Preventing Preterm Birth: What Works, What Doesn???t

Evolution of psychomotor development in pre-school children born prematurely

INTRODUCTION

The rate of premature births has significantly increased, and it is important to determine its effects. The objective of this study is to determine the psychomotor development profile of a group of children born prematurely, at the age of 4, 5 and 6, and to compare them with a group of full-term birth children, in order to detect any differences.

PATIENTS AND METHODS

The sample consisted of 98 participants, evenly distributed into two groups, premature and full-term born children. A prospective longitudinal observational analytical study, with a design of cases and controls, was carried out. For some analyses, the separation into early pre-term, moderate pre-term, and late pre-term was considered. The evaluations were performed using the McCarthy Scale of Aptitudes and Psychomotor skills for children.

RESULTS

The data show achievements within the middle intervals. However, there are more difficulties in development at 4 years in the group of premature children, according to gestational age. Early pre-term (gestational age less than 32 weeks) showed significantly lower scores compared to moderate and late pre-term, mainly at 6 years, and with those born at term, at 4 and 6 years.

CONCLUSIONS

Development difficulties are greater at a lower gestational age, and may affect the Primary Education stage. The need to monitor all premature children in the preschool stage is suggested, as well as to evaluate more specific skills and continue with the care from specialist teams.

Cervical stitch (cerclage) in combination with other treatments for preventing spontaneous preterm birth in singleton pregnancies

BACKGROUND

Preterm birth (PTB) remains the foremost global cause of perinatal morbidity and mortality. Thus, the prevention of spontaneous PTB still remains of critical importance. In an attempt to prevent PTB in singleton pregnancies, cervical cerclage, in combination with other treatments, has been advocated. This is because, cervical cerclage is an intervention that is commonly recommended in women with a short cervix at high risk of preterm birth but, despite this, many women still deliver prematurely, as the biological mechanism is incompletely understood. Additionally, previous Cochrane Reviews have been published on the effectiveness of cervical cerclage in singleton and multiple pregnancies, however, none has evaluated the effectiveness of using cervical cerclage in combination with other treatments.

OBJECTIVES

To assess whether antibiotics administration, vaginal pessary, reinforcing or second cerclage placement, tocolytic, progesterone, or other interventions at the time of cervical cerclage placement prolong singleton gestation in women at high risk of pregnancy loss based on prior history and/or ultrasound finding of 'short cervix' and/or physical examination. History-indicated cerclage is defined as a cerclage placed usually between 12 and 15 weeks gestation based solely on poor prior obstetrical history, e.g. multiple second trimester losses due to painless dilatation. Ultrasound-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation for transvaginal ultrasound cervical length < 20 mm in a woman without cervical dilatation. Physical exam-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation because of cervical dilatation of one or more centimetres detected on physical (manual) examination.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (26 September 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

We included published, unpublished or ongoing randomised controlled trial (RCTs). Studies using a cluster-RCT design were also eligible for inclusion in this review but none were identified. We excluded quasi-RCTs (e.g. those randomised by date of birth or hospital number) and studies using a cross-over design. We also excluded studies that specified addition of the combination therapy after cervical cerclage because the woman subsequently became symptomatic. We included studies comparing cervical cerclage in combination with one, two or more interventions with cervical cerclage alone in singleton pregnancies.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of all retrieved articles, selected studies for inclusion, extracted data, assessed risk of bias, and evaluated the certainty of the evidence for this review's main outcomes. Data were checked for accuracy. Standard Cochrane review methods were used throughout.

MAIN RESULTS

We identified two studies (involving a total of 73 women) comparing cervical cerclage alone to a different comparator. We also identified three ongoing studies (one investigating vaginal progesterone after cerclage, and two investigating cerclage plus pessary). One study (20 women), conducted in the UK, comparing cervical cerclage in combination with a tocolytic (salbutamol) with cervical cerclage alone in women with singleton pregnancy did not provide any useable data for this review. The other study (involving 53 women, with data from 50 women) took place in the USA and compared cervical cerclage in combination with a tocolytic (indomethacin) and antibiotics (cefazolin or clindamycin) versus cervical cerclage alone - this study did provide useable data for this review (and the study authors also provided additional data on request) but meta-analyses were not possible. This study was generally at a low risk of bias, apart from issues relating to blinding. We downgraded the certainty of evidence for serious risk of bias and imprecision (few participants, few events and wide 95% confidence intervals). Cervical cerclage in combination with an antibiotic and tocolytic versus cervical cerclage alone (one study, 50 women/babies) We are unclear about the effect of cervical cerclage in combination with antibiotics and a tocolytic compared with cervical cerclage alone on the risk of serious neonatal morbidity (RR 0.62, 95% CI 0.31 to 1.24; very low-certainty evidence); perinatal loss (data for miscarriage and stillbirth only - data not available for neonatal death) (RR 0.46, 95% CI 0.13 to 1.64; very low-certainty evidence) or preterm birth < 34 completed weeks of pregnancy (RR 0.78, 95% CI 0.44 to 1.40; very low-certainty evidence). There were no stillbirths (intrauterine death at 24 or more weeks). The trial authors did not report on the numbers of babies discharged home healthy (without obvious pathology) or on the risk of neonatal death.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to evaluate the effect of combining a tocolytic (indomethacin) and antibiotics (cefazolin/clindamycin) with cervical cerclage compared with cervical cerclage alone for preventing spontaneous PTB in women with singleton pregnancies. Future studies should recruit sufficient numbers of women to provide meaningful results and should measure neonatal death and numbers of babies discharged home healthy, as well as other important outcomes listed in this review. We did not identify any studies looking at other treatments in combination with cervical cerclage. Future research needs to focus on the role of other interventions such as vaginal support pessary, reinforcing or second cervical cerclage placement, 17-alpha-hydroxyprogesterone caproate or dydrogesterone or vaginal micronised progesterone, omega-3 long chain polyunsaturated fatty acid supplementation and bed rest.

The Effect of Empowerment Program on Maternal Discharge Preparation and Neonatal Length of Hospital Stay: A Randomized Controlled Trial

Background:

Despite the increased survival of premature infants, many infants are discharged from the hospital while they still require care and follow-up. The present study aimed to determine the effect of empowerment program on maternal discharge preparation and infants' length of hospital stay.

Materials and Methods:

In this pretest-posttest clinical trial, 60 premature infants along with their mothers were selected from the neonatal intensive care unit (NICU) of a teaching hospital in Kermanshah in 2016 via convenience sampling and were allocated to experimental and control groups. Mothers in the control group performed routine care and those in experimental group, in addition to the routine care, performed an intervention program, training sessions including touching and massage, bathing, infection prevention, warning signs, and neonatal resuscitation. Data were collected by a maternal and neonatal demographic questionnaire and a discharge preparation checklist, performed twice (at admission and before discharge), by the researcher. The collected data were analyzed by independent and paired t-test.

Results:

The mean (standard deviation) of the total score of maternal discharge preparation in intervention group 44.65 (3.90) was significantly higher than that of the control group 33.00 (8.28) (t = -6.58, p <0.001). The mean length of neonatal hospitalization in the intervention group (14.79 days) was significantly shorter than that of the control group (20.43 days) (p = 0.020).

Conclusions:

The increasing maternal discharge readiness and reducing the length of neonatal hospital stay would decrease the medical costs and supply more beds for admission of other infants.

Placental villous hypermaturation is associated with idiopathic preterm birth

OBJECTIVE

Pregnancy complications such as intra-amniotic infection, preeclampsia, and fetal intrauterine growth restriction (IUGR) account for most cases of preterm birth (PTB), but many spontaneous PTB cases do not have a clear etiology. We hypothesize that placental insufficiency may be a potential cause of idiopathic PTB.

METHODS

Secondary analysis of 82 placental samples from women with PTB obtained from a multicenter trial of repeat versus single antenatal corticosteroids. Samples were centrally reviewed by a single placental pathologist masked to clinical outcomes. The histopathologic criterion for infection was the presence of acute chorioamnionitis defined as neutrophils marginating into the chorionic plate. Placental villous hypermaturation (PVH) was defined as a predominance of terminal villi (similar to term placenta) with extensive syncytial knotting. Idiopathic PTB comprised a group without another known etiology such as preeclampsia, IUGR or infection.

RESULTS

Acute chorioamnionitis was observed in 33/82 (40%) cases. Other known causes of PTB were reported in 18/82 (22%). The remaining 31/82 (38%) were idiopathic. The frequency of PVH in idiopathic PTB (26/31 = 84%) was similar to cases with IUGR or preeclampsia (16/18 = 89%), but significantly more common than PVH in the group with acute chorioamnionitis (10/33 = 30%) (p < 0.001).

CONCLUSIONS

PVH, which is a histologic marker of relative placental insufficiency, is a common finding in idiopathic PTB.

Effect of antenatal tocolysis on neonatal outcomes

OBJECTIVE

Detail adverse neonatal effects in pregnancies treated with indomethacin (I), magnesium sulfate (M) or nifedipine (N).

METHODS

Women in acute preterm labor with cervical dilatation 1-6 cm were randomized to receive one of three first-line tocolytic drugs.

RESULTS

There were 317 neonates (I = 103, M = 95, N = 119) whose mothers were treated with tocolytic therapy. There was no difference in gestational age at randomization (average 28.6 weeks' gestation) or at delivery (31.6 weeks' gestation, p = 0.551), birth weight (p = 0.871) or ventilator days (p = 0.089) between the three groups. Neonatal morbidity was not different between the three groups; respiratory distress syndrome (p = 0.086), patent ductus arteriosus (p = 0.592), sepsis (p = 0.590), necrotizing enterocolitis (p = 0.770), intraventricular hemorrhage (p = 0.669) and periventricular leukomalacia (p = 0.124).

CONCLUSIONS

There were no statistically significant differences between the three tocolytics as far as composite neonatal morbidity or mortality was concerned.

[Preterm birth: evolution 1994 to 2006]

OBJECTIVE

Evaluate the incidence of births before 33 weeks of amenorrhea over a 12-year period and the place of prematurity induced among them. Determine the evolution of various causes of birth prior to that and draw up a detailed inventory.

PATIENTS AND METHODS

This is a retrospective study from 1994 to 2006, concerning mothers who gave birth in the Network Users Association of computerized records in Pediatrics, Obstetrics and Gynecology (AUDIPOG) between 22 and 32+6 days of maternity. A total of 3781 deliveries were included. The statistical significance of links between the degree of prematurity (high prematurity/extreme prematurity) and the type of prematurity (induced/spontaneous) or mode of early work in the event of induced prematurity (trigger/prior cesarean work) was determined. The evolution of different etiologies was also studied with a complete inventory in 2006.

RESULTS

We observed a significant increase in the rate of births before 33 SA: it was multiplied by 3 in 12 years and stood at 1.7% of births in 2006. No increase in prematurity induced was observed, but in case of preterm labor induced the number of births by caesarean section increased significantly. Concerning the evolution of etiologies, vaginal and urinary infections decreased the most, followed by fetal malformations. Only multiple pregnancies increased significantly. The principle cause of preterm birth was hypertension. Prior to 28 SA, premature births were caused by metrorrhagia and infections at greater levels than 28-32 SA.

DISCUSSION AND CONCLUSION

The growing number of births before 33 SA is a serious phenomenon that must be monitored as they are increasingly common in France.

The prevalence of vaginal microorganisms in pregnant women with preterm labor and preterm birth

Background

To investigate the risk factors for vaginal infections and antimicrobial susceptibilities of vaginal microorganisms among women who experienced preterm birth (PTB), we compared the prevalence of vaginal microorganisms between women who experienced preterm labor (PTL) without preterm delivery and spontaneous PTB.

Methods

Vaginal swab specimens from 126 pregnant women who experienced PTL were tested for group B streptococcus (GBS), Mycoplasma hominis, Mycoplasma genitalium, Ureaplasma urealyticum, Chlamydia trachomatis, Trichomonas vaginalis, Neisseria gonorrhoeae, Treponema pallidum, herpes simplex virus (HSV) I and II, and bacterial vaginosis. A control group of 91 pregnant women was tested for GBS. Antimicrobial susceptibility tests were performed for GBS, M. hominis, and U. urealyticum.

Results

The overall detection rates for each microorganism were: U. urealyticum, 62.7%; M. hominis, 12.7%; GBS, 7.9%; C. trachomatis, 2.4%; and HSV type II, 0.8%. The colonization rate of GBS in control group was 17.6%. The prevalence of GBS, M. hominis, and U. urealyticum in PTL without preterm delivery and spontaneous PTB were 3.8% and 8.7% (relative risk [RR], 2.26), 3.8% and 17.3% (RR, 4.52), and 53.8% and 60.9% (RR, 1.13), respectively, showing no significant difference between the 2 groups. The detection rate of M. hominis by PCR was higher than that by culture method (11.1% vs. 4.0%, P=0.010). The detection rates of U. urealyticum by PCR and culture method were 16.7% and 57.1%, respectively.

Conclusions

There was no significant difference in the prevalence of GBS, M. hominis, and U. urealyticum between the spontaneous PTB and PTL without preterm delivery groups.

Biopsychosocial risk factors for preterm birth and postpartum emotional well-being: a case-control study on Turkish women without chronic illnesses

AIMS AND OBJECTIVES

The study aimed to determine bio-psycho-social risk factors for preterm birth in a sample of Turkish women without chronic illnesses and evaluate their anxiety and depression in early postpartum period.

BACKGROUND

Preterm birth is a devastating event with long-term health and social implications. Studies have identified several risk factors; however, the contribution of these causes differs by ethnic groups.

DESIGN

This case-control study was conducted in a tertiary hospital in Istanbul over one year. In total, 149 preterm mothers were included in the case group and 150 term mothers who delivered in the same day with a case group woman were included in the control group. Chronic illnesses and anomalies were excluded.

