Prevention of Preterm Birth

Jeffrey M. Denney; Jennifer F. Culhane; Robert L. Goldenberg

Disclosures

Women's Health. 2008;4(6):625-638. 

In This Article

Preterm Premature Rupture of the Membranes

Spontaneous preterm birth is customarily defined as any delivery following either spontaneous preterm labor or pPROM. Even though these events are defined as distinct entities; there is considerable evidence that the risk factors for their occurrence are similar and the distinction maybe largely a matter of semantics. Most prevention strategies for spontaneous preterm birth target both conditions and these will not be discussed separately for pPROM.

In the absence of clinical evidence suggesting infection, delaying the delivery after diagnosis of pPROM at less than 34 weeks gestation becomes the obstetrician's primary goal. Such delay increases the likelihood of fetal organ maturation, especially that of the lungs. However, this delay concomitantly increases the fetus's risk of in utero infection. As these infections pose risk to both the mother and fetus/neonate, pPROM was historically an indication for expeditious delivery, regardless of gestational age. Even without induction, most women diagnosed with pPROM have spontaneous labor and, subsequently, deliver within a week. Rather than trying to reduce the rate of preterm delivery in the context of pPROM, the goal of treatment in these pregnancies has been to lengthen the time from preterm rupture of the membranes to delivery (i.e., to facilitate more time for fetal maturation) or reducing morbidity and mortality in mothers and infants. To date, no strategies have been identified that reduce the occurrence of preterm birth after pPROM; thus, most pregnancies complicated by pPROM end in preterm birth.

With the availability of more potent antibiotics and a better understanding of the risk of infection as compared with the risk of complications of prematurity, management of preterm rupture of the membranes at less than 32 or 34 weeks of gestation has evolved into a policy of watchful waiting with antibiotics, with delivery at any sign of infection. Prophylactic antibiotic therapy has been found to be effective in prolonging the period between preterm rupture of the membranes and delivery.[140,141,142,143] The largest studies to date have also demonstrated that antibiotic treatment reduces the risks of maternal chorioamnionitis, neonatal respiratory distress syndrome and neonatal sepsis.[142,143] Thus, antibiotics are beneficial in prolonging the interval between pPROM and delivery, as well as in reducing neonatal morbidity. Corticosteroids may augment this benefit. It is worth noting that most practice algorithms adopt the use of antibiotics for latency between 24 and 34 weeks and steroids within the same time interval. The combined use of corticosteroids and antibiotics has been associated with a reduced risk of respiratory distress syndrome, as compared with the use of corticosteroids alone.[144]

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