What is the recommended management for preterm labour according to the National Institute for Health and Care Excellence (NICE) guideline?

Management of Preterm Labour According to NICE Guidelines

Note: The evidence provided does not contain NICE (National Institute for Health and Care Excellence) guidelines specifically; however, comprehensive management recommendations from ACOG (American College of Obstetricians and Gynecologists) guidelines are available and provide evidence-based protocols for preterm labour management.

Initial Assessment and Diagnosis

• Evaluate for signs of infection (maternal fever, tachycardia, purulent cervical discharge, fetal tachycardia, uterine tenderness), placental abruption, and fetal well-being at presentation 1, 2
• Perform transvaginal ultrasound for cervical length measurement as the most reliable diagnostic tool to differentiate threatened from true preterm labour 1
• Conduct digital cervical examination to assess dilation and effacement 1
• Obtain fetal biometry, amniotic fluid volume assessment, and fetal Doppler waveform analysis at first diagnosis 1, 2

Gestational Age-Specific Management Algorithm

Previable Period (<24 weeks)

• Offer abortion care to all patients with previable PPROM due to high maternal risks (maternal sepsis up to 6.8%, maternal death 45 per 100,000) and poor fetal outcomes (no surviving neonates reported after PPROM <16 weeks) 3, 2
• If expectant management chosen, consider antibiotics for PPROM at 20 0/7 to 23 6/7 weeks (Grade 2C recommendation) 1, 3, 2
• Emergency ("rescue") cerclage can be considered when fetal membranes are visible at or past the external cervical os in the absence of contractions or PPROM at <24 weeks 4, 1
• Do NOT administer antenatal corticosteroids or magnesium sulfate until the gestational age when neonatal resuscitation would be pursued 3

Periviable Period (24-34 weeks)

• Administer antenatal corticosteroids between 24+0 and 34+0 weeks gestation to accelerate fetal lung maturity and reduce death, intraventricular hemorrhage, periventricular leukomalacia, and necrotizing enterocolitis 4, 1, 2
• Administer magnesium sulfate for fetal neuroprotection when delivery is anticipated before 32 weeks gestation (reduces cerebral palsy: RR 0.68,95% CI 0.54-0.87, without increasing mortality) 4, 1, 2
• Strongly recommend antibiotics (Grade 1B) for PPROM ≥24 weeks to prolong latency and reduce neonatal morbidity 1, 3, 2

Antibiotic Therapy Protocol

• Administer a 7-day course: IV ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for 5 days 1, 3, 2
• Azithromycin can replace erythromycin if unavailable 1, 3, 2
• CRITICAL: Avoid amoxicillin-clavulanic acid due to increased risk of necrotizing enterocolitis 4, 1, 3, 2
• Do NOT use antibiotics for preterm labour with intact membranes (no evidence of benefit and potential risks) 4
• Do NOT use prolonged or repeated antibiotic courses beyond the standard 7-day regimen 1, 3

Tocolytic Therapy

Nifedipine (calcium channel blocker) is the preferred first-line tocolytic agent based on superior efficacy and safety profile 5, 6:

• Reduces preterm birth (RR 0.89,95% CI 0.80-0.98) and very preterm birth (RR 0.78,95% CI 0.66-0.93) compared to betamimetics 6
• Reduces respiratory distress syndrome (RR 0.64,95% CI 0.48-0.86), necrotizing enterocolitis (RR 0.21,95% CI 0.05-0.96), and intraventricular hemorrhage (RR 0.53,95% CI 0.34-0.84) 6
• Fewer maternal adverse effects (RR 0.36,95% CI 0.24-0.53) and discontinuations due to side effects (RR 0.22,95% CI 0.10-0.48) compared to betamimetics 6
• Prolongs pregnancy by average 4.38 days and increases gestational age by 0.71 weeks 6

Alternative tocolytic options:

• Indomethacin may be reasonable for acute tocolysis at <32 weeks gestation, but avoid prolonged use (>48 hours) 5
• Atosiban has the best maternal and fetal safety profile but does not reduce neonatal complications 5, 7
• Tocolytics may delay delivery 48-72 hours after 26 weeks, allowing time for corticosteroid administration and maternal transfer 4, 1, 5

Cerclage Management with PPROM

• Either remove the cerclage or leave it in situ after discussing risks and benefits (Grade 2C) - randomized trial showed no pregnancy prolongation benefit with retention 1, 3, 2

Monitoring During Expectant Management

Inpatient Phase

• Initial hospital observation to ensure stability without preterm labour, abruption, or infection before considering discharge 3

Outpatient Phase

• Weekly outpatient visits for maternal vital signs, fetal heart rate, physical examination, and laboratory evaluation for leukocytosis 1, 3, 2
• Daily patient self-monitoring for temperature, vaginal bleeding, discolored or malodorous discharge, contractions, and abdominal pain 1, 3, 2

Readmission Criteria

• Hemorrhage or placental abruption 3
• Signs of infection (note: intraamniotic infection may present without maternal fever, especially at earlier gestational ages) 3
• Fetal demise or fetal compromise on surveillance testing 3
• Reaching gestational age when neonatal resuscitation would be appropriate 3

Interventions NOT Recommended

• Serial amnioinfusions are NOT recommended for routine care (Grade 1B) - two large trials showed no reduction in perinatal morbidity 1, 3
• Amniopatch is investigational only and should be used only in clinical trial settings (Grade 1B) 1, 3, 2
• Routine cesarean delivery is NOT recommended for periviable delivery alone (has not been shown to decrease mortality or intraventricular hemorrhage) 4
• Combination tocolytic therapy lacks evidence of benefit over single agents 8

Critical Pitfalls to Avoid

• Delaying diagnosis of intraamniotic infection due to absence of maternal fever - infection can progress rapidly without obvious symptoms 1, 3
• Using amoxicillin-clavulanic acid - significantly increases necrotizing enterocolitis risk 4, 1, 3, 2
• Administering corticosteroids and magnesium sulfate before the gestational age when neonatal resuscitation would be pursued 1, 3
• Prolonged antibiotic courses beyond standard 7-day regimen - compromises antibiotic stewardship 1, 3

Subsequent Pregnancy Management

• Nearly 50% of immediate subsequent pregnancies result in recurrent preterm birth after previable/periviable PPROM 3
• Manage according to guidelines for previous spontaneous preterm birth (Grade 1C), typically including progesterone supplementation and increased surveillance 3
• Consider induction at 39-40 weeks to balance optimal fetal maturity against residual membrane weakness 3