Overview of prevention and management of pre-term births

RC Pattinson MRC Maternal and Infant Health Care Strategies Unit

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

Drivers contributing to the increase in preterm birth rate of the United States from 1989 to 2004
Preterm birth rate (%)
13.0

12.5
1.0 12.0 0.1 11.5 0.2 11.0 0.3 0.4

0.3

12.5

0.1
10.6 0.0 Preterm Increasing birth maternal rate age (1989)

0.1

Race

Assisted NonNonStillbirths Others/ Maternal Preterm reproductive ART medically averted unknown education birth technology multiple indicated rate (ART) gestation induction + (2004) Caesarean

50% of the increase cannot be explained

Data Sources: Chang et al Lancet 2012
Born Too Soon: The Global Action Report on Preterm Birth

- 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
Born Too Soon: The Global Action Report on Preterm Birth

Born Too Soon: The Global Action Report on Preterm Birth

Iatrogenic PTB vs Spontaneous PTB

Iatrogenic
Save mother
Pre-eclampsia etc.
Calcium supplementation

Save baby
Congenital abnormalities Rhesus disease
Anti-D

Spontaneous

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

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

Secondary prevention (Prevent spontaneous delivery)

Suppress labour
Tocolytics
Nifedipine Indomethacin Atosiban (Oxytocin antagonists)

Treat cause
Antibiotics

Antibiotics and preterm labour

PPROM Preterm labour with intact membranes
Oracle Trial versus PRAM Long term neurological effects of antibiotics

Tertiary prevention
(Prevention of neonatal 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

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)

Actions
Collaborative effort Alter Lifestyle Promote Contraceptive use Prevent teenage pregnancies

Actions
Interventions for use now

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

During labour
Tocolytics Antenatal corticosteroids Antibiotics for PPROM Magnesium sulphate for neuro-protection In-utero transfer

After birth
Delayed cord clamping Neonatal resuscitation .

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 very high 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, 2012Cochrane Library Cochrane Library: www.thecochranelibrary.com/