Download PRETERM biRTh - Intermountain Healthcare

Care Process Model
June
2014
PREVENTION AND MANAGEMENT OF
PRETERM birth
(spontaneous and indicated)
This care process model (CPM) was developed by Intermountain Healthcare’s
OB Development Team under the guidance of the Women and Newborns
Clinical Program. It recommends an evidence-based approach for preventing and
managing spontaneous or medically indicated deliveries before 37 weeks gestation.
Why Focus ON Preterm Birth?
• It’s common. Approximately 12% of U.S. births occur before term. 1,2
Of these, about 70% to 80% are spontaneous preterm births (PTBs); the
remaining are medically indicated due to maternal or fetal problems. 3
• It’s dangerous. PTB accounts for 75% of perinatal deaths and is a major
determinant of short- and long-term morbidity in infants and children. 2,3
Up to 50% of cases of long-term neurologic impairment in children are
attributed to PTB. 1
• It’s expensive. The Institute of Medicine estimates that the combined annual
cost of PTB in the U.S. is $26.2 billion — more than $51,000 per infant. 4
• Consistent, evidence-based care can improve outcomes. Effective clinical
practice has been hampered by numerous challenges: the pathophysiology
of preterm labor remains poorly understood; there are few interventions
supported by evidence; the few available interventions don’t work for all
women. 5,6 Nevertheless, studies suggest that we can improve clinical outcomes
if we consistently identify patients at risk for PTB and, when possible, provide
appropriate, risk-specific treatment to prevent or mitigate it. 2,7-9 Additionally,
a practical and evidence-based approach to managing preterm labor (PTL)
should help us use resources wisely and know which women can be safely
discharged without treatment.
What’s inside
PTB Prevention.................... 2
PTB Prevention Map. . ................ 2
PTB Risk Factors, Interventions.......... 3
Recommended Evaluations. . .............. 4
Estimating PTB Recurrence. . .............. 5
Supporting Planned &
Healthy Pregnancies.......................... 9
Substance Use Screening &
Intervention....................................... 11
Risk-specific Protocols
for Care in Pregnancy. . .................... 12
Prior Spontaneous PTB....................... 13
Prior Indicated PTB-Preeclampsia........ 14
Short Cervix...................................... 15
Chronic Hypertension during
Pregnancy........................................ 16
IDDM............................................... 17
Twins.. .............................................. 18
APS.................................................. 19
Discussions: Cerclage &
Progesterone................................ 20
PTL Management............... 22
PTL Management Algorithm...... 22
Algorithm Notes & Medication Table.... 23
Resources & References...... 24
Summary of Resources................... 24
Key Recommendations for
•
Providers
Identify all patient risk factors for preterm birth — and implement
best-practice interventions to lower these risks. This CPM gives numerous
recommendations for screening, education, medication, monitoring, and other
measures to prevent PTB.
•
Use every contact with your patient — before, during, and after pregnancy —
to educate her about preterm birth and what she can do to lower her risk of
delivering early. For a woman with a prior preterm birth, education should include
an individual PTB recurrence risk assessment.
•
Follow the risk-specific care protocols presented in this CPM, noting that among
the clinical interventions supported by evidence, the appropriate use of progesterone
and cerclage yield the most improvement in outcomes.
References. . .................................. 26
Goals & Measures
This CPM aims to help reduce the rate
of preterm birth among our patients
and to improve clinical and financial
outcomes associated with preterm birth.
As part of its implementation,
Intermountain measures several aspects
of care; these are identified in the
text by the measurement symbol.
Prevention and management of preterm birth
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PTB Prevention Map
Most preterm birth occurs among women with no known risk factors — and there are few interventions proven effective to address
known risks. 10,11 Nevertheless, recent studies show that targeted prevention efforts can yield positive results and that even a modest
reduction in PTB has significant impact, improving lives and lowering costs. 7,9, 12-16 The map below outlines how Intermountain
pursues this reduction, by focusing on key moments of contact with patients before, during, and after pregnancy; identifying
PTB risk factors as early as possible; and aggressively providing best-practice interventions to lower risk and improve outcomes.
The map also identifies the measures we’ll use to assess practice and document the impact of implementing the model across the
Intermountain system.
Postpartum Care
Preconception Care
Prenatal Care
FOR ALL PATIENTS, as part of routine
preconception care:
FOR ALL PATIENTS, as part of routine
prenatal care:
•• Identify PTB risk factors and
counsel/ refer /treat as
appropriate (page 3); note these
recommended interventions:
–– SCREEN for and TREAT
asymptomatic bacteriuria
–– SCREEN for and TREAT smoking
and substance abuse
–– SCREEN for short cervical
length on routine anatomic survey
(abdominal u/s)
•• Identify PTB risk factors and
counsel/ refer /treat as
appropriate (page 3); note these
recommended interventions:
–– COUNSEL re: family planning
–– SCREEN for and TREAT all
genitourinary infections
–– SCREEN for and TREAT smoking
and substance abuse
–– OPTIMIZE treatment of
chronic disease
•• SET EXPECTATIONS for prenatal
care, especially for patients with
IDDM, APS chronic hypertension
and other conditions requiring special
care during pregnancy (pages 12–19)
Patient with
prior PTB?
Of all risk factors,
prior PTB is most
strongly associated
with PTB
Patient with any of these risk factors:
prior PTB
short cervical length on transvaginal u/s
multiple gestation
chronic hypertension
IDDM
APS?
Provide interventions listed above and
Provide interventions listed
above and
•• Determine and discuss:
–– evaluations recommended or
received (page 4)
–– patient’s PTB recurrence risk
(pages 5–7)
–– interventions recommended
before or during next pregnancy
(pages 12–19)
•• Follow RISK-SPECIFIC care
protocol (pages 12–19); protocols give
guidance re:
–– medication (17P, progesterone
suppositories, antihypertensives, ASA,
VTE prophylaxis, etc.)
–– cerclage placement
–– extra monitoring for mother and baby
–– timing of delivery
•• In the hospital, before patient
is discharged
•• In targeted follow-up, with
patients with prior PTB
FOR ALL PATIENTS, before
hospital discharge:
•• Counsel re: family planning,
especially the importance of ≥18
month pregnancy interval and need
for highly effective contraception
(page 8)
Patient with
prior PTB?
In the hospital and in follow-up visits
(at the NICU bedside, in the clinic),
provide interventions listed above and
•• Determine and discuss:
–– evaluations recommended or
received (page 4)
–– patient’s PTB recurrence risk
(pages 5–7)
–– interventions recommended
before or during next pregnancy
(pages 12–19)
•• PROVIDE highly effective
contraception (page 9), if not
already done
Measures:
•Screen for short cervix on routine anatomic survey (all patients)
•Provide progesterone as appropriate (patients with prior PTB and/or short cervix)
•Offer cervical cerclage as appropriate (patients with short cervix)
Preventive care supported by intermountain Patient education: See page 25 for a list of relevant materials for patients and families
2 ©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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prevention and management of preterm birth
PTB Risk Factors and Interventions
The table below lists risk factors and preventive interventions for spontaneous and indicated preterm birth. Note that there are often
multiple associations between risk factors and that for most of these factors, no PTB interventions are supported by evidence.
• Factors in boldface are most strongly associated with PTB. 2,10,17
• Factors iningray
grayshaded
shadedareas
areas have preventive interventions recommended in this CPM.
RISK FACTORS for spontaneous or indicated PTB
Family
planning
Interpregnancy interval <6 months
Maternal age <18 or >40
Treatment for infertility
Infection
Asymptomatic bacteriuria
Other genitourinary infections,
including bacterial vaginosis, other STIs
Pyelonephritis
Appendicitis
Pneumonia
Systemic infection
General
maternal
health,
lifestyle
•• For infertility treatment, implement measures to reduce chance of multiple gestation
(page 10).
•• At a preconception consult, screen for and treat all genitourinary infections,
including STIs.
•• In prenatal care:
–– Screen all patients for asymptomatic bacteriuria in first trimester (urine culture);
treat all cases.
–– Screen for bacterial vaginosis in all patients with prior PTB, and treat all cases. BV
increases the risk of PTB by almost 300%. 2
–– Treat other infections selectively; most studies show no reduction in PTB with treatment,
though it may be recommended to prevent other maternal/fetal complications. Note that
you should NOT treat trichomoniasis in pregnancy; treatment increases PTB risk. 10
–– Screen for risk factors such as smoking and substance abuse; treat/refer as needed
Substance abuse
Chronic hypertension
APS (antiphospholipid antibody syndrome)
Poor nutrition, either low or high BMI
Periodontal disease
Anemia (but not in 3rd trimester)
Low socioeconomic status, education
Inadequate prenatal care
Anxiety, depression
Life events (divorce/separation, death)
Prior preterm delivery
(page 11).
–– For patients with IDDM, APS, or other chronic condition, optimize management
(may need to consult with other providers to adjust treatment plan).
•• In prenatal care:
–– Provide smoking cessation counseling and referrals; refer for substance abuse
counseling (page 11). Cocaine and opioid use are strongly associated with PTB.
–– Follow care protocols for patients with:
›› Chronic hypertension: BP monitoring and antihypertensive therapy initiated as
needed; possible medication for fetal benefit; fetal surveillance (page 16)
›› IDDM: frequent monitoring of BG and BP; optimizing DM control and initiating
antihypertensive medication as needed; fetal surveillance; possible medication for
fetal benefit (page 17)
›› APS: BP monitoring and antihypertensive medication as needed; low-dose ASA; VTE
prophylaxis, fetal surveillance (page 19)
•• In prenatal care:
Short cervix on transvaginal
ultrasound (TVU)
–– Screen for short cervical length at time of fetal anatomic survey at 18–20 weeks
Multiple gestation
–– Follow care protocols for patients with:
Uterine anomaly, leiomyoma
History of cervical surgery, anomaly
Polyhydramnios
History of second trimester abortion
Family history of PTB (first-degree relative)
Excessive uterine contractility
Placenta previa or placental abruption
Vaginal bleeding, esp. after 1st trimester
Abdominal surgery
Fetal growth restriction
Fetal anomaly
Ethnicity
•• In preconception and postpartum contact, counsel on family planning, especially the need
for highly effective contraception and the benefits of an interpregnancy interval ≥18
months (page 9).
•• At a preconception consult:
Smoking
IDDM (insulin-dependent diabetes)
Pregnancy,
reproductive
history
and health
Recommended Preventive interventions
gestation; if <3 cm, schedule TVU
›› Prior spontaneous PTB: 17P initiated at 16 weeks; possible cerclage; possible
antibiotics, tocolysis, possible medication for fetal benefit (page 13)
›› Prior indicated PTB due to preeclampsia: BP monitoring and antihypertensive
therapy initiated as needed; low-dose ASA; possible heparin; possible medication for
fetal benefit; fetal surveillance (page 14)
›› Short cervix: vaginal progesterone (suppositories or gel); possible inpatient
observation; possible cerclage; possible medication for fetal benefit (page 15)
›› Twins: confirm placentation (TTTS checks twice monthly if mono/di); TVUs; fetal
growth assessment; BP monitoring with antihypertensive therapy as needed; possible
steroids; fetal surveillance (page 18)
African-American
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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Prevention and management of preterm birth
Key Actions for providers:
ˆˆ In the weeks after a PTB,
follow up, evaluate as needed
to understand risks, and guide
future management.
Preventing PTB:
Can it be done?
How much does it matter?
One recent Utah-based study of women
with a history of PTB demonstrated that
targeted, evidence-based care in a PTB
prevention clinic can result in 7:
•
Lower rates of recurrent spontaneous
PTB (48.6% for those receiving specialty
care, vs. 63.4% for usual-care patients).
•
Later deliveries (36.1 weeks vs. 34.9
weeks).
•
Lower rates of composite major neonatal
morbidity (5.7% vs. 16.3%).
Additionally, data show that it is possible
to reduce the rate of PTB on a larger
scale — and that even a modest reduction
has a significant and lasting impact.
•
•
•
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Recommended Evaluations After PTB
Prior preterm birth is the greatest risk factor for preterm birth. All patients with this
history warrant special care in subsequent pregnancies — and some may also benefit
from follow-up evaluation in the weeks after the PTB.
The list below shows the evaluations recommended after a preterm birth in three
particular circumstances. Evaluation results may help you identify underlying risk
factors, estimate risk of PTB recurrence for subsequent pregnancy, guide management of
the patient’s overall health, and indicate need for special care in subsequent pregnancies.
Spontaneous PTB at less than 28 weeks gestation
• Consider ordering HSG or sonohysterogram after 6 weeks postpartum
to check for uterine anomaly or pathology. Up to 20% of women with second
trimester losses and/or preterm birth may have uterine cavity anomalies. 8
• Recommend preconception consult to set expectation for 17P at 16 weeks
gestation, possible cerclage (per care protocol page 13).
Indicated PTB at less than 28 weeks gestation due to
severe preeclampsia, HELLP
• Evaluate for APS. Order test for lupus anticoagulant, anticardiolipin antibodies,
and anti-beta 2 glycoprotein 1 antibodies.
• Check blood pressure at 6 weeks postpartum; if >140/90 mm Hg, take steps to
manage hypertension.
• Recommend preconception consult to assess risk and to plan management prior to
and during next pregnancy (per care protocol page 14).
Indicated PTB due to IDDM
After Utah accepted the challenge of The
Association of State and Territorial Health
Officials (ASTHO) and the March of
Dimes to prevent preterm birth, statewide
rate of PTB has decreased from 9.78% to
9.13% between 2009 and 2012.18
• Check HbA1C at 6 weeks postpartum visit or as possible.
This 0.6% reduction in three years
represents approximately 1,000 fewer
preterm deliveries and a significant
decrease in associated morbidity,
mortality, and cost.
• Follow-up with endocrinology. Share notes with the provider who regularly
Reaching the ASTHO goal of 8.9% PTB
rate for Utah would mean an estimated
savings of $24 million annually.
4 • Evaluate renal function as needed. Patients with known renal compromise prior to
pregnancy or with history of worsening renal function during pregnancy should have
baseline renal function evaluated after pregnancy.
oversees patient’s diabetes treatment and agree on goals for blood glucose control in
advance of any future pregnancies.
• Recommend preconception consult to assess adequacy of blood glucose control,
to assess risk, and to plan management before and during next pregnancy (per care
protocol page 17).
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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prevention and management of preterm birth
Estimating PTB Recurrence
A previous PTB is the single greatest risk factor for subsequent PTB. In several
studies the recurrence rate ranges from 25% to 40% depending on the number and
severity (very early or late preterm) of spontaneous PTBs, the number of term births,
and birth order. 17,19,20 Approximately 15% of all spontaneous PTBs occur in women
with a prior spontaneous PTB. 21
This CPM recommends estimating — and communicating to the patient — the risk
of PTB recurrence. Doing so can powerfully support best-practice interventions in
subsequent pregnancies, allowing you to:
• Highlight the importance of early and aggressive intervention
• Estimate the impact of potential interventions
Key moments,
key questions
After a preterm birth, take every
opportunity to teach your patient:
•
Postpartum, before she is discharged
from the hospital
•
At the NICU bedside
•
In maternal follow-up visits at the clinic
•
In pediatric clinic visits
•
Through outreach by your practice
(letters, emails, phone calls)
Teaching should answer these three
patient questions 23:
• Emphasize warning signs and need for evaluation
Research suggests that this aspect of care is often overlooked: Among women
whose pregnancies had ended in very preterm birth, only 24.3% were aware of
their individual PTB risk. 22 The following sections explain how to estimate a
patient’s individual risk based on the figures provided.
•
“Why did this happen?”
•
“What are the chances of this
happening again?”
•
“How can I prevent another
preterm birth?”
About the risk estimate tools
Estimates of PTB recurrence risk use data from several sources depending on the
cause of the previous PTB. Most recurrence risks are based on the number and
severity of previous PTB and whether or not the patient has had an intervening
uncomplicated pregnancy. All of the estimation tools included in this CPM use
information that is readily available at the time of a preconception consultation or
even a first prenatal visit.
Intermountain’s
Preterm Birth Risk Worksheet
Patient communication
tool: PTB Risk Worksheet
Use Intermountain’s fact sheet,
Preterm Birth Risk Worksheet, to
create personalized education for
women who have had a previous
PTB. The worksheet can help
you communicate:
•
Individual circumstances and
factors in the patient’s PTB
•
Her individual risk assessment
•
Recommended evaluations
or follow-up
•
Opportunities to lower PTB risk for
future pregnancies: contraception
to achieve pregnancy interval
greater than 18 months, smoking
cessation, etc.
•
Expectation of special prenatal care
in the future (for example, a patient
with IDDM will require extra
monitoring during pregnancy)
YOUR PREVENTION PLAN
What you can do to lower your risk of another preterm birth
We suggest these steps (your healthcare provider will check all that apply to you):
Wait 18 months before considering another
pregnancy. To ensure this spacing, use a highly
effective contraception such as an IUD or implant.
ˆ Have an imaging test to check for a problem
with your uterus. Name of the test:
ˆ Have a blood test to check for a condition that
may affect you and your pregnancies. Name of
the recommended test(s):
ˆ Start 17P by the 16th week of your next
pregnancy. Your doctor will prescribe and give
the 17P medication in weekly injections. For
some women with a prior preterm birth, 17P
treatment in the second trimester of pregnancy
lowers the risk of preterm birth.
ˆ Have a cervical cerclage in your next
pregnancy. This is a procedure to stitch your
cervix closed. Studies show that for some
women with a history of preterm delivery,
cerclage helps prolong pregnancy and prevent
premature birth.
ˆ Take low-dose (81 mg) aspirin every day
before (or early in) your next pregnancy.
ˆ Take medication to help lower your
blood pressure.
ˆ Meet with your doctor before your next
pregnancy to discuss ways to reduce your risk
Give this worksheet along with the
general-use fact sheet, Preterm
Birth: 10 Steps to Help Prevent It.
See page 25 for a list of all related
patient and provider resources and
instructions for accessing them.
of delivering early again.
ˆ Other actions:
ˆ Have your doctor measure cervical length by
ultrasound in your next pregnancy. Cervical
shortening early in pregnancy can be a warning
sign of preterm labor.
For more advice and information, ask
your provider for Intermountain’s
fact sheet, Preterm Birth: 10 Steps
to Help Prevent It.
Also visit the official website for the March of
Dimes. The March of Dimes is an international
nonprofit organization dedicated to helping women
have full-term pregnancies and researching the
problems that threaten
the health of babies:
www.marchofdimes.com.
© 2014 Intermountain Healthcare. All rights reserved. The content presented here is for your information only. It is not a substitute for professional medical advice, and it
should not be used to diagnose or treat a health problem or disease. Please consult your healthcare provider if you have any questions or concerns. More health information is
available at intermountainhealthcare.org. Patient and Provider Publications 801-442-2963 FS405 - 06/14 Also available in Spanish.
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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Prevention and management of preterm birth
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Spontaneous preterm birth: risk of recurrence
For patients with a history of spontaneous PTB, the number and order of previous
deliveries, both term and preterm, may be used to estimate the risk in a subsequent
pregnancy. The recurrence risk estimation tool below (Figure 1) uses information
gathered on all singleton preterm births in the state of Utah between 1989 and 2002.17
The tool shows the outcomes of a subset of study participants (17,410 women) with three
consecutive births.
Women with prior PTB may have lower
rates of recurrent PTB when prenatal care
emphasizes open communication between
the patient and her caregivers. 9
To use this tool to calculate the risk of spontaneous PTB in the current pregnancy,
follow the order of the 2 most recent pregnancies of the patient. For example, a woman
with a history of spontaneous PTB in her penultimate (second to last) pregnancy and a
term birth in her most recent pregnancy would be estimated to have a risk of 16.1% for
spontaneous PTB in the current pregnancy. A woman with two previous spontaneous
PTBs would be expected to have a risk of 46.2%.
FIGURE 1. Spontaneous Preterm Birth: Risk of Recurrence 17
Proportion of preterm births (<37 weeks) in a woman’s first, second, and third birth,
excluding women with any indicated preterm inductions (n=17410).
Term
n=15947
91.6%
Term
n=14908
93.5%
RR=1.00
Preterm
n=1463
8.4%
First Birth
Preterm
n=1039
6.5%
Second Birth
Term
n=1067
72.9%
RR=4.15
(3.8-4.6)
Preterm
n=396
27.1%
Third Birth
Term
n=14039
94.2%
Preterm
n=869
5.8%
RR=1.00
6 Term
n=762
73.3%
Preterm
n=277
26.7%
RR=4.81
(4.1-5.2)
Term
n=895
83.9%
Preterm
n=172
16.1%
RR=2.95
(2.4-3.2)
Term
n=213
53.8%
Preterm
n=183
46.2%
RR=7.93
(7.0-9.0)
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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prevention and management of preterm birth
Indicated preterm birth: risk of recurrence
In general, maternal and fetal factors that necessitate preterm delivery also increase the risk
of recurrent PTB, both indicated and spontaneous. An indicated PTB is associated with an
increased risk for subsequent spontaneous PTB because indicated and spontaneous PTBs
often share the same underlying etiologies, such as inflammation or stress.
Key Actions for providers:
ˆˆ For all women with prior PTB,
counsel on recurrence risk,
recommended interventions.
• Use the tool below (Figure 2) to calculate recurrence risk after an indicated
PTB due to preeclampsia.
• To calculate recurrence risk after a PTB due to any other maternal or fetal
indication, use the tool (Figure 3) on the following page.
Risk after an indicated PTB due to preeclampsia
An estimate of the risk of recurrence following a PTB due to preeclampsia can be
made using information reported in the literature. 24 Investigators found that the rate of
recurrence in this situation is influenced by two factors: the gestational age of the most
recent PTB and the patient’s BMI. Earlier gestational age and increasing BMI are both
associated with an increasing risk of recurrence.
To use the Figure 2 tool to calculate the risk of preeclampsia recurrence, locate the
patient’s BMI in the appropriate GA category (categories are gestational age at time
of previous PTB due to preeclampsia). For example, a woman with a previous PTB due
to preeclampsia at 30 weeks gestation and a BMI of 23.0 would be expected to have a
recurrence risk of 29.3%.
FIGURE 2. Preeclampsia: Risk of Recurrence 24
Preeclampsia recurrence risk estimates, based on maternal BMI and gestational age at time
of prior indicated PTB due to preeclampsia. Developed from outcome data for singleton
births in more than 100,000 women between 1989 and 1997.
12.5
BMI >35.0
BMI 30.0–34.9
BMI 25.0–29.9
2.3
BMI 18.5–24.9
0
1.0
<18.5
10
8.6 9.4
GA at prior delivery: 20–32 weeks
17.2
14.3
1.7
4.6
1.0
10.3
5.0
GA at prior delivery: 33–36 weeks
Prior preeclampsia
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
29.1
17.5 17.8
12.4
9.5
7.7
5.0
3.6
1.0
2.0
0.6
BMI >35.0
20
25.0
BMI 30.0–34.9
23.1
25.3
BMI 25.0–29.9
BMI 18.5–24.9
BMI <18.5
29.3 30.6
32.4
BMI >35.0
BMI 18.5–24.9
30
40.0
BMI 30.0–34.9
BMI 25.0–29.9
BMI <18.5
40
BMI
Preeclampsia risk (%) in second pregnancy
50
GA at prior delivery: 37–47 weeks
No prior preeclampsia
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Prevention and management of preterm birth
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Risk after an indicated PTB due to maternal or fetal factors
The recurrence risk estimation tool below (Figure 3) was developed based on outcomes of more than 70,000 women who delivered in
the state of Utah between 1989 and 2007.25
To use this tool to calculate the risk of PTB in the current pregnancy, track the outcome(s) beginning with the patient’s first indicated PTB.
For example, a woman who experienced an indicated PTB in her first pregnancy has an overall PTB risk of 17.5% (1.3% risk for preterm
premature rupture of membranes (pPROM) + 7.2% risk for spontaneous PTB (sPTB) + 9.0% risk of indicated PTB) in her next pregnancy.
In addition, if the woman experiences another indicated PTB in her second pregnancy, her overall risk for recurrence of any type of PTB in
her third pregnancy is estimated to be 51.3% (4.3% risk for pPROM + 9.4% risk for sPTB + 37.6% risk for indicated PTB).
FIGURE 3. PTB Recurrence Risk After Indicated Preterm Birth 25
Outcomes across Utah women’s first through third live births between 1989 and 2007,
stratified by outcome in first live birth (N=76,657 women).
Live Birth 1
Live Birth 2
Live Birth 3
Term birth
923 (86.6%)
Term birth
1,066 (82.4%)
pPROM
11 (1.0%)
sPTB
57 (5.3%)
Indicated PTB
75 (7.0%)
Term birth
10 (58.8%)
pPROM
17 (1.3%)
pPROM
1 (5.9%)
sPTB
2 (11.7%)
Indicated PTB
4 (23.5%)
Indicated PTB
1,293 (1.7%)
Term birth
52 (55.9%)
sPTB
93 (7.2%)
pPROM
2 (2.2%)
sPTB
23 (24.7%)
Indicated PTB
16 (17.2%)
Term birth
57 (48.7%)
Indicated PTB
117 (9.0%)
pPROM
5 (4.3%)
sPTB
11 (9.4%)
Indicated PTB
44 (37.6%)
8 ©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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prevention and management of preterm birth
Supporting Planned and Healthy Pregnancies
Key Actions for providers:
Several of the strongest risk factors for PTB are in the domain of family planning. This
section focuses on what providers can do to lower risks of short interpregnancy intervals,
unplanned pregnancies, and multiple gestations (in context of fertility treatment).
ˆˆ Promote interpregnancy interval
≥18 months.
ˆˆ Offer highly effective
Pregnancy spacing and planned pregnancies
contraception.
Multiple studies have demonstrated the value of interpregnancy intervals of 18 months
or greater. 26-28 Providers should therefore actively promote the use of highly effective
contraception at every possible patient contact — in the hospital after a birth, in
postpartum follow-up, in preconception consults.
• Educate patient and family to promote an interpregnancy interval of
18 months or greater. Ask about their desired family size and the timing
they envision. Consider the talking points in the sidebar at right.
• Make it easy for your patient to begin contraception. Offer contraception
early and often. Use the chart shown below, and privilege these options in order:
Talking points: discussing
birth control in the
postpartum period
•
Half of all pregnancies are unplanned.
You’ll be busy this year, so let’s make sure
we have a plan in place now.
•
If you don’t want any more children, now
may be the best time to ensure that. Here
are your options for permanent birth
control….
•
If you hope to have another child, it’s best
to have at least two years between them.
This birth spacing improves your chance
for a healthy pregnancy and a healthy
baby. It lowers the chance that your baby
will be born too early or too small.
•
Waiting at least two years also gives your
body a chance to recover and strengthen
after this pregnancy — and gives you a
chance to focus on your new baby.
–– First-line contraception methods: IUD, contraceptive implant (prior to hospital
discharge if able, or at 4 week postpartum visit), or if permanent sterilization
desired, advise vasectomy or female sterilization and provide referral.
–– Second-line contraception methods: Injectable contraception (prior to hospital
discharge, if desired), contraceptive pill, contraceptive patch, or vaginal ring
(earliest initiation possible as appropriate for breast feeding status).
–– Third-line contraception methods: condoms, diaphragm/cap. If using these
methods, encourage use of two or three methods simultaneously.
Comparing effectiveness of contraception methods
most effective
to make the method
more effective…
less than 1 pregnancy per 100 women in one year
highly effective contraception:
the methods in this row prevent pregnancy more than 99% of the time
implants
(Implanon, Nexplanon)
IUD
(Mirena, ParaGard)
female
sterilization
vasectomy
effective contraception:
the methods in this row prevent pregnancy more than 90% of the time
injectables
(Depo-Provera)
birth control pills
patch
diaphragm
spermicides
female condoms
periodic abstinence
(fertility awareness
method, rhythm method)
•• Injectables: Get repeat
injections on time.
•• Birth control pills:
Take a pill every day.
•• Patch, ring: Keep in
place, change on time.
vaginal ring
(NuvaRing)
less effective contraception:
the methods listed below prevent pregnancy 70% and 90% of the time
male condoms
•• Vasectomy
(male sterilization):
Use another method
for first 3 months.
•• Condoms, diaphragm:
Use correctly every time.
•• Periodic abstinence
methods: Use condoms
on fertile days (or
don’t have sex then).
Newer methods such as
Standard Days Method
or Two Day Method may
be easier to use.
•• Spermicide: Use correctly
every time you have sex.
Combine it with another
method (e.g., condoms)
to increase effectiveness.
Patient tool:
fact sheet on Preterm
Birth prevention
Adapted from World Health
Organization materials, this
contraception chart appears in
Intermountain’s fact sheet, Preterm
Birth: 10 Steps to Help Prevent It. Use
it with patients to support counseling
re: highly effective contraception.
Additional fact sheets to support
contraception counseling are:
•
•
Birth Control Basics
Birth Control Pills:
5 Things You Need to Know
See page 25 for a list of all related
patient and provider resources and
instructions for accessing them.
least effective
about 30 pregnancies per 100 women in one year
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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Prevention and management of preterm birth
J u n e 2 014
Strategies for reducing risk of multiple gestation
Key Actions for providers:
ˆˆ When treating for infertility,
implement strategies to lower the
risk of multiple gestation.
Multiple gestation is a major risk factor for preterm birth; since 1980, there has been
a steady increase in the incidence of multiple births. Experts agree that this increase is
due to rise of infertility treatment and calculate that 31:
• 40% of twin births are result of infertility treatment (21% to 23% from ovulation
induction (OI) or superovulation (SO) treatments with medications, 8% to 12%
from artificial reproductive technologies such as in vitro fertilization (IVF) and intra
cytoplasmic sperm injection (ICSI)).
PTB and infertility treatment
In 2004, an estimated 4% of all preterm
births in the U.S. resulted from assisted
reproductive technology (ART), with
associated costs reaching $1 billion. 29,30
• 80% of high order multiple births are the result of infertility treatment (33% to 66%
from OI or SO; 13% to 44% from ARTs).
Given the risks of multiple gestation for both mother and babies, responsible obstetric
care will aim to reduce the likelihood of occurrence. In particular, this CPM
recommends the following care for women seeking treatment for infertility:
• When prescribing fertility medications, start with first-line medications at the
lowest effective dose to achieve the desired outcome.
–– The goal of ovulation induction for anovulatory patients is the maturation and
ovulation of a single follicle.
–– Oral medications such as clomiphene citrate and letrozole are associated
with lower risks of twin and higher order multiple gestations than injectable
gonadotropins; for this reason, clomiphene citrate and letrozole are first line for
ovulation induction or superovulation for patients with WHO class II anovulation.
Productive Endocrinology:
when to refer?
If initial fertility treatments are unsuccessful,
consider referring the patient to a
reproductive endocrinologist. Referrals are
also recommended for patients in these
circumstances (may indicate need for IVF):
Tubal disease
• Decreased ovarian reserve or
advanced maternal age
• Significant male factor infertility
•
Additionally, consider early referrals for
patients with hypothalamic dysfunction;
these patients may require prolonged
ovulation induction with gonadotropins to
achieve ovulation.
Note that for patients with hypothalamic dysfunction, oral medications are
unlikely to be effective; these patients should be referred to a reproductive
endocrinologist to discuss gonadotropin ovulation induction.
–– Do not increase the dose of an oral agent if a patient does not get pregnant in
the first month of treatment unless they fail to respond to the initial dose. Do not
increase the dose for ovulatory patients.
–– Oral or injectable fertility medications should not be used for fertile patients who
only wish to increase the probability of multifetal gestations. Multifetal gestations
are an adverse outcome associated with treating infertility. Decline patient
requests to use infertility medications when they are not indicated.
• For patients with past pregnancies conceived with the assistance of fertility
treatments, don’t immediately assume that the woman will need fertility
treatment to conceive again. Circumstances may change and it is prudent
to re-evaluate the patient’s fertility potential after each pregnancy to decide if
fertility‑promoting medications are indicated.
• Consider referring to a reproductive endocrinologist if initial treatments are
unsuccessful. Also, consider early referral for specific patient populations listed in
the sidebar at left.
• Educate patients about the treatment-associated risks of multiple gestation.
Patients may choose less aggressive regimens when they understand the rationale for
strategies aimed at avoiding multiple gestation. Explain that every risk of pregnancy
is increased in a multiple gestation pregnancy — including the risk of miscarriage
and preterm birth.
10 ©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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prevention and management of preterm birth
Substance Use Screening and Intervention
Of the 4.3 million infants born annually in the U.S., between 800,000 and
1 million are born to women who used drugs during pregnancy. 32
Key Actions for providers:
ˆˆ Screen every patient for substance
use or abuse — and educate
every patient, regardless of
screening results.
• 1 in 5 infants are exposed to nicotine
• 1 in 9 infants are exposed to alcohol
• 1 in 20 are exposed to illegal drugs
Because prenatal substance abuse has a host of direct and indirect effects on the risk of
preterm birth, we recommend the following:
• Screen every patient at each encounter, or at least once per trimester during
pregnancy. This approach reduces subjectivity, discomfort, and bias — and is far
more effective than guessing. Ask about tobacco use, and screen for other substances
using a validated tool like the 4P’s, shown below. 33,34 Also, to identify patients who
take prescription pain medication, consider asking this additional screening question:
“When you have pain, what do you do for the pain?”
In some cases, signs and symptoms will suggest abuse, even when screening
is negative.
Smoking cessation in
pregnancy
Pregnant women are uniquely
receptive to smoking-cessation
programs, especially when physicians
recommend them directly and repeatedly.
Smoking-cessation programs in pregnancy
have been reported to reduce the rate of
preterm birth by 16% to 31%.9
Facts About opioid use
in pregnancy
•
The 4P’s
Women who use opiates are three times
as likely to have preterm birth as those
who don’t. 35
This screening device is often used as a way to begin a discussion about drug or alcohol use.
Any “yes” warrants further assessment.
1. Have you ever used drugs or alcohol during this pregnancy?
2. Have you had a problem with drugs or alcohol in the past?
•
3. Does your partner have a problem with drugs or alcohol?
Utah is a hot spot for opioid use
and abuse. In 2008, Utah’s
age‑adjusted overdose death rate was
18.4 per 100,000; Idaho’s rate for the
same year was almost half that, 9.7. 37
Between 1999 and 2007, Utah deaths
attributed to poisoning by prescription
pain medications increased by over
500%; the Utah Department of Health
reports that “the increase was mostly
due to increased numbers of deaths
from prescription opioid pain
medications, including methadone,
oxycodone, hydrocodone, and fentanyl. 36
4. Do you consider one of your parents to be an addict or an alcoholic?
• Educate every patient — regardless of screening results. You can assume that
all women have some knowledge of the effects of drugs, alcohol, and cigarettes in
pregnancy. Ask patients what they know, then fill in as needed. 34 Make sure patients
understand that prescription medication — not just “street drugs”— can
be misused and present risk. See patient education resources listed on page 25.
• Intervene and refer as needed. For patients at lower risk for substance use, goals
should be to increase insight and awareness about their use and to motivate behavior
change. Patients at higher risk should be referred to specialty care. See page 24.
Like cocaine use, opioid use is an
important risk factor for PTB.
•
Opioid use may be particularly
problematic for women. Some experts
believe that women become dependent on
prescription pain medication more easily
than men. This is especially concerning
given studies showing that, compared
to men, women are more likely to have
chronic pain, are more likely to be given
prescription pain medication, are given
higher doses, and use prescription pain
medication for longer periods of time. 37
•
Treatment helps. Pregnant women
who receive treatment for substance
abuse early in their pregnancy can
achieve the same health outcomes
as pregnant women with no
substance abuse. 38
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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Prevention and management of preterm birth
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Risk-specific Protocols for Care in Pregnancy
About these care protocols
The protocols on pages 13 to 19 aim to
provide consistent, evidence-based care
and education to those women at highest
risk for preterm birth. In a recent pilot study
using the protocols for prior spontaneous
PTB and short cervix, case-control
comparisons showed the following results: MAN
•
28% reduction in spontaneous
PTB <37 weeks gestation
•
Pregnancy prolongation >1 week
on average
•
Reduction in the rate of
neonatal morbidity
The sections that follow provide guidance for prenatal care of patients in any of the
following high-risk circumstances:
• Prior spontaneous PTB. Of the more than 500,000 preterm births in the U.S. each
year, about 15% occur in women with a prior preterm birth. Effective interventions
— such as those presented on page 15 — could potentially eliminate as many as 35%
to 50% of recurrent preterm births. 9
• Prior indicated PTB due to preeclampsia. Preeclampsia and related hypertensive
disorders of pregnancy affect about 6% of all births in the United States. 39 See page
14 for the protocol for managing this risk factor in pregnancy.
• Short cervix during pregnancy. Short cervical length (CL) on ultrasound has been
shown to be one of the best predictors of preterm birth. 40 Progesterone therapy
and cerclage placement are sometimes indicated to manage this risk factor; see the
protocol on page 15 and the discussion on page 20.
• Chronic hypertension during pregnancy. Women with chronic hypertension
are at increased risk of superimposed preeclampsia; however, even those who don’t
develop preeclampsia tend to have poorer perinatal outcomes than other women. 41
Evidence‑based management is focused on close monitoring and management of
blood pressure and increased fetal surveillance. 42 See the protocol on page 16.
• Insulin-dependent diabetes mellitus (IDDM). Diabetes is a risk factor for the
development of preeclampsia. 11 Studies show that good glycemic control prior
to conception and in early pregnancy is associated with significant reductions in
adverse pregnancy outcome (malformation, stillbirth, and neonatal death) and very
premature delivery. 43,44 See page 17 for the protocol.
• Twins. Nearly 60% of twins are born preterm. 45 Care during multiple gestation
pregnancies should include increased fetal surveillance and close monitoring of blood
pressure. Note that although the ACOG Committee Opinion (number 560, April
2013) suggests that mono-di twins be delivered “between 34 weeks and 6 days and
37 weeks and 6 days,” data recently published by Sullivan et al support waiting until
at least 37 weeks to deliver in otherwise-uncomplicated cases of mono-di twins. See
page 18 for guidance. 46,47
• Antiphospholipid antibody syndrome (APS). Approximately one-third of women
with APS will develop preeclampsia during pregnancy. APS is also associated
with numerous other obstetric complications, including recurrent miscarriage,
oligohydramnios, prematurity, intrauterine growth restriction, fetal distress, arterial
or venous thrombosis and placental insufficiency. 48,49 Management of APS in
pregnancy involves medication to prevent thrombosis, increased fetal surveillance,
and close monitoring and management of hypertension; see page 19.
The risk-specific care protocols in this CPM represent best practice based on evidence
and expert opinion. The protocols are meant to serve as a guidelines; modify care as
needed to meet an individual patient’s clinical scenario.
12 ©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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prevention and management of preterm birth
Care Protocol: Prior Spontaneous PTB
Gestational age
Evaluation
Treatment
<20 weeks
gestation
•• Detailed obstetric history with
personalized risk assessment
(see pages 5 to 8).
•• Urine culture.
•• Vaginal wet mount.
•• Transvaginal ultrasound (TVU)
to measure cervical length (CL)
at 16–18 weeks.
•• Initiate 17P at 16 weeks. See progesterone discussion, page 20.
•• Review signs and symptoms
of labor.
•• Urinalysis with culture if
indicated by symptoms or urine
dipstick findings.
•• Vaginal wet mount.
•• TVU CL at 20–23 weeks.
•• Assess compliance with
progesterone therapy.
•• Treat bacteriuria or bacterial vaginosis with antibiotics if test results positive.
20–26 weeks
gestation
•• Treat bacteriuria or bacterial vaginosis with antibiotics if test results positive.
•• Consider prophylactic cerclage, if indicated by CL on TVU. See the Care Protocol:
Short Cervix on page 15, cerclage discussion on page 20.
•• If TVU reveals short cervix:
–– Offer ultrasound-indicated cerclage if CL <2.5 cm and no multiple gestation. See the
Care Protocol: Short Cervix on page 15, cerclage discussion on page 20.
–– Consider vaginal progesterone in addition to or in place of 17P, per the Care Protocol:
Short Cervix on page 15, cerclage discussion on page 20.
–– Monitor for uterine contractions. If documented uterine contractions and patient is >23
weeks gestation, consider management per the PTL Assessment and Management Algorithm
on page 22:
→→ Consider tocolysis. See PTL/PTB Medication Table on page 23.
→→ Consider steroids. See PTL/PTB Medication Table on page 23.
→→ Consider magnesium sulfate. See PTL/PTB Medication Table on page 23.
27–30 weeks
gestation
Patient
educ ation
Material s
•• Review signs and symptoms
of labor.
•• Urinalysis with culture
if indicated.
•• Vaginal wet mount.
•• TVU CL at 26–30 weeks.
•• Assess compliance with
progesterone therapy.
•• Treat bacteriuria or bacterial vaginosis with antibiotics If test results positive.
•• If TVU reveals short cervix, monitor for uterine contractions. If documented uterine
contractions and patient is >23 weeks gestation, consider management per the PTL Assessment
and Management Algorithm on page 22:
→→ Consider tocolysis. See PTL/PTB Medication Table on page 23.
→→ Consider steroids. See PTL/PTB Medication Table on page 23.
→→ Consider magnesium sulfate. See PTL/PTB Medication Table on page 23.
Intermountain fact sheets supporting this risk-specific protocol:
•
•
17P for Preventing Preterm Birth
Cervical Cerclage
Fact sheets available in English and Spanish. See page 25 for a
list of all related resources, instructions for accessing them.
Key Actions for providers:
ˆˆ Initiate 17P before 20
weeks gestation.
ˆˆ Obtain serial cervical length
measurements as indicated
in the protocol.
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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Prevention and management of preterm birth
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Care protocol: Previous Indicated PTB due to Preeclampsia
Gestational age
Recommended Intervention
<20 weeks
gestation
•• Confirm GA/EDC.
•• Check blood pressure (BP) and determine need for treatment; If BP >160/100 mm Hg, initiate antihypertensive therapy:
–– Labetalol – first-line medication choice.
–– Nifedipine – second-line medication choice.
•• Obtain baseline results for:
–– 24-hour urine for total protein and serum creatinine.
–– Liver function (AST/ALT).
–– Platelet count.
•• Initiate low-dose aspirin therapy as early as possible in pregnancy.
•• Initiate home BP monitoring and establish BP review every 2–4 weeks; instruct patient to call if readings are
consistently >160/100.
•• Review signs and symptoms of preeclampsia.
20 –28 weeks
gestation
•• Review BP.
–– If BP consistently >160/100, initiate or increase antihypertensive medication; see first- and second-line medication
choices in row above.
•• Perform ultrasound for fetal growth and AFI at 28–30 weeks gestation in any of these circumstances:
–– If BP is elevated (>140/90).
–– If BP is normal but patient is on antihypertensive therapy.
–– If clinical suspicion of growth restriction.
•• Consider admission to hospital and Maternal-Fetal Medicine consult; treat with magnesium sulfate (if not already
receiving for seizure prophylaxis) and steroids in any of the circumstances listed below; see PTL/PTB Medication Table on page 23:
–– If BP >160/100.
–– If evidence of placental dysfunction (IUGR, oligohydramnios, or elevated umbilical artery Doppler velocimetry).
–– If significant concern for preeclampsia.
29 – 32 weeks
gestation
•• Review BP.
–– If BP consistently >160/100, initiate or increase antihypertensive medication; see first- and second-line medication
choices in first row of this table.
•• Consider admission to hospital and Maternal-Fetal Medicine consult and treat with magnesium sulfate (if not
already receiving for seizure prophylaxis) and steroids in any of the circumstances listed below; see PTL/PTB Medication Table on
page 23:
–– If BP >160/100.
–– If evidence of placental dysfunction (IUGR, oligohydramnios, or elevated umbilical artery Doppler velocimetry).
–– If significant concern for preeclampsia.
•• Initiate antenatal surveillance (nonstress test, amniotic fluid assessment, and biophysical profile) per schedule below:
–– No hypertension, IUGR, or oligohydramnios: consider weekly testing beginning at 32 weeks gestation.
–– Mild hypertension (>140/90) or preeclampsia: test twice a week beginning at 32 weeks or at diagnosis.
–– Severe preeclampsia: test twice a week beginning at 28 weeks or at diagnosis.
Delivery timing
•• Preterm delivery is generally accepted if any of the following are present:
–– Eclampsia.
–– Blood pressure of 160 mm Hg systolic or higher, or 110 mm Hg diastolic or higher on at least two occasions while the patient is at rest
and which does not respond to antihypertensive treatment.
–– Oliguria of less than 500 mL in 24 hours.
–– Cerebral or visual disturbances.
–– Pulmonary edema.
–– Epigastric or right upper-quadrant abdominal pain.
Key Actions for providers:
–– Impaired liver function as demonstrated by elevated liver enzymes (AST >100).
ˆˆ Initiate ASA therapy before 12 weeks
–– Thrombocytopenia (platelet count <100,000).
gestation.
–– Fetal growth restriction or oligohydramnios (in the setting of preeclampsia).
Patient
educ ation
Material s
Intermountain fact sheets supporting this risk-specific protocol:
• 24-hour Urine Specimen
•• Preeclampsia
•• How to Monitor Your Blood Pressure
•• BP Tracker
• Fetal Testing (nonstress test, amniotic fluid assessment, and biophysical profile)
ˆˆ Initiate home BP measuring and
review log every 2–4 weeks.
ˆˆ Follow delivery timing guidelines in
this protocol.
Fact sheets available in English and Spanish. See page 25 for
a list of all related resources, instructions for accessing them.
14 ©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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prevention and management of preterm birth
Care protocol: Short Cervix
Gestational age
PREVIOUS PTB
NO previous PTB
<23 weeks
gestation
If cervical length (CL) 1.50 cm–2.50 cm on transvaginal
ultrasound (TVU):
If cervical length (CL) 1.50 cm–2.50 cm on transvaginal
ultrasound (TVU):
•• Refer for Maternal-Fetal Medicine consult; patient should be
seen within one week (ideally within 1 or 2 days).
•• Refer for Maternal-Fetal Medicine consult; patient
should be seen within one week (ideally within 1 or 2 days).
•• Start or adjust progesterone therapy; note that for patients
with both short cervix and prior PTB, evidence re: the best form
of progesterone is unclear (see progesterone discussion page 20).
Give ANY ONE of the following acceptable options:
•• Start vaginal progesterone therapy, either crinone gel
(8% - 90 mg progesterone daily), OR natural progesterone
vaginal suppositories (200 mg nightly).
–– Vaginal progesterone: either crinone gel (8% - 90
mg progesterone daily), OR natural progesterone vaginal
suppositories (200 mg nightly).
–– 17P injections, per prior PTB protocol (see page 13).
–– BOTH 17P injections and vaginal progesterone
(gel or suppository).
If CL <1.50 cm on TVU:
•• Refer immediately to labor and delivery for further assessment.
•• Admit patient for a minimum 23-hour observation period
to assess for active labor and/or intra-amniotic infection
(IAI). The CL will be reassessed via sterile digital examination
and/or TVU at the discretion of the attending physician.
–– If evidence of active labor and/or IAI at <24.0 weeks gestation,
counsel the patient regarding risks of maternal morbidity
with attempted continuation of pregnancy.
–– If no evidence of active labor or IAI, offer an
ultrasound‑indicated cerclage placement
(unless multiple gestation; see cerclage discussion page 21).
Consider amniocentesis prior to cerclage placement.
•• Start or adjust progesterone therapy; note that for patients
with both short cervix and prior PTB, evidence re: the best form of
progesterone is unclear (see discussion page 20). Give ANY ONE
of the following acceptable options:
–– Vaginal progesterone: either crinone gel (8% - 90 mg progesterone
daily) OR natural progesterone vaginal suppositories (200 mg nightly).
–– 17P injections, per prior PTB protocol on page 13.
–– BOTH 17P injections and vaginal progesterone (gel or suppository).
