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Safe Deliveries
Colorado
Webinar: Preterm Labor Assessment and Management Guidelines
K. Joseph Hurt, MD PhD
Maternal Fetal Medicine
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The problem – big picture
• Preterm Labor is an important clinical problem
o 12% of births in the USA
o $26 billion annually
• Three-quarters of perinatal mortality
• Half of long term morbidity
• Up 50% preceded by “preterm labor”
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Preterm Birth: Later is Better
Hurt, Guile, Bienstock, et al (eds). Johns Hopkins Manual of Gynecology and Obstetrics 4th ed. (2011) Dennis and Althaus. Preterm Labor and PPROM. Adapted from Pediatrix/Obstetrix Medical Group outcomes data at: www.pediatrix.com/body_university.cfm.
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The problem – Colorado
http://www.marchofdimes.org/peristats/pdflib/998/premature-birth-report-card-Colorado.pdf
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The problem – Colorado
http://www.marchofdimes.org/peristats/pdflib/998/premature-birth-report-card-Colorado.pdf
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The problem – Locally
http://www.marchofdimes.org/peristats/pdflib/998/premature-birth-report-card-Colorado.pdf
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March of Dimes Toolkit: PLAT
www.prematurityprevention.org
•Step-by-step guide
•Standard clinical pathway
•Assessment and disposition of preterm labor
•Reduce unnecessary hospitalization
•Increase appropriate corticosteroid administration
•Facilitate transfer decisions for NICU care
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Components of the PLAT
• Overview of preterm labor and clinical issues
• Algorithm/decision model, protocol, and order set
• Data collection recommendations
• Implementation guidelines
• Patient education and home care materials
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PLAT: Overview
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PLAT: Evidence Base
• IV hydration has no benefit
• Terbutaline does not improve outcomes
• Preterm contractions are overtreated
• Preterm labor is undertreated
• ~3/4’s of preterm labor delivers at term
• Negative fFN and contractions are overtreated
• fFN decreases triage time, admission, cost
• Overdiagnosis of preterm labor is common
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Diagnosis of “preterm labor”
• Painful contractions 6/hour
• Cervical dilation of 3 cm
• Cervical effacement of 80%
• Vaginal bleeding or PROM
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PLAT tools: fetal Fibronectin
(fFN)
• Negative predictive value 95-99%
• Positive predictive value 13-40%
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PLAT tools: fetal Fibronectin
(fFN)
• Not useful at less than 24w
• Not useful at more than 34w
• Sterile speculum exam
• Not if
– Bleeding
– Exam or intercourse <24h
– Cervix 3cm dilated
– PPROM/BBOW
– Cervical or vaginal lesions
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PLAT tools: transvaginal cervical
length ultrasound (TVCL)
• Better than digital exam
• Alone or in combination with fFN
• >25mm TVCL has negative predictive value of 95% for <32week delivery
• Not if
– <15w or >28w
– Vaginal bleeding present
– With bleeding previa
– With full bladder
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Disposition using fFN and TVCL
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PLAT: the algorithm
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PLAT: the algorithm
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PLAT: Sample Orderset
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PLAT: Implementation
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PLAT: Implementation
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Next:
PLAT: Real Life in Colorado
Thank you!