Management of pregnant women after inhibition of acute preterm labor
- Steve Caritis, MD
Steve Caritis, MD
- Professor of Obstetrics, Gynecology, and Reproductive Sciences
- University of Pittsburgh School of Medicine
- Hyagriv N Simhan, MD, MS
Hyagriv N Simhan, MD, MS
- Professor & Chief, Division of Maternal-Fetal Medicine
- Executive Vice Chair, Obstetrical Services Department of Ob/Gyn/RS
- University of Pittsburgh School of Medicine
- Medical Director of Obstetrical Services
- Magee-Womens Hospital of UPMC
The optimal management of pregnancies after resolution of an acute episode of preterm labor (PTL) is unknown. No large randomized trials have compared various management strategies.
This topic will review management of women who do not have advanced cervical dilation after treatment of acute idiopathic PTL. The evaluation and management of women with suspected PTL are discussed separately. (See "Diagnosis of preterm labor and overview of preterm birth" and "Inhibition of acute preterm labor".)
Is hospitalization beneficial? — The value of prolonged hospitalization for stable women after treatment of an episode of suspected PTL has not been studied. We consider women with advanced cervical dilation, vaginal bleeding, nonreassuring fetal status, or a long travel time to a hospital with appropriate levels of obstetric and neonatal care services examples of obstetrically unstable patients in whom ongoing in-hospital observation may be useful, but we make this decision on a case-by-case basis, depending on patient-specific factors. These situations are associated with an increased probability of birth away from a tertiary care center and a birth that may incur significant morbidity for the mother and/or newborn.
The only randomized trial designed to determine whether hospitalization of women with arrested PTL increased the proportion of deliveries ≥36 weeks compared with women discharged home did not find a benefit . In this trial, 101 women with singleton gestations, intact membranes, mean cervical dilation of 2.7 cm, and a diagnosis of arrested PTL between 240/7 and 334/7 weeks of gestation were randomly assigned to hospitalization until 34 weeks or discharged home upon completion of a course of dexamethasone. Tocolytics were not given; contractions ceased with conservative management alone. In both groups, about 70 percent of women delivered at ≥36 weeks of gestation. This trial was underpowered and is not generalizable to the more clinically relevant population of women with arrested PTL after tocolytic therapy .
Is bed rest beneficial? — There is no evidence supporting bed rest as an effective intervention for prevention of spontaneous preterm birth in singletons [3,4] or twins . Bed rest has known potential harms: It promotes loss of trabecular bone density, increases venous thromboembolism risk, produces musculoskeletal deconditioning, and places significant psychosocial strain on individuals and families [3,6-12]. Based on lack of evidence of efficacy in prematurity prevention, and known significant risks, we do not recommend bed rest for women with a recent history of PTL.
- Yost NP, Bloom SL, McIntire DD, Leveno KJ. Hospitalization for women with arrested preterm labor: a randomized trial. Obstet Gynecol 2005; 106:14.
- Goldenberg RL. Arrested preterm labor: do the data support home or hospital care? Obstet Gynecol 2005; 106:3.
- Goldenberg RL, Cliver SP, Bronstein J, et al. Bed rest in pregnancy. Obstet Gynecol 1994; 84:131.
- Sosa CG, Althabe F, Belizán JM, Bergel E. Bed rest in singleton pregnancies for preventing preterm birth. Cochrane Database Syst Rev 2015; :CD003581.
- Crowther CA, Han S. Hospitalisation and bed rest for multiple pregnancy. Cochrane Database Syst Rev 2010; :CD000110.
- Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 1999; 354:1229.
- Kovacevich GJ, Gaich SA, Lavin JP, et al. The prevalence of thromboembolic events among women with extended bed rest prescribed as part of the treatment for premature labor or preterm premature rupture of membranes. Am J Obstet Gynecol 2000; 182:1089.
- Maloni JA, Schneider BS. Inactivity: symptoms associated with gastrocnemius muscle disuse during pregnancy. AACN Clin Issues 2002; 13:248.
- Maloni JA, Kane JH, Suen LJ, Wang KK. Dysphoria among high-risk pregnant hospitalized women on bed rest: a longitudinal study. Nurs Res 2002; 51:92.
- Maloni JA, Alexander GR, Schluchter MD, et al. Antepartum bed rest: maternal weight change and infant birth weight. Biol Res Nurs 2004; 5:177.
- Maloni JA, Park S. Postpartum symptoms after antepartum bed rest. J Obstet Gynecol Neonatal Nurs 2005; 34:163.
- Promislow JH, Hertz-Picciotto I, Schramm M, et al. Bed rest and other determinants of bone loss during pregnancy. Am J Obstet Gynecol 2004; 191:1077.
- Mozurkewich EL, Luke B, Avni M, Wolf FM. Working conditions and adverse pregnancy outcome: a meta-analysis. Obstet Gynecol 2000; 95:623.
- McCulloch J. Health risks associated with prolonged standing. Work 2002; 19:201.
- Luke B, Mamelle N, Keith L, et al. The association between occupational factors and preterm birth: a United States nurses' study. Research Committee of the Association of Women's Health, Obstetric, and Neonatal Nurses. Am J Obstet Gynecol 1995; 173:849.
- Bonzini M, Coggon D, Palmer KT. Risk of prematurity, low birthweight and pre-eclampsia in relation to working hours and physical activities: a systematic review. Occup Environ Med 2007; 64:228.