23–28 weeks
gestation
•• Consider serial
cervical length
every 2 weeks
until 28 weeks
gestation
•• If further
shortening noted:
–– Add tocolysis
If CL <2.5 cm:
•• Refer immediately to labor and delivery for further assessment.
•• Admit patient for a minimum 23-hour observation period
if contractions are noted.
•• Give steroids. See PTL/PTB Medication Table on page 23.
•• Give magnesium sulfate. See PTL/PTB Medication Table on
page 23.
•• If evidence of regular contractions on uterine monitor,
give tocolysis. See PTL/PTB Medication Table on page 23.
with nifedipine
–– Treat with
steroids if not
done previously
Patient
educ ation
Material s
Intermountain fact sheets supporting this risk-specific protocol:
• 17P for Preventing Preterm Birth
• Cervical Cerclage
Fact sheets available in English and Spanish. See page 25 for
a list of all related resources, instructions for accessing them.
If CL <1.50 cm on TVU:
•• Refer immediately to labor and delivery for
further assessment.
•• Admit patient for a minimum 23-hour observation
period if contractions are noted. The CL will be reassessed
via sterile speculum examination and/or TVU at the discretion
of the attending physician.
–– If evidence of active labor and/or IAI at <24.0 weeks
gestation, counsel the patient regarding risks
of maternal morbidity with attempted continuation of
pregnancy.
–– If no evidence of active labor or IAI AND membranes visible
on sterile digital exam, offer an ultrasound-indicated
cerclage placement (unless multiple gestation; see
discussion page 21). Consider amniocentesis prior to
cerclage placement.
•• Start vaginal progesterone therapy, either crinone gel
(8% - 90 mg progesterone daily), or natural progesterone
vaginal suppositories (200 mg nightly).
If CL 1.5 cm–2.5 cm:
•• Monitor for uterine contractions:
–– If no contractions, discharge with follow-up in one week.
–– If contractions noted, admit the patient. See pages 22–23.
If CL <1.5 cm:
•• Refer immediately to labor and delivery for further
assessment.
•• Admit patient for a minimum 23-hour observation
period if contractions are noted.
•• Give steroids. See PTL/PTB Medication Table on page 23.
•• Give magnesium sulfate. See PTL/PTB Medication Table
on page 23.
•• If evidence of regular contractions on uterine
monitor, give tocolysis. See PTL/PTB Medication Table on
page 23.
Key Actions for providers:
ˆˆ Initiate progesterone therapy
at diagnosis, and promote
adherence to therapy
throughout the pregnancy
ˆˆ Offer cervical cerclage
as/when appropriate.
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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Prevention and management of preterm birth
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Care protocol: Chronic Hypertension during Pregnancy
Gestational age
<20 weeks
gestation
Recommended Intervention
•• Confirm GA/EDC.
•• Check blood pressure (BP) and determine need for treatment; if BP >160/100, initiate antihypertensive therapy:
–– Labetalol – first-line medication choice.
–– Nifedipine – second-line medication choice.
•• Obtain baseline results for:
–– 24-hour urine for total protein and serum creatinine.
–– Liver function tests.
–– Platelet count.
•• Initiate home BP monitoring and establish BP review every 2 to 4 weeks; instruct patient to call if readings are
consistently >160/100.
•• Review signs and symptoms of preeclampsia.
20–28 weeks
gestation
•• Perform ultrasound to assess fetal growth and AFI at 28–30 weeks gestation.
•• Check BP and determine need to initiate or adjust antihypertensive therapy (see first- and second-line choices in row
above); consider antenatal surveillance if hypertension or preeclampsia (see schedule in the row below).
•• Repeat 24-hour urine test if evidence of proteinuria on urine dip or concern re: preeclampsia.
•• If indications of superimposed preeclampsia or placental dysfunction:
–– Admit for evaluation of maternal/fetal condition. Transfer to tertiary care center if appropriate NICU services
are not available.
–– Give steroids. See PTL/PTB Medication Table on page 23.
–– Give magnesium sulfate (if not already receiving for seizure prophylaxis). See PTL/PTB Medication Table on page 23.
29–32 weeks
gestation
•• Check BP and determine need to initiate or adjust antihypertensive therapy (see first- and second-line choices in
row above).
•• If indications of superimposed preeclampsia or placental dysfunction:
–– Admit for evaluation of maternal/fetal condition. Transfer to tertiary care center if appropriate NICU services
are not available.
–– Give steroids. See PTL/PTB Medication Table on page 23.
–– Give magnesium sulfate (if not already receiving for seizure prophylaxis). See PTL/PTB Medication Table on page 23.
•• Initiate antenatal surveillance (nonstress test, amniotic fluid assessment, and biophysical profile) per schedule below:
–– No hypertension, IUGR, or oligohydramnios: consider weekly testing beginning at 32 weeks gestation.
–– Mild hypertension (>140/90) or preeclampsia: test twice a week beginning at 32 weeks or at diagnosis.
–– Severe preeclampsia: test twice a week beginning at 28 weeks or at diagnosis.
Delivery timing
Delivery will occur at >37 weeks GA unless one of the following occurs:
•• Severe preeclampsia.
•• Nonreassuring fetal status noted on antenatal surveillance.
Patient
educ ation
Material s
Intermountain fact sheets supporting this risk-specific protocol:
•• How to Monitor Your Blood Pressure
•• BP Tracker
•• Fetal Testing (nonstress test, amniotic fluid assessment, and biophysical profile)
Fact sheets available in English and Spanish. See page 25 for
a list of all related resources, instructions for accessing them.
Key Actions for providers:
ˆˆ Initiate home BP measuring and
review log every 2–4 weeks.
ˆˆ Follow delivery timing guidelines in
this protocol.
16 ©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
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prevention and management of preterm birth
Care protocol: Insulin-dependent Diabetes Mellitus (IDDM)
Gestational age
Recommended intervention
<20 weeks
gestation
•• As early as possible in pregnancy, contact the provider who normally oversees the patient’s diabetes treatment
to establish goals and a plan for caring for the patient in pregnancy.
•• Confirm GA/EDC.
•• Evaluate blood glucose (BG) control:
–– Check HbA1C.
–– Review BG records and document adequacy of BG control; adequate control is >75% of BG values in these target ranges:
››Fasting value <95 mg/dL.
››1-hour postprandial value <140 mg/dL.
››2-hour postprandial value <130 mg/dL.
•• Check blood pressure (BP) and determine need for treatment; if BP >160/100, initiate antihypertensive therapy:
1. Labetalol – first-line medication choice.
2. Nifedipine – second-line medication choice.
•• Obtain baseline results for:
–– 24-hour urine for total protein and serum creatinine.
–– Liver function (AST/ALT).
–– Platelet count.
•• Refer for diabetes education/dietitian consult (see resources page 24).
•• Refer to ophthalmologist for retinal exam.
•• Refer for fetal echocardiogram for any of the following findings:
–– HbA1c >7%.
–– Inadequate views of cardiac and outflow tracts on targeted ultrasound.
–– Suspicious cardiac findings on targeted ultrasound.
•• Establish BG review every 1 to 2 weeks; instruct patient to call if readings are consistently outside target ranges above.
20 –28 weeks
gestation
•• Perform ultrasound to assess fetal growth and AFI at 28–30 weeks GA.
•• Check BP and determine need to initiate or adjust antihypertensive therapy (see first- and second-line choices in row
above); consider antenatal surveillance if hypertension or preeclampsia (see schedule in the row below).
•• Repeat 24-hour urine test if evidence of proteinuria on urine dip or concern re: preeclampsia.
•• Evaluate blood glucose (BG) control:
–– Check HbA1C.
–– Review patient’s BG records and adjust insulin therapy if >25% BG values are out of target range (see row above for targets).
•• If indications of preeclampsia, IUGR, or PTL:
–– Admit for evaluation of preeclampsia, insulin drip, and hourly BG assessment; transfer to tertiary care center if
appropriate NICU services are not available.
–– Give steroids. See PTL/PTB Medication Table on page 23.
–– Give magnesium sulfate. See PTL/PTB Medication Table on page 23.
–– Give tocolysis for PTL indication. See PTL/PTB Medication Table on page 23.
29 –32 weeks
gestation
•• Check BP and determine need to initiate or adjust antihypertensive therapy (see first- and second-line choices in first row).
•• If indications of preeclampsia, IUGR, or PTL:
–– Admit for evaluation of maternal/fetal condition. Transfer to tertiary care center if appropriate NICU services
are not available.
–– Give steroids. See PTL/PTB Medication Table on page 23.
–– Give magnesium sulfate. See PTL/PTB Medication Table on page 23.
–– Give tocolysis for PTL indication. See PTL/PTB Medication Table on page 23.
•• Evaluate blood glucose (BG) control:
–– Check HbA1C.
–– Review patient’s BG records and adjust insulin therapy if >50% BG values are out of target range (see row above for targets).
•• Initiate antenatal surveillance (nonstress test, amniotic fluid assessment, and biophysical profile) per schedule below:
–– Twice weekly at 32 weeks gestation.
–– Mild hypertension or preeclampsia – twice weekly at 32 weeks or at diagnosis.
–– Severe hypertension – twice weekly beginning at 28 weeks.
Delivery timing
Delivery will occur at >37 weeks GA unless one of the following occurs:
•• Severe preeclampsia.
•• Nonreassuring results noted on antenatal surveillance.
•• Severe IUGR (<10%) and oligohydramnios (AFI <5 cm).
Patient education
Materials
Intermountain fact sheets supporting this risk-specific protocol:
• Diabetes Care Before and During Pregnancy
• BG Tracker
Fact sheets available in English and Spanish. See page 25 for a list of all
related resources, instructions for accessing them.
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
Key Actions for providers:
ˆˆ Initiate home BG monitoring and
review log every 1–2 weeks.
ˆˆ Follow delivery timing guidelines in
this protocol.
17
Prevention and management of preterm birth
J u n e 2 014
Care protocol: Twins
Gestational age
Mono-Di Twins
Di-Di Twins
<23 weeks
gestation
•• Confirm GA/EDC.
•• Confirm placentation.
•• Review risks and signs and symptoms of preterm
labor, pPROM.
•• Initiate checks for twin-to-twin transfusion syndrome
(TTTS) every 2 weeks (may be performed in clinic).
•• Measure cervical length (CL) with transvaginal ultrasound
(TVU) at 20–24 weeks gestation; if CL <2.5 cm refer to short
cervix protocol on page 15 for guidance.
•• Confirm GA/EDC.
•• Confirm placentation.
•• Review risks and signs and symptoms of preterm
labor, pPROM.
•• Measure cervical length (CL) with transvaginal
ultrasound (TVU) at 20–24 weeks gestation; if CL <2.5 cm
refer to short cervix protocol on page 15 for guidance.
23–28 weeks
gestation
•• Perform ultrasound to assess fetal growth and AFI
at 28–30 weeks gestation.
•• Check BP and determine need for treatment; if BP
>160/100, initiate antihypertensive therapy:
–– Labetalol – first-line medication choice.
–– Nifedipine – second-line medication choice.
•• Perform glucose tolerance testing at 26–28 weeks.
•• If indications of preeclampsia, IUGR, fetal distress,
or documented preterm labor:
•• Perform ultrasound to assess fetal growth and AFI at
28–30 weeks gestation.
•• Check BP and determine need for treatment; if BP
>160/100, initiate antihypertensive therapy:
–– Labetalol – first-line medication choice.
–– Nifedipine – second-line medication choice.
•• Perform glucose tolerance testing at 26–28 weeks.
•• If indications of preeclampsia, IUGR, fetal distress, or
documented preterm labor:
–– Admit for evaluation of maternal/fetal condition.
Transfer to tertiary care center if appropriate NICU
services are not available.
–– Give steroids. See PTL/PTB Medication Table on page 23.
–– Give magnesium sulfate. See PTL/PTB Medication Table
–– Admit for evaluation of maternal/fetal condition.
Transfer to tertiary care center if appropriate NICU
services are not available.
–– Give steroids. See PTL/PTB Medication Table on page 23.
–– Give magnesium sulfate. See PTL/PTB Medication Table
–– Give tocolysis for PTL indication. See PTL/PTB
–– Give tocolysis for PTL indication. See PTL/PTB
on page 23.