METHOD

Data were gathered using a form that addressed risk factors for preterm birth. Multidimensional Scale of Perceived Social Support, Beck Depression Inventory and Spielberger's State-Trait Anxiety Inventory were administered within 24-72 hours after birth.

RESULTS

Logistic regression analysis revealed that partner's lower education (≤ 8 years), history of preterm birth, antenatal hospitalisation, genitourinary infection and irregular prenatal care were significant risk factors. Perceived social support from family and friends were significantly lower in preterm group. Preterm mothers experienced significantly more anxiety and depressive symptoms in early postpartum.

CONCLUSION

Many of the socio-economical and obstetric causes of preterm births were similar to other countries with higher preterm birth rates. Preterm births were associated with lower social support along with more anxiety and depressive symptoms in early postpartum.

RELEVANCE TO CLINICAL PRACTICE

Women who have established risk factors can be targeted for more intensive antenatal care for the prevention of preterm birth. Increased maternal anxiety and depression reveal the necessity of emotional support immediately after birth.

Practices for predicting and preventing preterm birth in Ireland: a national survey

BACKGROUND

Preterm birth can result in adverse outcomes for the neonate and/or his/her family. The accurate prediction and prevention of preterm birth is paramount. This study describes and critically analyses practices for predicting and preventing preterm birth in Ireland.

METHODS

A questionnaire seeking information on practices for predicting and preventing preterm birth was mailed to all consultant obstetricians practising in Ireland in February 2006.

RESULTS

For predicting preterm birth, 97% of respondents did not use foetal fibronectin testing, 71% carried out routine second and third trimester cervical assessments and 75% routinely screened for genital tract infection. For preventing preterm birth, 62% prescribed bed rest, 24% prescribed antibiotics, 14% routinely inserted a cervical cerclage in women with a history of mid-trimester miscarriage and 61% routinely used tocolytics.

CONCLUSION

The findings of this survey, for the most part, reflect the empirical evidence base, international practices and best practice recommendations.

Redirection of cytokine production by lymphocytes from women with pre-term delivery by dydrogesterone

PROBLEM

To study the ability of dydrogesterone to modulate the production of pro-inflammatory and anti-inflammatory cytokines by lymphocytes from women undergoing pre-term delivery (PTD).

METHOD OF STUDY

Peripheral blood mononuclear cells (PBMC) from 18 subjects undergoing PTD were stimulated with the mitogen phytohemagglutinin in the presence and absence of progesterone and dydrogesterone. The levels of interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha, interleukin (IL)-4, and IL-10 in culture supernatants were then estimated by enzyme-linked immunoabsorbant assay. Cytokine production in the presence and absence of progesterone and dydrogesterone were compared.

RESULTS

The exposure of PBMC to dydrogesterone resulted in a significant inhibition in the production of the pro-inflammatory cytokines IFN-gamma and TNF-alpha and a significant increase in the levels of the anti-inflammatory cytokine IL-4, resulting in a substantial shift in the ratio of Th1/Th2 cytokines.

CONCLUSION

Dydrogesterone induces a shift in cytokine bias, by inhibiting pro-inflammatory cytokine production and increasing anti-inflammatory cytokine production.

Assisted conception and retinopathy of prematurity: 8-year follow-up study

AIMS

To assess the effect of assisted conception (AC) on retinopathy of prematurity (ROP) and ROP screening. Follow-up to the study by McKibbin et al.

METHODS

Retrospective study utilising computerised databases of ROP screening, live births, AC and multiple births between 1st April 2000 and 31st August 2003 at St James's Hospital (SJUH) Leeds. chi(2) tests of significance were used.

RESULTS

ROP screening was undertaken in 11/265 (4.2%) of AC births versus 1.6% of all SJUH births. This is significantly less than the 20.3% of AC babies screened in McKibbin et al study (P=<0.01). There was no ROP detected in the 11 AC babies. Of all AC births, 36.9% were one of twins and 1.5% from triplet births compared to 46.0% one of twins and 18.6% one of triplets in McKibbin's study.

CONCLUSIONS

The percentage of AC babies requiring ROP screening has fallen since McKibbin et al study which was performed between August 1991 and December 1994. This appears to be at least partially due to the reduced multiple birth rates. This reduction in the multiple birth rates follows evidence that reducing the number of embryos transferred does not reduce the number of couples taking home a baby and Human Fertility and Embryology Association guidelines recommending 'no more than two embryos should be transferred in an IVF cycle'. Changes in clinical practice at SJUH have significantly reduced the likelihood of AC babies requiring ROP screening and developing ROP.