Population: Pregnant women ≥20 wk EGA in preterm labor.

Organizations

ACOG 2016, Cochrane Database of Systematic Reviews 2013, NICE 2015

Recommendations

Evaluation

–Consider fetal fibronectin testing and/or the cervical length measurement as part of a diagnosis of preterm labor and to predict preterm birth in symptomatic women, but do not rely exclusively on these tests to direct management as the positive predictive value is poor.

• Cervical length: if >1.5 cm, preterm labor is unlikely; if ≤1.5 cm and clinical situation suggests it, diagnose and manage preterm labor. (NICE)

• Fetal fibronectin: use to determine likelihood of birth within 48 h if cervical length measurement not available. (NICE)

Management

–Give a single dose of corticosteroids for pregnant women between 24 and 34 gestational weeks or women with ROM or multiple gestations who may deliver within 7 d.

• Consider corticosteroids at earlier gestation (ACOG: starting at 23 wk; NICE: starting at 22 wk) if risk of delivery within 7 d.

• Consider corticosteroids between 34 and 35-6/7 wk if at risk of delivery within 7d.

• Betamethasone or dexamethasone IM are the most widely studied options.

–Consider second course of corticosteroids for women <34-wk EGA who are >7 d remote from their first course and are at very high risk of giving birth within 48 h.

–Give magnesium sulfate (4 g IV ×1, then 1 g/h ×24 h) for neuroprotection.

• ACOG: give if possible preterm delivery prior to 32 wk.

• NICE: give between 24 and 29-6/7 wk; consider as early as 23 wk and as late as 33-6/7 wk.

• Indomethacin is a potential option for use in conjunction with magnesium sulfate.

–Consider tocolysis for up to 48 h. Do not use after 34-wk gestation. Do not recommend maintenance therapy. Options include:

• Beta-agonists.

• Nifedipine (NICE: first line).

• Indomethacin.

–Do not use tocolytics for women with preterm contractions without cervical change, especially if <2 cm.

–Do not use antibiotics in preterm labor with intact membranes.

–Do not routinely recommend bedrest and hydration, as they have not been shown to prevent preterm birth.

Sources

–Obstet Gynecol. 2016;128:e155-e164.

–http://www.cochrane.org/CD003096/PREG_hydration-for-treatment-of-preterm-labour