Medication Table on page 23.
29–32 weeks
gestation
•• Perform ultrasound to assess fetal growth and AFI at
28–30 weeks gestation.
•• Check BP and determine need for treatment; if BP
>160/100, initiate antihypertensive therapy. See
medication choices in row above.
•• Initiate antenatal surveillance: twice weekly NST/AFI
beginning at 32 weeks gestation.
•• If indications of preeclampsia, IUGR, fetal distress, or
documented preterm labor:
–– Admit for evaluation of maternal/fetal condition.
Transfer to tertiary care center if appropriate NICU
services are not available.
–– Give steroids. See PTL/PTB Medication Table on page 23.
–– Give magnesium sulfate. See PTL/PTB Medication Table
–– Admit for evaluation of maternal/fetal condition.
Transfer to tertiary care center if appropriate NICU
services are not available.
–– Give steroids. See PTL/PTB Medication Table on page 23.
–– Give magnesium sulfate. See PTL/PTB Medication Table
–– Give tocolysis for PTL indication. See PTL/PTB
–– Give tocolysis for PTL indication. See PTL/PTB
Medication Table on page 23.
Patient education
Materials
Medication Table on page 23.
•• Perform ultrasound to assess fetal growth and AFI at
28–30 weeks gestation.
•• Check BP and determine need for treatment; if BP
>160/100, initiate antihypertensive therapy. See
medication choices in row above.
•• Initiate antenatal surveillance: twice weekly NST/AFI
beginning at 32 weeks gestation.
•• If indications of preeclampsia, IUGR, fetal distress, or
documented preterm labor:
on page 23.
Delivery Timing
on page 23.
Delivery will occur at >37 weeks GA 47 unless one of the
following occurs:
•• Severe preeclampsia.
•• Fetal distress noted on antenatal surveillance.
•• IUGR of one or both infants (<10%).
•• pPROM.
on page 23.
Medication Table on page 23.
Delivery will occur at >37 weeks GA unless one of the
following occurs:
•• Severe preeclampsia.
•• Fetal distress noted on antenatal surveillance.
•• IUGR of one or both infants (<10%).
•• pPROM.
Intermountain fact sheets supporting this risk-specific protocol:
•• Fetal Testing (nonstress test, amniotic fluid assessment, and biophysical profile)
Fact sheets available in English and Spanish. See page 25 for
a list of all related resources, instructions for accessing them.
Key Actions for providers:
ˆˆ Initiate twice weekly NST/AFI
surveillance beginning at 32 weeks.
ˆˆ Follow delivery timing guidelines in
this protocol.
18 ©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
J u n e 2 014
prevention and management of preterm birth
Care protocol: Antiphospholipid Antibody Syndrome (APS)
Gestational age
<20 weeks
gestation
Recommended intervention
•• Obtain consult with Maternal-Fetal Medicine.
•• Confirm GA/EDC.
•• Check blood pressure (BP) and determine need for treatment; if BP >140/90, initiate antihypertensive therapy:
–– Labetalol – first-line medication choice.
–– Nifedipine – second-line medication choice.
•• Obtain baseline results for:
–– 24-hour urine for total protein and serum creatinine.
–– Liver function tests (AST/ALT).
–– Platelet count.
•• Initiate low-dose aspirin therapy as early as possible in pregnancy.
•• Initiate heparin prophylaxis with appropriate monitoring:
–– If NO history of VTE,
›› Give either: heparin 7,500 units subcutaneous twice a day, or Lovenox 40 mg subcutaneous once a day.
›› Follow platelet count every 3 days x 2 weeks to rule out heparin-induced thrombocytopenia (HIT).
–– If HISTORY of VTE,
›› Initiate Lovenox 1 mg/kg subcutaneous twice a day.
›› Follow platelet count every 3 days x 2 weeks to rule out heparin-induced thrombocytopenia (HIT).
›› Adjust dose of Lovenox to achieve serial Anti-Factor Xa levels in the upper half of therapeutic range.
•• Initiate home BP monitoring and establish BP review every 2 to 4 weeks; instruct patient to call if readings
are consistently >140/90 mm Hg.
•• Review signs and symptoms of preeclampsia with the patient.
20 –28 weeks
gestation
•• Perform ultrasound to assess fetal growth and AFI at 28–30 weeks GA.
•• Review BP and determine need to initiate or adjust antihypertensive therapy (see first- and second-line choices in row
above); consider antenatal surveillance if hypertension or preeclampsia develops (see schedule in the row below).
•• If indications of preeclampsia, IUGR or fetal distress:
–– Admit for evaluation of maternal/fetal condition. Transfer to tertiary care center if appropriate NICU services
are not available.
–– Give steroids. See PTL/PTB Medication Table on page 23.
–– Give magnesium sulfate. See PTL/PTB Medication Table on page 23.
29 –32 weeks
gestation
•• Review BP and determine need to initiate or adjust antihypertensive therapy (see first- and second-line choices in
first row above).
•• Initiate antenatal surveillance (nonstress test, amniotic fluid assessment, and biophysical profile) per schedule below:
–– No hypertension, IUGR, or oligohydramnios – weekly at 32 weeks gestation.
–– Mild hypertension or preeclampsia – twice weekly at 32 weeks or at diagnosis.
–– Severe hypertension – twice weekly beginning at 28 weeks or at diagnosis.
•• If indications of preeclampsia, IUGR or fetal distress:
–– Admit for evaluation of maternal/fetal condition. Transfer to tertiary care center if appropriate NICU services
are not available.
–– Give steroids. See PTL/PTB Medication Table on page 23.
–– Give magnesium sulfate. See PTL/PTB Medication Table on page 23.
Delivery timing
Patient
educ ation
Material s
•• Delivery will occur at >37 weeks GA unless one of the following occurs:
–– Severe preeclampsia.
–– Nonreassuring results noted on antenatal surveillance abnormal NST, positive CST, BPP <6 or abnormal UA Doppler.
–– Severe IUGR (<10%) with oligohydramnios (AFI <5 cm).
Intermountain fact sheets supporting this risk-specific protocol:
•• Anticoagulant Injections
•• Preeclampsia
•• How to Monitor Your Blood Pressure
•• BP Tracker
•• Fetal Testing (nonstress test, amniotic fluid assessment, and biophysical profile)
Fact sheets available in English and Spanish. See page 25 for
a list of all related resources, instructions for accessing them.
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
Key Actions for providers:
ˆˆ Initiate ASA therapy before 12 weeks
gestation.
ˆˆ Initiate heparin prophylaxis before 12
weeks gestation.
ˆˆ Follow delivery timing guidelines in
this protocol.
19
Prevention and management of preterm birth
J u n e 2 014
Discussions: Cerclage and Progesterone
Cervical Cerclage
Indications for cerclage
Cerclage is indicated on the basis of patient history, ultrasound finding of short cervix,
and exam. The list below provides notes on each indication.
• History-indicated cerclage:
–– Women with a clear history of cervical insufficiency (painless cervical dilation at
24 weeks or less in a previous pregnancy) may be offered prophylactic cerclage at
12 to 14 weeks gestation. There are no data suggesting whether a McDonald or
Shirodkar cerclage is associated with better outcomes in this setting.
–– For a patient with a history of cervical insufficiency and significant cervical
Cervical Cerclage: This fact sheet
explains indications for cervical
cerclage and summarizes its risks,
potential benefits and alternatives.
Use to support informed consent for
this intervention.
FACT SHEET FOR PATIENTS AND FAMILIES
About the cervix in pregnancy
The cervix is the neck-like opening at the bottom of the
uterus. Normally, the cervix stays closed until about 37
weeks of pregnancy, when it gradually shortens and opens
as the body prepares for childbirth.
To block any pain during the procedure, the woman will
have either regional anesthesia (a spinal or epidural) or
general anesthesia. The procedure itself usually lasts less
than an hour. It’s done in the hospital, usually as an
outpatient procedure.
A cerclage is temporary. It’s removed when the pregnancy
draws close to full term (36 to 37 weeks of pregnancy),
when the woman goes into labor, or if her water breaks
early (premature rupture of membranes) — whichever
comes first.
shortening (CL <2.5 cm) prior to 24 weeks gestation are candidates for
ultrasound-indicated cerclage.
• Exam-indicated:
cerclage
cervix
About cerclage: how is it done?
The closure can be done in different ways. One common
method is to place stitches around the outside of the
cervix. Another method involves tying special tape
around the cervix and then stitching it in place.
–– Women with history of spontaneous preterm birth and with cervical
cervix (without membranes visible) prior to 24 weeks gestation have not been
shown to benefit from cerclage; offer these women vaginal progesterone therapy.
Cervical cerclage is a procedure done in pregnancy to help
prevent preterm birth. It involves temporarily stitching
the cervix closed. This fact sheet explains how it’s done,
why it’s sometimes recommended, and its risks and
potential benefits. It also briefly explains what to expect
before and after a cerclage procedure.
Cervical cerclage involves placing stitches to keep the
cervix closed. The stitches are usually placed transvaginally
(through the vagina), though they can also be placed
through an incision in the abdomen.
• Ultrasound-indicated:
–– Women without a history of spontaneous preterm birth found to have a short
Cervical Cerclage
Sometimes a woman’s cervix will begin to shorten and open
too early in pregnancy. You may have heard this described
as a “weak” or insufficient cervix — and it is a major risk
factor for a preterm birth. Cervical cerclage is one way to
treat this risk factor and possibly prolong a pregnancy.
scarring or a short cervix following LEEP or cervical surgery, the Shirodkar
approach may be best; this patient may also be offered the alternative plan of
expectant management with serial cervical length assessment with transvaginal
ultrasound between 16 and 24 weeks gestation.
–– Women with amniotic membranes visible at the external os of the cervix on
When is cerclage recommended?
Your doctor or midwife may recommend cervical cerclage
in a circumstance such as the following:
speculum exam are candidates for an exam-indicated (or “rescue”) cerclage.
• You have had a previous preterm delivery, and a vaginal
ultrasound shows that your cervix is changing —
shortening or opening — too early in this pregnancy.
• You have had previous pregnancy losses or preterm
deliveries that may be due to a weak cervix. In this case,
your provider may suggest cerclage to try to prevent
another bad outcome in this pregnancy.
• Your doctor or midwife notes cervical changes before
24 weeks of pregnancy and sees that the amniotic sac
(bag of waters) is beginning to bulge through the
opening. In this case, the procedure might be called an
emergency or rescue cerclage.
–– Exam-indicated cerclage should only be placed in women who are less than 24
1
Available in English and Spanish. See
page 25 for a list of all related resources,
instructions for accessing them.
weeks pregnant.
Cerclage removal
• In most cases, the cerclage should be removed when delivery is anticipated — usually
at 36 or 37 weeks in asymptomatic patients. This timing maximizes the chance of fetal
maturity while minimizing the chance of cervical injury due to the onset of labor.
• Women who have threatened preterm birth associated with vaginal pain or bleeding
should have the cerclage removed if attempts at tocolysis are not successful.
• There is some controversy about the timing of cerclage removal after preterm
premature rupture of the membranes. Some literature suggests that the latency will
be prolonged if the cerclage is left in place. However, other studies suggest that there
is an increased risk of infection if the cerclage is left in place. Among maternal-fetal
medicine providers at Intermountain, practice is generally as follows:
–– For women who are greater than 32 weeks gestation, the cerclage is removed at the
time of diagnosis of PROM.
–– For women with preterm PROM at less than 32 weeks gestation, decisions are
made on a case-by-case basis; it’s possible that women at very early gestation may
benefit more from leaving the cerclage in place to help prolong pregnancy.
20 ©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
J u n e 2 014
prevention and management of preterm birth
Cerclage in multiple gestation pregnancies
The role of cerclage in twin pregnancy is unclear. Only a few studies have examined
the use of cerclage for short cervix in twins. Despite the limited information, it appears
that maternal and neonatal outcomes are worse with cerclage for the twin patient with
a short cervix found on transvaginal ultrasound. Thus, cerclage is not recommended in
a twin pregnancy — unless the patient has a prior diagnosis of cervical insufficiency, in
which case she should be offered a prophylactic cerclage.
