Management of Preterm Birth: Best Practices in Prediction, Prevention, and Treatment

Preface

Alice Reeves Goepfert, MDGuest Editor

Preterm birth, or delivery prior to 37 weeks’ gestation, continues to be a major publichealth concern in the United States and is the leading cause of infant mortalityexcluding congenital malformations. The annual health care costs for the care of infantsborn preterm are substantial. However, for the first time in decades, the preterm birth ratein the United States has reached a plateau and begun to decline slightly, currentlyaccounting for just over 12% of the 4 million births annually in the country. Fortunately,with increased public awareness to this plight of women and infants as well as funding forresearch and attention to outcomes by the federal government and private agencies, thebusy clinician now has more effective options than ever before for screening, prevention,and treatment of women at risk for preterm birth.

In this edition of Obstetrics and Gynecology Clinics of North America, selectedexperts have been invited to review screening and prevention strategies as well asmanagement options once preterm labor or preterm premature rupture of membranes(PROM) is diagnosed. These authors discuss the most current and relevant evidenceand suggest strategies for preterm birth management based on that evidence.Importantly, the authors in this edition have not only been involved in cutting edgeresearch in the field of preterm birth but also have busy clinical practices; they canoffer therefore a practical approach to those of us struggling to determine the bestoptions for our patients.

Drs Carla Ransom and Amy Murtha discuss the hot topic of progesterone for theprevention of preterm birth. New clinical studies on this preventive therapy are beingpublished on a regular basis and will continue to afford healthy debate regarding thebest practices. Drs Melissa Mancuso and John Owen review transvaginal ultrasoundfor cervical length in high-risk women and prevention strategies using cervicalcerclage in the setting of a short cervix. With the recent multicenter study publishedby Hassan and colleagues,1 the debate heats up regarding the efficiency of proceed-ing with routine screening by transvaginal ultrasound for cervical length in low-riskwomen and treatment with vaginal progesterone versus the need for additionalresearch; clinicians are encouraged to pay attention to further discussion on thissubject from leaders in the field. Although the initial excitement regarding treatment ofmaternal periodontal disease for the prevention of preterm birth has not been

Obstet Gynecol Clin N Am 39 (2012) xiii–xvdoi:10.1016/j.ogc.2012.02.001 obgyn.theclinics.com

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supported by several larger randomized controlled trials done in this country, DrsAmanda Horton and Kim Boggess review the evidence on this subject; clinicians arerecommended to encourage oral health maintenance for maternal general healthbenefit.

Antenatal corticosteroids continue to be an important component of the manage-ment of women at risk for preterm birth and have resulted in improved neonataloutcome; Drs Clarissa Bonanno and Ronald Wapner discuss the history behind thistreatment strategy, efficacy in special populations, choice of agent, and timing ofadministration. Dr Brian Mercer reviews the use of antibiotics in the management ofPROM and preterm labor and presents a new meta-analysis that supports aggressive,broad-spectrum treatment for improved latency and decreased morbidity in the setting ofconservative management of PROM. Drs Adi Abramovici, Jessica Cantu, and SheriJenkins review the use of tocolytic therapy for acute preterm labor. Magnesium sulfate forneuroprotection before anticipated preterm birth is also discussed in their article; we haveadopted this strategy at our own center based on our assessment of the best availableevidence. Clinicians are encouraged to review recent publications on this subject,2,3 aswell as ACOG Committee Opinion No. 4554 and a recently published SMFM debate5,6 tossist in their own decisions regarding use of this preventive therapy.

A component of the observed decrease in preterm births in the United States haseen attributed to more conservative approaches to the delivery of late preterm births.ecommendations from a recent workshop on appropriate late preterm and early termirths, cosponsored by the SMFM and NICHD, have recently been published.7 Dr Cynthiayamfi-Bannerman reviews management dilemmas for these late preterm births. Inddition, Drs Luisa Wetta and Alan Tita discuss considerations in management of earlyerm births.

My hope is that this issue of Obstetrics and Gynecology Clinics will assist cliniciansn choosing the best available options for the management of their patients at risk forreterm birth. In addition, as we continue to focus our efforts on maximizing patientafety, improving quality of care, and monitoring our patient outcomes, I hope theserticles will provide guidance for improved care of women and infants.

Thank you to Elsevier for the opportunity to participate as guest editor for this issuend to Stephanie Donley, editor of Clinics, for her patience and persistence in making

t a reality.

Alice Reeves Goepfert, MDDivision of Maternal-Fetal Medicine

Department of Obstetrics and GynecologyUniversity of Alabama at Birmingham

176F 10270 North, Women & Infants Center619 19th Street South

Birmingham, AL 35249-7333, USA

E-mail address:aliceg@uab.edu

REFERENCES

1. Hassan SS, Romero R, Vidyadhari D, et al, for the PREGNANT Trial. Vaginal proges-terone reduces the rate of preterm birth in women with a sonographic short cervix: amulticenter, randomized, double-blind, placebo-controlled trial. Ultrasound ObstetGynecol 2011;38:18–31.

. Rouse DJ. Magnesium sulfate for the prevention of cerebral palsy. Am J Obstet

Gynecol 2009;200(6):610–2.

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3. Rouse DJ, Hirtz DG, Thom E, et al, Roberts JM for the Eunice Kennedy Shriver NICHDMFMU Network. A randomized, controlled trial of magnesium sulfate for the preventionof cerebral palsy. N Engl J Med 2008;359:895–905.

. American College of Obstetricians and Gynecologists Committee on Obstetric Prac-tice; Society for Maternal-Fetal Medicine. Committee Opinion No. 455: Magnesiumsulfate before anticipated preterm birth for neuroprotection. Obstet Gynecol 2010;115(3):669–71.

. Rouse DJ. Magnesium sulfate for fetal neuroprotection. Am J Obstet Gynecol 2011;205(4):296–7.

. Sibai BM. Magnesium sulfate for neuroprotection in patients at risk for early delivery: notyet. Am J Obstet Gynecol 2011;205(4):296–7.

. Spong CY, Mercer BM, D’Alton M, et al. Timing of indicated late-preterm and early-term birth. Obstet Gynecol 2011;118:323–33.