Updates on management of Preterm Births- News from ACOG Annual Clinical and Scientific Meeting 2016.

The 2016 Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists is ongoing from May 14 to May 17 at the Washington Convention Center in Washington, DC.

Recent clinical trials have led to two important changes in recommendations by ACOG and SMFM on management of preterm births. Steroids are recommended at 23 weeks and at 34-36 weeks to reduce the risks associated with preterm delivery.

Dr. Uma Reddy, MD, MPH, Pregnancy and Perinatology Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health said “All of these changes in practice recommendations will have a real impact on preterm birth.”  “We have already seen a significant decrease in preterm births since a high of 12.8 percent in 2006,” she added. “Preterm birth fell to 11.4 percent in 2013, the last year for which we have complete data. We have had a positive impact in reducing preterm birth.”

The latest recommendations were discussed at Saturday clinical seminar at ACOG annual conference on Saturday May 14, 2016.

 ACOG and the Society for Maternal-Fetal Medicine (SMFM) is now suggesting a single course of steroids for pregnant women starting at 23 weeks who are at risk for preterm birth within seven days. This recommendation is based on a cohort study involving US top 23 academic pediatric centers. It was seen that infants born at 23 to 25 weeks who received antenatal steroids had lower rates of death and lower rates of neurodevelopmental impairment at 18 to 22 months.

The second important recommendation was based on results of the Antenatal Later Preterm Steroids (ALPS) trial reported earlier this year by the Maternal-Fetal Medicine Units Network. A single course of betamethasone in singleton pregnancies between 34 and 36 weeks in women at risk for preterm birth should be given.

The trial showed reduction in the need for respiratory support, reduction in severe respiratory complications, decreased transient tachypnea(TTN), bronchopulmonary dysplasia, and the need for postnatal surfactant. There was no increase in neonatal sepsis, chorioamnionitis, or endometritis, but hypoglycemia was more common in infants exposed to betamethasone. 

These new recommendations are in addition to old recommendations that suggest that all pregnant women between 24 and 34 weeks who are at risk for preterm delivery within seven days receive a single course of corticosteroids. A single rescue course should be considered if a prior course was given at least seven days earlier and the woman remains at risk for preterm birth before 34 weeks.

In summary:

• With the release of this new data and until further guidance is released, administration of betamethasone may be considered in women with a singleton pregnancy between 34 0/7 and 36 6/7 weeks gestation at imminent risk of preterm birth within 7 days. 
• For women in active labor, it is advised to wait for cervical dilatation up-to 3 cm or 75% effacement before administering betamethasone. 
• Tocolysis should not be used in order to delay delivery to allow for administration of late preterm antenatal corticosteroids, nor should an indicated late preterm delivery (such as for preeclampsia with severe features) be postponed for steroid administration.
• All hospitals should utilize standard guidelines for management of hypoglycemia in late preterm newborns.
• Late preterm antenatal corticosteroid administration should not be used in women diagnosed with chorioamnionitis.
• Administration of late preterm antenatal corticosteroids should not be given if the pregnancy was already exposed to antenatal corticosteroids.
• Because the ALPS trial excluded pregnant women with diabetes, multifetal gestations, previous exposure to steroids during pregnancy, or pregnancies with major non-lethal fetal malformations, ACOG is reviewing these topics and will issue any updated clinical guidance as appropriate.

References:

http://www.acogdailynews.com/latest-trials-change-preterm-birth-guidance/

http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Antenatal-Corticosteroid-Administration-in-the-Late-Preterm-Period

http://www.nejm.org/doi/full/10.1056/NEJMoa1516783?af=R&rss=currentIssue

ACOG updates guidelines on External Cephalic Version

According to the new practice bulletin published in the February issue of Obstetrics & Gynecology, all antenatal patients near term with breech presentation should be offered External Cephalic Version (ECV)  to decrease unnecessary C-sections provided they have no contraindication for it.

This replaces the earlier guidelines issued in February 2000.

