[object Object],[object Object],[object Object],[object Object]
PPROM Interventions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PPROM interventions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Oracle 1 trial ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Oracle 1 trial ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Cerebral Palsy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Conclusions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Conclusions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
References: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
References: ,[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object]
PROM @ 34-37, “Near-term” ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PPROM 30-36 weeks: Metanalysis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Risk of Preterm Birth < 35 weeks compared to cervical length of the 75% 1.0 1.0 75% 40 mm 9.5 6.7 10% 26 mm 13.9 9.5 5% 22 mm 24.9 14 1% 13 mm 28 weeks RR of PTB 24 weeks RR of PTB Percentile On Curve Length
Lifestyle: Drug Screening ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Vaginal Progesterone ,[object Object],[object Object],[object Object]
Tocolytics:  - mimetics 2004 Systematic Review OR 0.79 CI (0.61-1.01) 5 RTC 55%, 332/601  mimetic 65%, 332/525 placebo LBW < 2,500 gms OR 0.76 CI (0.57-1.01) 6 RTC 18%, 117/639  mimetic 25%, 140/565 placebo RDS OR 1.08 CI (0.72-1.62) 7 RTC 9%, 62/682  mimetic 8%, 48/604 placebo Perinatal Mortality OR Sample Finding

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Preterm Labor Prevention Guide for High-Risk Patients

  • 1. Preterm Labor Prevention and Treatment Kerry Watrin MD August 2 nd 2007
  • 2.
  • 3.
  • 4. Race/Ethnicity and Prematurity 2000to 2002 1.5% 10.7% White 1.4% 10.2% Asian 1.7% 11.4% Hispanic 2.0% 12.9% Native American 4.1% 17.6% Black 1.9% 11.9% All US < 32wk US < 37wk Race/Ethnicity
  • 5.
  • 6.
  • 7.
  • 8.
  • 9.
  • 10.
  • 11. Expected pregnancy weight gain 15+ lbs > 29 Obese 15-25 lbs 26-29 High 25-35 lbs 19.8-26 Normal 28-40 lbs <19.8 Low Recommended wt gain BMI Kg/m2 Wt/ht category
  • 12.
  • 13.
  • 15.
  • 16.
  • 17.
  • 18.
  • 19.
  • 20. Preterm outcomes and Progesterone NNT Relative Risk Placebo N=153 Progest N=306 7 0.66 (.51-.87) 62 41.1% 82 27.2% LBW < 2500 gm 12 0.58 (.37-.91) 30 19.6% 35 11.4% Delivery < 32 wk 10 0.67 (.48-.93) 47 30.7% 63 20.6% Delivery < 35 wk 5 0.66 (.54-.81) 84 54.9% 111 36.3% Delivery < 37 wk
  • 21.
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  • 24.
  • 25.
  • 26.
  • 27.
  • 28.
  • 29.
  • 30.
  • 31.
  • 32.
  • 33. Rate of Preterm Birth <35 weeks by Cervical Length at 24 weeks 34 % < 13 mm 20 % <20 mm 8 %  25 mm Rate Delivery Length
  • 34. Ultrasound Cervical Length Prediction of PTB < 35 weeks 17.2% 96.6% 94.5% 25.4% Funneling At 24 wk 17.8% 97% 92.2% 37.3% 25mm 24 weeks 16.7% 97.6% 94.7% 31.3% 20 mm 28 weeks 25.7% 96.7% 97% 23% 20mm 24 weeks PPV NPV Specificity Sensitivity Finding
  • 35.
  • 36.
  • 37.
  • 38.
  • 39.
  • 40.
  • 41.
  • 42. Contractions what to do? 4 (7%) 4 (6%) 5 (9%) PTB < 34 wks $687 $966 $717 Mean cost < 24 hours 5 (8%) 8 (13%) 7 (13%) admitted 8 (13%) 8 (13%) 10 (18%) More tocolysis 79% 57% 64% Triage < 4hrs 4.1  5.1 hrs 6.0  5.7 hrs 5.2  5.1 hrs Mean time to discharge Terbutaline x1, n=61 Hydration N=62 Observation N=56
  • 43.
  • 44.
  • 45. The Recommendations MMWR, Vol 51 (RR-11)
  • 46.
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  • 78.
  • 79.
  • 80.
  • 81.
  • 82.
  • 83.
  • 84.
  • 85.
  • 86.
  • 87. Risk of Preterm Birth < 35 weeks compared to cervical length of the 75% 1.0 1.0 75% 40 mm 9.5 6.7 10% 26 mm 13.9 9.5 5% 22 mm 24.9 14 1% 13 mm 28 weeks RR of PTB 24 weeks RR of PTB Percentile On Curve Length
  • 88.
  • 89.
  • 90. Tocolytics:  - mimetics 2004 Systematic Review OR 0.79 CI (0.61-1.01) 5 RTC 55%, 332/601  mimetic 65%, 332/525 placebo LBW < 2,500 gms OR 0.76 CI (0.57-1.01) 6 RTC 18%, 117/639  mimetic 25%, 140/565 placebo RDS OR 1.08 CI (0.72-1.62) 7 RTC 9%, 62/682  mimetic 8%, 48/604 placebo Perinatal Mortality OR Sample Finding

Hinweis der Redaktion

  1. Workshop 9/14/2004 32 nd Annual Advances in Family Practice and Primary Care: Perinatal Case Studies