Progesterone in multiple gestation pregnancies
In twin pregnancies with no history of preterm delivery, 17P does not appear to help
prevent preterm birth. However, when the patient has a history of preterm delivery,
17P may be helpful.
Vaginal progesterone has not been well studied in the context of multiple gestation
pregnancies. In the case of cervical shortening in twins, the benefits of the use of
vaginal progesterone may outweigh the risks.
17P for Preventing Preterm Birth:
This fact sheet explains the
indications for 17P injections and
includes space for provider to write
specific instructions for this therapy.
Available in English and Spanish. See
page 25 for a list of all related resources,
instructions for accessing them.
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
21
Prevention and management of preterm birth
J u n e 2 014
ALGORITHM: PTL Assessment and management
Pregnant patient with SYMPTOMS
consistent with preterm labor (a)
ADMISSION, INITIAL ASSESSMENT
If evident intrauterine
infection, placental
abruption, or fetal
compromise:
•• Determine presence/frequency of contractions (palpation and external monitor),
other signs and symptoms of PTL. (a)
•• Determine whether there is uterine bleeding (suggesting placental abruption, placenta previa).
•• Check fetal well-being with electronic fetal monitor (EFM).
•• Send urine for urinalysis (UA) with reflex to urine culture if positive.
•• Perform sterile speculum exam: visually inspect for PROM, cervicitis, umbilical cord prolapse,
or fetal prolapse; assess cervical dilation and effacement; obtain and hold fetal fibronectin (fFN)
and GBS culture before digital exam (if penicillin allergic, request sensitivities at time of culture).
yes
TVU available?
DELIVER
EXPEDITIOUSLY
If PROM:
FOLLOW
PROM CPM
no
Triage
Triage
•• Do TVU
•• Triage based on cervical LENGTH (cl) on TVU
•• Do digital exam
•• Triage based on cervical Dilation
LOW RISK OF PTB
CL ≥ 3 cm
MEDIUM RISK OF
PTB CL 2–3 cm
HIGH RISK OF PTB
CL < 2 cm
Discard
fFN
Send
fFN
Discard
fFN
negative
fFN
DISCHARGE
HOME.
Follow-up. (b)
≥ 3 cm DILATED
< 3 cm DILATED
Depending on clinical
concern, either:
Discard
fFN
Monitor
positive
fFN
Send
fFN
Check for cervical change
with serial digital exams
every 1–2 hours
negative
fFN
Inpatient care
1. Admit for inpatient management
(transfer to tertiary care center as per
leveling criteria)
2. Consult Maternal-Fetal Medicine and
Neonatology
3. Give IVF hydration
4. Send GBS culture and CBC
Discard
fFN
cervical
change
positive
fFN
NO cervical
Change
DISCHARGE HOME.
Follow-up. (b)
no
TVU available
within 12 hours?
yes
Medication (c)
Use Preterm Labor
Admission Orders
Measures
As appropriate for threatened PTB:
• Admit/transfer to appropriate
facility per leveling criteria
• Administer steroids to lower
RDS risk
• Administer magnesium sulfate
for fetal neuroprotection
Give medication as appropriate for:
––fetal benefit
––tocolysis
––GBS prophylaxis
infants <30 weeks gestation
22 •• Do TVU when available
•• Triage based on cervical LENGTH (cl) on TVU
Delivery
At delivery:
––If <30 weeks milk umbilical cord
(three times, from close to the base of
the placental cord insertion toward the
neonate with 1–2 second pause between.
Total milking time ≅10–15 seconds )
––Obtain cord gas
At delivery:
• Milk umbilical cord of all
Assess further
Cervical LENGTH
< 2.5 cm
Cervical LENGTH
≥ 2.5 cm
Notify perinatal
care manager, then
DISCHARGE HOME.
Follow-up. (b)
Newborn/NICU and postpartum
care for infant and mother
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
J u n e 2 014
prevention and management of preterm birth
Algorithm notes
Identifying women with preterm contractions who will deliver early is an inexact process. In one review, about 30% of preterm labors
resolved spontaneously. Others have reported that 50% of patients hospitalized for PTL go on to deliver at term. 3 This algorithm presents
a practical and evidence-based approach to assessing and managing women with symptoms of preterm labor.
(a) Signs and symptoms of PTL
•• Menstrual-like cramping, low back pain
•• Uterine contractions (should be confirmed/documented via palpation
and external monitoring)
•• Vaginal discharge
Cervical change, effacement, and/or dilation are included in PTL diagnostic
criteria; the algorithm indicates how cervix should be assessed.
(b) Follow-up after evaluation and
discharge for PTL
•• Instruct patient to call if additional signs
and symptoms of PTL (give Preterm Labor
Discharge Instructions)
•• Schedule a visit within 1 to 2 weeks
(c) PTL/PTB Medication Table
The use of these medications is generally reserved for pregnancies between ≅ 22 and 34 weeks gestation. For pregnancies at 24 or fewer weeks,
consult with neonatologists and counsel patient and family to determine choices for care and resuscitation. For pregnancies at 34 weeks gestation,
consider allowing labor to progress to delivery without use of tocolytics; medication for fetal benefit is not indicated at this gestational age.
Note that per risk-specific protocols, some high-risk patients may already be receiving medication for fetal benefit and tocolysis.
Use in PTB
Recommendations
FETAL
Benefit
To lower risk of RDS, give a corticosteroid to all patients 23 to 34 weeks gestation: .
‰‰Betamethasone: 12 mg IM every 24 hours x 2 doses.
If betamethasone isn’t available, may use dexamethasone: 6 mg IM every 12 hours x 4 doses.
For neuroprotection at ≤31 weeks gestation, give:
‰‰Magnesium sulfate, IV: Bolus 6 grams over 40 minutes, then infuse 2 grams/hour maintenance dose from
premixed 20 gram/500 mL bag until delivery or until 12 hours of therapy. (If preterm delivery seems unlikely after 12
hours of therapy, discontinue therapy.)
If magnesium is used for neuroprotection and patient continues to have contractions, magnesium may be combined
with another medication for tocolysis. 1 (see row below.)
TOCOLYSIS
GBS
PROPHYLAXIS
(if the patient is
penicillin allergic,
request sensitivities
at time of culture)
For short-term prolongation of pregnancy (to allow time for transfer of patient, administration of medications for fetal
benefit), give a tocolytic for up to 48 hours:
If <32 weeks gestation, give:
Notes:
ˆˆ as first choice, indomethacin: 50 mg PO x 1, then 25 mg PO
every 6 hours up to 48 hours
ˆˆ as second choice, nifedipine: 10 mg PO, may repeat every 15
minutes x 4 doses, then 20 mg PO every 6 hours up to 48 hours
(maximum dose 160 mg in 24 hours)
If 32 to 34 weeks gestation, give:
‰‰Nifedipine:
10 mg PO, may repeat every 15 minutes x 4 doses, then 20 mg PO
every 6 hours up to 48 hours (maximum dose 160 mg in 24 hours)
•• Tocolysis is contraindicated when risks of use
outweigh potential benefits; e.g., in case of
nonreassuring fetal status, severe preeclampsia or
eclampsia, maternal bleeding with hemodynamic
instability, chorioamnionitis, preterm PROM, or
agent-specific maternal contradictions.
•• In multiple gestation pregnancies, use tocolytics
judiciously; in these pregnancies, tocolytics
have not been shown to improve outcomes and
are associated with a greater risk of maternal
complications such as pulmonary edema. 1
Follow Intermountain’s Prevention of Perinatal GBS algorithm. For all patients, as needed give either:
‰‰Penicillin G: 5 million units IV initial dose, then 2.5–3.0 million units every 4 hours until delivery
‰‰Ampicillin: 2 grams IV initial dose, then 1 gram every 4 hours until delivery or the threat of PTB is low
If penicillin allergy, low risk (e.g., isolated maculopapular rash without urticaria or pruritus):
‰‰Cefazolin: 2 grams IV initial dose, then 1 gram every 8 hours until delivery
If penicillin allergy, high risk (e.g., anaphylaxis, angioedema, respiratory distress, urticaria):
‰‰Clindamycin: 900 mg IV every 8 hours until delivery
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
23
Prevention and management of preterm birth
J u n e 2 014
Summary of intermountain resources
Provider education and tools
For Intermountain tools related to this topic, go to www.intermountainphysician.org/
clinicalprograms and select “Preterm Labor” from the topic list on the right side of the
screen. Resources include:
• CPMs and guidelines on PROM, GBS prophylaxis, and magnesium sulfate
for neuroprophylaxis
• Forms and order sets to support preterm admission and discharge
• Patient education (see next page)
Consults and referrals
• Diabetes education and medical nutrition therapy. These services are covered by
most commercial insurance providers and by Medicaid. For help locating diabetes
educators in the area of your practice, call Intermountain’s Primary Care Program at
801-442-2990.
•• Care management. SelectHealth and Medicaid patients are eligible to receive
one-on-one support, educational materials, and follow-up phone calls to support
best practice in prenatal care and high-risk pregnancy management. Call the Healthy
Beginnings care management intake number at 801-442-5052.
•• Referrals for substance abuse and mental health. For opioid dependence in
pregnancy, refer patient to medication-assisted therapy (MAT) with methadone
(first line) or buprenorphine. Also consider mental health referral and cessation
support groups (such as 12-step organizations). Use the Substance Abuse and
Mental Health Services Administration (SAMHSA) website to locate providers:
www.findtreatment.samhsa.gov.
•• Maternal-fetal medicine specialists. For a consultation or referral, contact one of
these Intermountain clinics:
–– McKay-Dee Maternal Fetal Medicine
Web Resources
•
•
March of Dimes
Prematurity Campaign
marchofdimes.org
Association of Women’s Health,
Obstetric, and Neonatal Nurses’
(AWHONN)
Prematurity Resource Center
awhonn.org
4401 Harrison Blvd, #4600
Ogden, UT 84403
801-387-4647
–– Maternal Fetal Medicine Specialists
5121 Cottonwood St, Ste 100
Murray, UT 84107
801-507-7400
801-507-7493
–– Utah Valley Maternal Fetal Medicine
1034 N 500 W
Provo, UT 84604
801-357-7706
801-442-0745
–– Dixie Maternal Fetal Medicine
544 S 400 E
St. George, UT 84770
435-688-4770
435-688-4835
24 ©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
J u n e 2 014
prevention and management of preterm birth
Patient education material
Patient education materials are available at www.i-printstore.com.
• Choose Patient and Provider Education Materials. Then search for items or use
the Category menu to browse.
• Click any item to see a description, then click View PDF to open the file or click
Add to Cart to order copies.
Note that four fact sheets directly support the preventive recommendations
in this care process model:
FACT SHEET FOR PATIENTS AND FAMILIES
• Preterm Birth Risk Worksheet: Use with patients after
Preterm Birth Risk Worksheet
This worksheet is for women who have delivered a baby too early in pregnancy — before 37 weeks of
gestation. Your healthcare provider will complete the worksheet and talk to you about it.
The goals: to help you better understand the circumstances of your preterm delivery, your risk for another
preterm delivery, and what you can do to help prevent it.
a spontaneous or indicated preterm birth to explain
the circumstances of the PTB, document the patient’s
recurrence risk, and promote appropriate follow-up
evaluations and preventive measures.
Preterm births: a few basics
About your own preterm delivery
Preterm births fall into two groups:
Your preterm delivery happened at
weeks of
gestation. (The due date is set for 40 weeks gestation.)
• A medically indicated preterm birth is a delivery
that’s recommended and initiated by the doctor. A
doctor will suggest an early delivery if either baby or
mother has a condition that makes continuing the
pregnancy dangerous.
The preterm birth happened:
ˆ Because of cervical insufficiency — your cervix
opened too early
• A spontaneous preterm birth happens when the woman
goes into preterm labor or when her water breaks too
early (premature rupture of membranes, or PROM).
Once preterm labor is advanced or the membranes
have ruptured, an early birth usually can’t be avoided.
Preterm babies are premature — their organs and systems
may not be completely mature or functional, not
completely ready for the outside world. Because of this,
these “preemies” face increased health risk. The earlier in
pregnancy a baby is born, the higher the risk.