- Kramer MS, McDonald SW. Aerobic exercise for women during pregnancy. Cochrane Database Syst Rev 2006; :CD000180.
- Goodlin RC, Schmidt W, Creevy DC. Uterine tension and fetal heart rate during maternal orgasm. Obstet Gynecol 1972; 39:125.
- Sahmay S, Atasu T, Karacan I. The effect of intrauterine insemination on uterine activity. Int J Fertil 1990; 35:310.
- Sayle AE, Savitz DA, Thorp JM Jr, et al. Sexual activity during late pregnancy and risk of preterm delivery. Obstet Gynecol 2001; 97:283.
- Hernández-Díaz S, Boeke CE, Romans AT, et al. Triggers of spontaneous preterm delivery--why today? Paediatr Perinat Epidemiol 2014; 28:79.
- Magann EF, Chauhan SP, Dahlke JD, et al. Air travel and pregnancy outcomes: a review of pregnancy regulations and outcomes for passengers, flight attendants, and aviators. Obstet Gynecol Surv 2010; 65:396.
- Akl N, Coghlan EA, Nathan EA, et al. Aeromedical transfer of women at risk of preterm delivery in remote and rural Western Australia: why are there no births in flight? Aust N Z J Obstet Gynaecol 2012; 52:327.
- Fry MJ, Cartwright DW, Huang RC, Davies MW. Preterm birth a long distance from home and its significant social and financial stress. Aust N Z J Obstet Gynaecol 2003; 43:317.
- Easa D, Pelke S, Loo SW, et al. Unexpected preterm delivery in tourists: implications for long-distance travel during pregnancy. J Perinatol 1994; 14:264.
- Agency for Healthcare Research and Quality. Management of preterm labor. Evidence report /Technology Assessment #18. Rockville, Maryland. 2000.
- American College of Obstetricians and Gynecologists. Management of preterm labor. ACOG practice bulletin 43. May 2003.
- Urquhart C, Currell R, Harlow F, Callow L. Home uterine monitoring for detecting preterm labour. Cochrane Database Syst Rev 2015; 1:CD006172.
- van Vliet E, Dijkema GH, Schuit E, et al. Nifedipine maintenance tocolysis and perinatal outcome: an individual participant data meta-analysis. BJOG 2016; 123:1753.
- Dodd JM, Crowther CA, Dare MR, Middleton P. Oral betamimetics for maintenance therapy after threatened preterm labour. Cochrane Database Syst Rev 2006; :CD003927.
- Chawanpaiboon S, Laopaiboon M, Lumbiganon P, et al. Terbutaline pump maintenance therapy after threatened preterm labour for reducing adverse neonatal outcomes. Cochrane Database Syst Rev 2014; :CD010800.
- Terbutaline: Label Change - Warnings Against Use for Treatment of Preterm Labor http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm243843.htm (Accessed on February 17, 2011).
- Gaudet L, Singh K, Weeks L, Skidmore B, Tsouros S, Tsertsvadze A, Daniel R, Doucette S, Walker M, Ansari MT. Terbutaline Pump for the Prevention of Preterm Birth. Comparative Effectiveness Review No. 35. (Prepared by the University of Ottawa Evidence-based Practice Center under Contract No. HHSA290-2007-10059-I.) AHRQ Publication No. 11-EHC068-EF. Rockville, MD: Agency for Healthcare Research and Quality. September 2011. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm.
- Han S, Crowther CA, Moore V. Magnesium maintenance therapy for preventing preterm birth after threatened preterm labour. Cochrane Database Syst Rev 2013; :CD000940.
- Kaplan W, Haymond MW, McKay S, Karaviti LP. Osteopenic effects of MgSO4 in multiple pregnancies. J Pediatr Endocrinol Metab 2006; 19:1225.
- Valenzuela GJ, Sanchez-Ramos L, Romero R, et al. Maintenance treatment of preterm labor with the oxytocin antagonist atosiban. The Atosiban PTL-098 Study Group. Am J Obstet Gynecol 2000; 182:1184.
- Papatsonis DN, Flenady V, Liley HG. Maintenance therapy with oxytocin antagonists for inhibiting preterm birth after threatened preterm labour. Cochrane Database Syst Rev 2013; :CD005938.
- Simcox R, Sin WT, Seed PT, et al. Prophylactic antibiotics for the prevention of preterm birth in women at risk: a meta-analysis. Aust N Z J Obstet Gynaecol 2007; 47:368.
- van den Broek NR, White SA, Goodall M, et al. The APPLe study: a randomized, community-based, placebo-controlled trial of azithromycin for the prevention of preterm birth, with meta-analysis. PLoS Med 2009; 6:e1000191.
- Verani JR, McGee L, Schrag SJ, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease--revised guidelines from CDC, 2010. MMWR Recomm Rep 2010; 59:1.
- PHYSICAL ACTIVITY
- Is hospitalization beneficial?
- Is bed rest beneficial?
- Should exercise and work be avoided?
- Should sexual activity be avoided?
- Should travel be avoided?
- TESTS AND DEVICES NOT USEFUL FOR PATIENT MONITORING
- Fetal fibronectin testing
- Home uterine activity monitoring
- MEDICATION MANAGEMENT
- Progesterone supplementation
- Repeated courses of antenatal corticosteroids
- Maintenance tocolysis
- Antibiotic prophylaxis
- - Group B streptococcus (GBS)
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS