Pattinson: Overview of Prevention and Management of Pre-Term Births

7/28/2019 Pattinson: Overview of Prevention and Management of Pre-Term Births

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Overview of prevention and

management of pre-term births

RC Pattinson

MRC Maternal and Infant Health Care StrategiesUnit


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Outline

The problem

Primary prevention Preventing labour

Secondary prevention Preventing delivery

Tertiary prevention Preventing neonatal death and disability

Actions Collaborative approach

Actions available and should be used now


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Born Too Soon: The Global Action Report on Preterm Birth

Drivers contributing to the increase in preterm birth rate

of the United States from 1989 to 2004

0.3

13.0

0.1

Increasing

maternal

age

0.1

Preterm birth rate (%)

12.5

Race

12.0

11.5

11.0

0.0Preterm

birth

rate

(2004)

12.5

Maternal

education

0.3

Others/

unknown

1.0

Stillbirths

averted

0.1

Non-

medically

indicated

induction +

Caesarean

0.4

Non-

ART

multiple

gestation

0.2

Assisted

reproductive

technology

(ART)

Preterm

birth

rate

(1989)

10.6

Data Sources: Chang et al Lancet 2012

50% of the increase cannot be explained


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- Review of preterm birth trend data (restricted to 39 high income countries

with good data)

- Potential to reduce rates based on current evidence based interventions

(mostly applicable to risks and health systems in high income settings) , but

also some middle income countries e.g., smoking

- Bottom line: in 39 high income countries the potential for preterm birth

prevention is VERY SMALL at about 5%

- URGENT need to examine preterm birth syndrome and understand and

develop solutions especially for spontaneous preterm birth

- EVEN more urgent for low income settings as likely much greater scope

possible in addressing high infection load in pregnancy, adolescent

pregnancy, birth spacing etc


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Iatrogenic PTB vs Spontaneous PTB

Iatrogenic

Save mother

Pre-eclampsia etc.

Calcium supplementation

Save baby

Congenital abnormalities

Rhesus disease

Anti-D

Spontaneous


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Primary prevention

(prevent spontaneous preterm labour) Identify women at risk during pregnancy

Only small proportion Cerclage, progesterone

Modify risk factors in pregnant women Smoking, obesity

Treat infections UTI

STI

HIV, malaria etc.

Cervical length measurement

Risk factors prior to pregnancy Birth spacing

Teenage pregnancies

Low-socioeconomic conditions and nutrition


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Primary prevention

Problems

Cannot alter risk factors if pregnant

Socio-economic status, level of education, etc.

Contraceptive use

Cannot identify majority of women at risk

Cervical length measurement

Not feasible vast majority of countries

Urine culture for asymptomatic bacteriuria

Bacterial vaginosis (STIs)

Not really effective


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Secondary prevention

(Prevent spontaneous delivery)

Suppress labour

Tocolytics

Nifedipine

Indomethacin

Atosiban (Oxytocin antagonists)

Treat cause

Antibiotics


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Antibiotics and preterm labour

PPROM

Preterm labour with intact membranes Oracle Trial versus PRAM

Long term neurological effects of antibiotics


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Tertiary prevention(Prevention ofneonatal death and disability)

Before birth

Antenatal corticosteroids

Antibiotics for PPROM

Magnesium sulphate for neuro-protection

Referral in-utero to appropriate site for delivery

After birth

Delayed cord clamping

Neonatal resuscitation


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Ineffective Interventions

Tocolysis with no cervical changes

Maintenance doses of tocolytic agents

Repeated doses of corticosteroids Bed rest, hydration and sedation

(Antibiotics with intact membranes)


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Actions

Collaborative effort

Alter Lifestyle Promote Contraceptive use

Prevent teenage pregnancies


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Actions

Interventions for use now


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Before and during pregnancy

(Primary prevention )

Before pregnancy

Birth spacing, contraceptive use

Lifestyle modification (smoking , manual labour etc.)

During pregnancy

Lifestyle modification (smoking , manual labour etc.)

Identify and manage appropriately women at risk

MSU

Treat STIs

HIV, malaria


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During labour

Tocolytics

Antenatal corticosteroids

Antibiotics for PPROM Magnesium sulphate for neuro-protection

In-utero transfer


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After birth

Delayed cord clamping

Neonatal resuscitation

.


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Acknowledgements:

Jeffrey Michael Smith, Director of Maternal Health, Jhpiego / MCHIP,Maternal Health Task Force

References: Chang, et. al. Preventing preterm births: an analysis of trends and

potential reductions with interventions in 39 countries with veryhigh human development index. Lancet Nov 2012

March of Dimes, PMNCH, Save the Children, WHO. Born Too Soon:the Global Action Report on Preterm Birth, Eds CP Howson, MV

Kinney, JE Lawn. World Health Organization, Geneva, 2012CochraneLibrary Cochrane Library: www.thecochranelibrary.com/
http://www.thecochranelibrary.com/http://www.thecochranelibrary.com/http://www.thecochranelibrary.com/

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Pattinson: Overview of Prevention and Management of Pre-Term Births