What is the management of preterm labour?

Management of Preterm Labour

The management of preterm labour requires a structured approach including antibiotics, antenatal corticosteroids, magnesium sulfate, and appropriate delivery timing based on gestational age, with individualized counseling about maternal and fetal risks and benefits. 1

Diagnosis and Initial Assessment

• Diagnosis is based on clinical symptoms, physical examination findings, and progressive effacement and dilation of the cervix 2
• Transvaginal ultrasound measurement of cervical length is a valuable tool to predict preterm delivery 3
• Biomarkers like fetal fibronectin can aid in diagnosis, though they are of secondary importance to clinical findings 2, 3

Pharmacological Management

Antibiotics

• Strongly recommended for pregnant individuals with PPROM at ≥24 0/7 weeks of gestation (GRADE 1B) 1
• Can be considered after PPROM at 20 0/7 to 23 6/7 weeks of gestation (GRADE 2C) 1
• For previable PPROM at <20 weeks, shared decision-making is recommended regarding antibiotic use 1
• When administered, follow similar regimens as for PPROM at later gestational ages (typically a 7-day course with ampicillin and erythromycin IV for 48 hours, followed by oral amoxicillin and erythromycin) 1
• Azithromycin can be used as an alternative to erythromycin when unavailable 1
• Avoid amoxicillin-clavulanic acid due to increased risk of necrotizing enterocolitis 1

Antenatal Corticosteroids

• Recommended between 24 and 34 weeks of gestation to accelerate fetal lung maturity 4, 3
• Standard regimen is two doses of 12 mg betamethasone 24 hours apart or two doses of 6 mg dexamethasone 5, 6
• Alternative regimen of betamethasone with 12-hour intervals may be considered when rapid lung maturation is needed 5
• Not recommended until the time when neonatal resuscitation and intensive care would be considered appropriate (GRADE 1B) 1
• A single course is recommended; multiple courses may be harmful and should be avoided 2, 6

Magnesium Sulfate

• Recommended for fetal neuroprotection when delivery is anticipated before 32 weeks 3
• Not recommended until the time when neonatal resuscitation would be appropriate (GRADE 1B) 1
• Requires careful monitoring due to potential maternal and fetal toxicity 7
• Contraindicated in severe renal impairment; urine output should be maintained at ≥100 mL over four hours preceding each dose 7
• Monitor for signs of magnesium toxicity: loss of patellar reflexes, respiratory depression, and serum magnesium levels 7

Tocolytics

• Can be used for short-term delay of delivery (up to 48 hours) to allow for corticosteroid administration 2, 3
• Options include:
  • Beta-sympathomimetics (short-term use only due to maternal side effects) 2
  • Calcium channel blockers (nifedipine) with fewer side effects 2
  • Oxytocin receptor antagonists (atosiban) 2
  • Prostaglandin synthetase inhibitors (indomethacin) prior to 32 weeks 2
• Not indicated after 34 weeks' gestation 2, 3

Management Based on Gestational Age

Previable PPROM (<20 weeks)

• Offer both abortion care and expectant management options (GRADE 1C) 1
• Provide individualized counseling about maternal and fetal risks and benefits 1
• Shared decision-making regarding antibiotic use 1

Periviable PPROM (20-23 6/7 weeks)

• Offer both abortion care and expectant management options (GRADE 1C) 1
• Consider antibiotics to prolong latency (GRADE 2C) 1
• Cerclage management requires shared decision-making; reasonable to either remove or leave in situ (GRADE 2C) 1

PPROM at ≥24 weeks

• Administer antibiotics (GRADE 1B) 1
• Consider antenatal corticosteroids and magnesium sulfate when appropriate 1
• Avoid serial amnioinfusions and amniopatch (considered investigational) (GRADE 1B) 1

Inpatient vs. Outpatient Management

• Initial observation in hospital is reasonable to ensure stability 1
• Outpatient management with close monitoring may be considered after stability is confirmed 1
• Monitor for signs of maternal complications such as hemorrhage or infection 1

Subsequent Pregnancies

• Follow guidelines for management of pregnant persons with previous spontaneous preterm birth (GRADE 1C) 1

Common Pitfalls to Avoid

• Prolonged or repeated antibiotic courses beyond what would be used for PPROM at later gestational ages 1
• Multiple courses of corticosteroids, which may be harmful 2, 6
• Routine cesarean delivery, which is not recommended for preterm labor 3
• Using amoxicillin-clavulanic acid, which increases risk of necrotizing enterocolitis 1
• Administering magnesium sulfate without proper monitoring for toxicity 7