The ACOG committee member says that “[ECV] is a valuable management technique and, in a properly selected population, poses little risk to either the woman or the fetus. If successful, ECV provides a clear benefit to the woman by allowing her an opportunity for a successful vertex vaginal delivery,"  

These recommendations are based on previous studies showing successful vaginal birth after ECV and a movement to decrease unnecessary Cesarean Deliveries.

The 6 points in the guidelines included 1 Level  A recommendation, 3 Level  B recommendations  and 2 recommendation based on expert opinion and consensus.

Level A recommendations:

1)      Every woman near term, with breech presentation should be offered ECV attempt near term unless contraindicated.  Women may choose not to undergo ECV because of fear of the procedure, incomplete information, and preference for scheduled cesarean delivery.

Level B recommendations:

1)      Fetal presentation should be confirmed beginning at 36 weeks to plan for ECV. The spontaneous version would have happened most likely by 36 weeks and chances of reversion to breech after ECV is also less at this time in pregnancy .

2)      Having a history of previous C-section  does not lessen the chance of success, but whether it augments the risk for uterine rupture is not known.

3)      Using parenteral beta-agonist improves the chance of successful version.

Expert opinion recommendations:

1)      A biophysical profile and nonstress test must be carried out before and after the ECV to ascertain fetal well being.

2)      The procedure should only be attempted in s setting where facilities for emergency C section are available round the clock.  

If ECV persists after the version, the mode of delivery should depend on the expertise of healthcare provider.

Absolute contraindications for ECV are those which are likely to be associated with increased mortality or morbidity:

1. where caesarean delivery is required
2. antepartum haemorrhage within the last 7 days
3. abnormal cardiotocography
4. major uterine anomaly
5. ruptured membranes
6. multiple pregnancy (except delivery of second twin).

Relative contraindications where ECV might be more complicated:

1. small-for-gestational-age fetus with abnormal Doppler parameters
2. proteinuric pre-eclampsia
3. oligohydramnios
4. major fetal anomalies
5. scarred uterus
6. unstable lie

References:

https://www.rcog.org.uk/globalassets/documents/guidelines/gt20aexternalcephalicversion.pdf

http://journals.lww.com/greenjournal/Abstract/2016/02000/Practice_Bulletin_No__161_Summary___External.44.aspx

http://libraryguides.missouri.edu/ACOG

Magnesium Sulfate Use in Obstetrics

The source of this  article is : Magnesium sulfate use in obstetrics. Committee Opinion No. 652. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e52–3.

The U.S. Food and Drug Administration advises against the use of magnesium sulfate injections for more than 5–7 days to stop preterm labor in pregnant women.

Based on this, the category of the drug was changed from ‘A’ to ‘D’ recently, when it was used for more than 5-7 days to prevent preterm labor in pregnant women.

Concerns for fetal and neonatal bone demineralization and fractures associated with long-term in utero exposure to magnesium sulfate prompted this change.

These concerns were based on reports to the FDA’s Adverse Event Reporting System and results from a number of epidemiologic analyses, although these studies have important limitations in designs.

In these population based studies the  average use of  prenatal Magnesium Sulphate was for 9.6 weeks and the dose was  3,700 g, a much longer duration and much higher dose than is currently recommended. The sample size in these studies were also small leading to bias and confounding in the conclusion drawn.

A total 18 cases were reported of fetal and neonatal long bone demineralization and fractures.

So this change of category addresses an unindicated and nonstandard use of magnesium sulfate in obstetric care.

 So, the use of Magnesium Sulphate that is appropriate in clinical practice is:

1. Prevention and treatment of seizures in women with preeclampsia or eclampsia and fetal neuroprotection before anticipated early preterm (less than 32 weeks of gestation) delivery.
2. Short-term prolongation of pregnancy (up to 48 hours) to allow for the administration of antenatal corticosteroids in pregnant women who are at risk of preterm delivery within 7 days.
3. Tocolysis is not recommended beyond 34 weeks of gestation, and is generally not recommended before 24 weeks of gestation but may be considered based on individual circumstances.

References:

https://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Magnesium_Sulfate_Use_in_Obstetrics?IsMobileSet=false