ˆ After preterm labor — you went into labor too early
ˆ After premature rupture of membranes (PROM) —
your water broke too early
An array of booklets and trackers
to support:
ˆ At the doctor’s recommendation because of:
• A problem with the pregnancy:
• A medical problem you had:
To understand and document the circumstances that led
to your own preterm delivery, go through the next section
of this worksheet with your healthcare provider.
• A fetal condition or concern:
ˆ Other:
ˆ Your recurrence risk
Your chance of delivering preterm in your next
pregnancy (your “recurrence risk”) is approximately:
%
Please note: This figure is based on studies of
F Awomen
CT S
who have delivered prematurely, in circumstances similar
to yours. It estimates your risk — but can’t predict your
future. Every person, every pregnancy, is unique.
HEET FOR PATIENTS AND FAMILIES
1
Preterm Birth: 10 Steps to Help Prevent It
Blood Pressure Management
What is it — and why does it matter?
Preterm birth is a birth that happens too soon — before 37
weeks of pregnancy. (Your due date is set for 40 weeks
gestation, so a preterm birth is 3 or more weeks early.)
Preterm births fall into two groups:
• A medically indicated preterm birth is a delivery that’s
recommended and initiated by the doctor. A doctor
will suggest an early delivery if either baby or mother
has a condition that makes continuing the pregnancy
dangerous. Common reasons for indicated preterm
birth include intrauterine growth restriction (IUGR, in
which the baby is grows poorly during the pregnancy),
preeclampsia, and placenta previa.
• A spontaneous preterm birth happens when the woman
goes into preterm labor or when her water breaks too
early (premature rupture of membranes, or PROM).
Once preterm labor begins or the membranes have
ruptured, an early birth usually can’t be avoided.
• Preterm Birth: 10 Steps to Help Prevent It. Use with all patients
Preterm babies are premature — their organs and systems
may not be completely mature or functional, not completely
ready for the outside world. Because of this, these
“preemies” face an increased health risk both immediately
after birth and in the long term. The earlier in pregnancy a
baby is born, the higher the risk.
Short-term problems. In the first few weeks of life,
a premature baby can have these problems:
to explain key measures to lower their risk for preterm delivery.
Includes general recommendations (e.g., use of highly effective
contraception to ensure safe interpregnancy interval) and those for
women at increased risk (17P, cerclage).
• Breathing problems. Premature babies often have
problems caused by underdeveloped lungs. Abnormal
pauses in breathing (apnea), difficult breathing (from
respiratory distress syndrome), and lung infections are
all common, particularly in babies born before 34 weeks.
• Heart problems. A premature baby may have a heart
opening (patent ductus arteriosus, or PDA) that will require
surgery to correct. Low blood pressure is also common.
• Brain problems. Premature babies, especially those born
before 28 weeks, have a higher chance of brain bleeds.
•
• Problems feeding and digesting. A small baby, born
too early, may not have the stamina to feed well. Also,
premature babies are at risk for a serious problem in the
intestines, necrotizing enterocolitis (NEC). It can
develop 2 to 3 weeks after birth, causing feeding
problems, diarrhea, and a swollen belly.
• Temperature control problems. Premature babies often
have trouble keeping their bodies warm. This can make
other problems worse, since the babies must use extra
energy to try to maintain a healthy temperature.
•
Long-term problems. Studies show that babies
born too early have a higher chance of having these
problems throughout life:
• Learning and behavioral problems. Children who
were born prematurely may lag behind their peers in
school. They may have trouble with social skills,
attention, and speech.
BP Tracker
BP Basics
• Cerebral palsy. This lifelong condition can affect
movement, balance, and posture.
• Vision and hearing loss.
• Chronic conditions. Asthma and allergies are often seen in
children who were born prematurely. Depression is also
more common in teenagers who began life as preemies.
Not all premature babies have health problems. Many do
well right from the start — and continue to do well all
their lives. However, given the high risk of problems, a
preterm birth is never the best end to a pregnancy.
1
FACT SHEET FOR PATIENTS AND FAMILIES
• 17P for Preventing Preterm Birth: Use with select patients
to support informed consent for this therapy.
17P for Preventing Preterm Birth
Why was I offered this treatment?
Your doctor or midwife may recommend 17P if you
meet both of these conditions:
• You’re carrying only one baby in this pregnancy
(that is, it’s a singleton pregnancy — not one with
twins, triplets, or more multiples)
AND
• You’ve already had at least one preterm
singleton birth
Studies have shown that 17P treatment in the second
trimester of pregnancy can lower the risk of preterm
birth for women who fit this high-risk profile.
In one recently published study, the rate of preterm birth
was reduced by one-third among these women. Other
pregnant women, however, may not need or benefit from
taking this medication.
• Cervical Cerclage: Use with select patients to support
Blood Glucose Management
What is 17P?
The abbreviation “17P” stands for 17-alphahydroxyprogesterone caproate. It’s a type of progesterone,
a hormone naturally produced by the placenta during
pregnancy. The medication 17P is prescribed by a doctor
to help prevent preterm birth.
Is 17P safe?
Experts believe that 17P is safe for mothers and
babies when given in the second and third trimesters
of pregnancy. In fact, the nation’s leading group of
pregnancy experts, the American Council of Obstetrics
and Gynecology (ACOG), approves and recommends
the use of 17P to prevent recurrent preterm birth.
Follow-up studies of children born to mothers treated
with 17P showed no ill effects from treatment.
•
Preterm birth means a birth before 37 weeks of pregnancy.
Preterm birth is dangerous for the baby’s health.
Why is it so important to prevent
preterm birth?
A baby born too early — a premature infant, often
called a “preemie” — will be smaller than normal and
may have underdeveloped organs. This can cause
FACT
problems with breathing and feeding and makes the
baby more vulnerable to infections, brain problems,
and other serious complications. A very small or sick
preemie may suffer life-long physical or learning
problems or, despite the best medical care, may die.
•
SHEET FOR PATIENTS AND FAMILIES
Cervical Cerclage
Despite these risks, many preemies do well. The closer
the birth is to the due date, the better the preemie’s
chances for good health at birth and throughout
life. cerclage is a procedure done in pregnancy to help
Cervical
Still, a preemie nearly always requires advanced
medical
prevent
preterm birth. It involves temporarily stitching
care in a newborn intensive care unit (NICU).
theCombined
cervix closed. This fact sheet explains how it’s done,
with an unexpected early labor, this makes for
a stressful
why
it’s sometimes recommended, and its risks and
beginning for a new life.
potential benefits. It also briefly explains what to expect
before and after a cerclage procedure.
About the cervix in pregnancy
BG Tracker
Living Well
with Diabetes
The cervix is the neck-like opening at the bottom of the
uterus. Normally, the cervix stays closed until about 37
1
weeks of pregnancy,
when it gradually shortens and opens
as the body prepares for childbirth.
informed consent for this intervention.
Sometimes a woman’s cervix will begin to shorten and open
too early in pregnancy. You may have heard this described
as a “weak” or insufficient cervix — and it is a major risk
factor for a preterm birth. Cervical cerclage is one way to
treat this risk factor and possibly prolong a pregnancy.
cerclage
cervix
About cerclage: how is it done?
Cervical cerclage involves placing stitches to keep the
cervix closed. The stitches are usually placed transvaginally
(through the vagina), though they can also be placed
through an incision in the abdomen.
The closure can be done in different ways. One common
method is to place stitches around the outside of the
cervix. Another method involves tying special tape
around the cervix and then stitching it in place.
To block any pain during the procedure, the woman will
have either regional anesthesia (a spinal or epidural) or
general anesthesia. The procedure itself usually lasts less
than an hour. It’s done in the hospital, usually as an
outpatient procedure.
A cerclage is temporary. It’s removed when the pregnancy
draws close to full term (36 to 37 weeks of pregnancy),
when the woman goes into labor, or if her water breaks
early (premature rupture of membranes) — whichever
comes first.
When is cerclage recommended?
Your doctor or midwife may recommend cervical cerclage
in a circumstance such as the following:
• You have had a previous preterm delivery, and a vaginal
ultrasound shows that your cervix is changing —
shortening or opening — too early in this pregnancy.
• You have had previous pregnancy losses or preterm
deliveries that may be due to a weak cervix. In this case,
your provider may suggest cerclage to try to prevent
another bad outcome in this pregnancy.
• Your doctor or midwife notes cervical changes before
24 weeks of pregnancy and sees that the amniotic sac
(bag of waters) is beginning to bulge through the
opening. In this case, the procedure might be called an
emergency or rescue cerclage.
1
Smoking Cessation
All fact sheets are available in English and Spanish; see the list below
for fact sheets related to this topic.
•
Quitting Tobacco:
Your Journey
to Freedom
Fact sheets in English and Spanish:
•• Anticoagulant Injections
•• Birth Control Basics
•• Birth Control Pills
•• Cervical Cerclage
•• Hysteroscopy
•• Sterilization
•• Diabetes Care Before and
During Your Pregnancy
•• Fetal Movement Counting
•• Fetal Testing
(nonstress test, amniotic
fluid assessment,
biophysical profile)
•• Trichomoniasis
•• Preeclampsia
•• Vaginal Infections:
•• Preterm Birth: 10 Steps to
•• 17P for Preventing
•• Preterm Birth Risk
Yeast and Bacteria
Preterm Birth
•• 24-Hour Urine Specimen
• Substance Use in
Pregnancy
• Prescription Pain
Medication in Pregnancy
• Newborn Withdrawal
Lifestyle Management
•
Live Well: The Weigh
to Health booklet,
Habit Tracker, and
other of assessment
and behavior
modification tools
Help Prevent It
Worksheet
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
25
p r e v e ntion a nd m a n a g e m e nt o f p r e t e r m bi r t h J U NE 2 0 1 4
References
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causes of preterm birth. Lancet. 2008;371(9606):75-84.
for California’s Healthcare System: Integrated Care with Aligned
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University of California, Berkeley; 2013: appendix XI. http://
berkeleyhealthcareforum.berkeley.edu/wp-content/uploads/
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3. Lockwood CJ. Overview of preterm labor and birth. UpToDate Web
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30. Practice Committee of American Society for Reproductive Medicine.
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early-term deliveries. Obstet Gynecol. 2013 Apr;121(4):908-910.
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Esplin MS. Delivery of monochorionic twins in the absence of
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De Domenico R, Monte S. Antiphospholipid Syndrome during
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homeandrecreationalsafety/rxbrief. Updated July 2, 2013. Accessed
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38. NC, Armstrong MA, Taillac CJ, Osejo VM. Substance abuse
treatment linked with prenatal visits improves perinatal outcomes: a
new standard. J Perinatol. 2008;28(9):597-603.
39. Health information: frequently asked questions. Preeclampsia
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40. Berghella V, Odibo AO, To MS, Rust OA, Althuisius SM. Cerclage
for short cervix on ultrasonography: meta-analysis of trials using
individual patient-level data. Obstet Gynecol. 2005;106(1):181-189.
41. Sibai BM. Chronic hypertension in pregnancy. Obstet Gynecol.
2002;100(2):369-377.
42. National Institute for Health and Care Excellence (NICE); National
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43. Temple RC, Aldridge VJ, Murphy HR. Prepregnancy care and
pregnancy outcomes in women with type 1 diabetes. Diabetes Care.
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44. Schwartz R, Teramo KA. Effects of diabetic pregnancy on the fetus
and newborn. Semin Perinatol. 2000;24(2):120-135.
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
27
p r e v e ntion a nd m a n a g e m e nt o f p r e t e r m bi r t h J U NE 2 0 1 4
This CPM presents a model of best care based on the best evidence at the time of publication. It
is not a prescription for every physician or every patient, nor does it replace clinical judgment. All
statements, protocols, and recommendations herein are viewed as transitory and iterative. Although
physicians are encouraged to follow the CPM to help focus on and measure quality, deviations are
a means for discovering improvements in patient care and expanding the knowledge base. Send
feedback to Teri Kiehn, Intermountain Healthcare, Operations Director, Women and Newborns
Clinical Program, [email protected].
28
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. Patient and Provider Publications 801-442-2963 CPM071 - 06/14