What is the management plan for a woman at risk of premature delivery?

Management of Women at Risk of Premature Delivery

For women at risk of preterm delivery, the cornerstone of management is administration of antenatal corticosteroids to reduce neonatal respiratory morbidity and mortality, with the specific regimen and timing determined by gestational age and clinical circumstances.

Antenatal Corticosteroid Administration

For Late Preterm Period (34 0/7 to 36 6/7 weeks)

• Offer a single course of betamethasone (2 doses of 12 mg intramuscularly 24 hours apart) to women with singleton pregnancies at high risk of delivery within 7 days 1
• This reduces the composite need for respiratory support (11.6% vs 14.4%) and severe respiratory morbidity (8.1% vs 12.1%) 1
• Do NOT administer corticosteroids to women with pregestational diabetes mellitus in this gestational age range due to increased risk of neonatal hypoglycemia 1
• Avoid use in women with low likelihood of delivery before 37 weeks 1

For Earlier Preterm Period (24 0/7 to 33 6/7 weeks)

• Administer a single course of corticosteroids to all women at risk of delivery within 7 days, including those with ruptured membranes and multiple gestations 2, 3
• This significantly reduces perinatal death (RR 0.85), neonatal death (RR 0.78), and respiratory distress syndrome (RR 0.71) 4
• May be considered starting at 23 0/7 weeks based on family decisions regarding resuscitation 2, 3

For Very Early Gestational Ages (before 34 weeks)

• Consider a single repeat course if the woman remains undelivered more than 14 days after the initial course and is still at risk of delivery within 7 days 2, 3
• Rescue courses may be provided as early as 7 days from prior dose if clinically indicated 2, 3
• Avoid multiple repeated courses due to concerns about reduced birthweight and head circumference 1

Fetal Neuroprotection

• Administer magnesium sulfate for fetal neuroprotection if delivery is planned or anticipated before 32 weeks gestation 1, 5
• This reduces the risk of neonatal cerebral palsy 1

Tocolytic Therapy

• Consider tocolysis (such as atosiban) to delay delivery for 48-72 hours, allowing time for corticosteroid administration and maternal transfer to a tertiary facility 5
• The primary goal is gaining time for interventions, not preventing preterm birth entirely 5
• Do not continue tocolysis when delivery would be beneficial for maternal or fetal indications 5

Timing of Corticosteroid Administration

Critical Timing Considerations:

• Steroids should be administered in a timed manner to optimize benefit 1
• Maximum benefit occurs when delivery happens 24 hours to 7 days after administration 1
• For women expected to deliver in less than 12 hours, consider corticosteroid use on a case-by-case basis 1

Special Populations

Multiple Gestations

• Corticosteroids are recommended for multiple pregnancies at risk of preterm delivery 2, 3
• Consider use in multiple gestations reduced to singleton on or after 14 0/7 weeks 1

Ruptured Membranes

• Administer corticosteroids regardless of membrane rupture status 2, 3

Hypertensive Disorders

• For women with preeclampsia at ≤34 weeks, administer corticosteroids if delivery is anticipated 1
• For gestational hypertension at ≤34 weeks, give corticosteroids only if delivery is considered within 7 days 1

Maternal Counseling

• Thoroughly counsel patients about potential risks and benefits of corticosteroid administration 1
• Inform them that long-term risks remain uncertain 1
• Discuss the increased risk of transient neonatal hypoglycemia (typically resolves within 24 hours in 93% of cases) 1

Common Pitfalls to Avoid

• Do not administer corticosteroids to women unlikely to deliver before 37 weeks - this represents overuse without proven benefit 1
• Avoid late preterm steroids in women with pregestational diabetes - the risk of severe neonatal hypoglycemia outweighs benefits 1
• Do not routinely give multiple courses of corticosteroids - repeated doses may reduce infant birthweight and head circumference 1
• Do not delay delivery when maternal or fetal conditions warrant immediate intervention simply to complete a steroid course 5

Monitoring and Surveillance

• Women receiving corticosteroids require close maternal and fetal surveillance 1
• Monitor for signs of infection, particularly in cases of ruptured membranes 1
• Assess fetal well-being with appropriate testing based on gestational age and clinical scenario 1