Preventing and Managing Prematurity

Abstract

In the past decade the prevention and management of prematurity have begun to be addressed with more appropriate designs. A few strategies-very few-can now be recommended. A few, some widely implemented, can be abandoned. The risks and benefits of most interventions still require clarification.It is commonly agreed among clinicians, researchers, and health policy makers in industrialized countries that the crucial perinatal problem is prematurity. One response to this recognition has been an emphasis on the need for a better understanding of the pathophysiology of prematurity as the key to prevention. Eastman's (19) classic comments-"only when the factors causing prematurity are clearly understood can any intelligent attempt at prevention be made"-is still quoted by those who hold this view, and it could still be regarded as largely true.In contrast, several recent articles call for a greater sense of urgency, exhorting clinicians to stop worrying about causes and to implement preventive programs instead (32;33;36). It is tempting, in the face of stable prematurity rates and the insatiable demand for more neonatal intensive care facilities, to respond enthusiastically to the call. The only trouble with this advice is its lack of clarity about preventive programs: What is the scope of prevention and what components of which programs actually work?First, the scope for prevention is limited by the fact that more than 60% of preterm deaths occur before labor or in infants with lethal malformations (86;87). Even when the infant is alive and not malformed at the onset of labor, some preterm deliveries are elective and others are complicated by factors that contraindicate delaying the delivery (e.g., bleeding). The remaining cases of preterm birth involving spontaneous uncomplicated preterm labor or preterm premature rupture of the membranes (PPROM) with a healthy fetus offer the widest scope for prevention; in some cases, however, delivery is already inevitable at the time of hospital admission. Potential preventive efforts in the uncomplicated group include true primary prevention, early identification of preterm labor or its premonitory signs, and inhibition of preterm labor.Though it is often blurred in practice, the distinction between prevention and inhibition of preterm labor is an important one because the potential for net negative outcomes is even greater with prophylactic interventions. These interventions are used in women at risk, rather than in ones with an established problem, and are used for a greater proportion of the pregnancy.

Epidemiology and risk factors in preterm deliveries

“…Etwa 1% aller Geburten sowie die Hälfte aller perinatalen Todesfälle entfallen auf sehr frühe Frühgeburten [1,2,3]. Woche nach der letzten Periode und stellt wegen der hohen Mortalität sowie des Risikos bleibender Behinderungen ein wichtiges Problem dar.…”

Low‐Birthweight Prevention Programs: The Enigma of Failure

“…Low birthweight is a multifaceted and seemingly intractable public health problem in the United States and the primary cause of neonatal morbidity and mortality ( 1,2). Some antenatal conditions cause infants to grow too slowly in utero, others precipitate preterm deliveries, and still others lead to medical and obstetric complications that necessitate preterm delivery ( 1‐5). The failure to differentiate among these subgroups of small babies creates observation biases that lead to flawed conclusions about the reasons for, and significance, treatment and prevention failures ( 1‐7).…”

“…The primary prevention programs of the 1960s and 1970s targeted all women of reproductive age ( 2). Unfortunately, the expectation that increased public funding for preconceptional and prenatal care would be accompanied by a reduction in the frequency of unintended pregnancies, in late and inadequate prenatal care, and in the numerous medical and behavioral factors that predispose women to low‐birthweight delivery, was overly optimistic ( 1‐5,9‐18). Rather, Haas et al in Massachusetts ( 14,15), followed by Harbert in Virginia ( 16) and Piper et al in Tennessee ( 17), reported that the expansions of Medicaid services funded by the federal Improving Pregnancy Outcome program were associated with an increase in the use of tocolytics and in higher hospitalization and cesarean delivery rates.…”

“…Such programs target women whose medical and social histories suggest that they were at increased risk for low birthweight for the potentially modifiable reasons listed in Table 2. They augment traditional prenatal care programs with intensive, multicomponent interventions designed to mitigate naturally occurring clusters of high‐risk, maternal characteristics ( 2,3,9,22‐24). The goal is to provide women with both the knowledge and the psychosocial and material support needed to meet their medical and nutritional needs, cope with stressful aspects of their lives, and avoid risky health behaviors.…”

Technology Assessment and Public Health

“…For example, use of intravenous lidocaine, which has not been shown to have any benefit following heart attack, continues to be recommended by experts as standard therapy, while post-attack clot-dissolving therapy was not mentioned in most major text books for many years after its effects on mortality had been clearly documented (2). Similarly, use of cortico-steroids in the management of lung complications related to premature birth is inconsistent, in spite of substantial evidence accumulated over many years demonstrating the effec tiveness of this therapy (68).…”