Preterm Labor and Delivery

Duration 16:35

 

00:07
hi everybody this is Chris Morosky in
00:09
this is a short video on preterm birth
00:11
and prematurity I’d like to thank dr.
00:13
Adam Borg eda for his contributions to
00:15
this video the goals and objectives of
00:18
this video are as follows discuss the
00:20
burden of prematurity review the trends
00:22
in Connecticut and national preterm
00:24
birth data understand the risk factors
00:26
and drivers of preterm birth describe
00:28
the tests available to predict preterm
00:30
birth and review the use of progesterone
00:32
to prevent recurrent preterm birth
00:35
preterm birth or prematurity is a single
00:37
most important cause of perinatal
00:39
mortality in the United States it is the
00:41
leading cause of neonatal mortality
00:42
defined as death within the first 28
00:45
days of life in the United States and is
00:47
also the second leading cause of infant
00:49
mortality defined as death in the first
00:51
year of life in the United States
00:54
preterm birth is a major determinant of
00:56
neonatal and infant illness this would
00:59
include neurodevelopmental handicaps
01:01
such as cerebral palsy or mental
01:02
retardation chronic respiratory problems
01:05
intraventricular hemorrhage
01:07
periventricular leukomalacia infection
01:10
retro Lendl fiber aplasia
01:12
necrotizing enterocolitis and neuro
01:14
sensory deficits such as hearing and
01:17
visual prematurity generates enormous
01:20
healthcare costs the average newborn
01:22
hospital charges for a term baby are
01:25
$4,300 vs. 58 thousand dollars for a
01:29
preterm baby the total u.s. Hospital at
01:31
charges for infants days due to
01:32
prematurity in low birth weight or
01:34
almost 12 billion dollars when you
01:37
include maternity and related expenses
01:38
this is often the largest cost to
01:40
employers health care plans as you can
01:43
see infant mortality death in the first
01:45
year of life has decreased in the United
01:47
States since 1915 to 2000 it’s going
01:50
down from proximally one out of ten to
01:52
now one in a thousand live births there
01:56
are multiple reasons for improved
01:57
survival one of these is NICU care we
01:59
now have ventilators total parenteral
02:01
nutrition and surfactant there’s also
02:04
improved obstetrical here we now have
02:06
steroids for lung maturity latency
02:08
antibiotics for preterm premature
02:11
rupture of membranes and we now have
02:12
ultrasounds
02:14
if you look at selected leading causes
02:16
of infant mortality in the United States
02:18
and compare 1996 vs. 2013 what you see
02:21
is that birth defects are down 164 to
02:25
121 per 1000 live births but preterm
02:28
birth and low birth weight is up 99 to
02:31
107 per 100,000 live births SIDS is down
02:34
RDS is down and importantly maternal
02:37
pregnancy complications are very much up
02:40
having gone from 32 to 40 per 100,000
02:43
live births and specifically in
02:47
Connecticut looking at the leading
02:48
causes of infant mortality to our most
02:50
up-to-date data from 2013 you can see
02:53
that Connecticut when compared to the
02:55
United States is very much lower when it
02:57
comes to birth defects preterm birth but
02:59
as higher in SIDS and is about even with
03:02
maternal pregnancy complications preterm
03:05
delivery in Connecticut compared to the
03:07
rest of the United States from 2007 to
03:09
2016 shows that overall our state is
03:13
slightly lower than the national average
03:15
however you can see that both
03:16
Connecticut and the nation have
03:18
approximately nine to ten percent of
03:20
live births that are preterm and when
03:23
broken down by race and ethnicity you
03:26
can see that Asian and Pacific Islanders
03:28
on average from 2013 2015 across the
03:31
nation had an 8.5% preterm birth rate
03:34
white ethnicity had eight point nine
03:36
percent Hispanic ethnicity or race was
03:38
nine point one percent American Indian
03:40
and Alaskan native was ten point five
03:42
percent and black women had a 13.3%
03:46
preterm birth rate what this shows is
03:48
that in the United States the preterm
03:49
birth rate among black women is 49
03:51
percent higher than the rate among all
03:53
other women there are various different
03:56
types of preterm births there is
03:58
spontaneous preterm birth which is the
04:00
spontaneous onset of labor and
04:02
contractions which lead to delivery of
04:04
the infant there’s preterm premature
04:06
rupture of membranes where the water
04:09
breaks prior to the onset of labor and
04:11
then there’s medical intervention or
04:13
what we call indicated preterm birth and
04:15
while the suggests distinct pathways
04:17
many of the risk factors for all three
04:19
are similar what you can see is that
04:23
over time there’s been changes in the
04:25
etiology of preterm birth the
04:27
graphs look at preterm birth from 1989
04:30
to 2001 looking at the graph on the left
04:33
you can see that for the most part all
04:35
preterm births ruptured membranes
04:37
medically indicated and spontaneous
04:40
preterm births seem to be changing
04:42
slightly when you superimpose them on
04:45
themselves and the right graph what you
04:47
can see is that the medically indicated
04:49
preterm births have greatly gone up over
04:52
that time period while all preterm
04:55
births spontaneous preterm births and
04:57
ruptured membranes causing preterm birth
05:00
have either stay the same or slightly
05:02
gone down what this suggests is that
05:04
there may be some changes in the health
05:05
of our mothers over that period of time
05:08
looking at some of the risk factors for
05:10
preterm birth
05:11
if previous preterm birth presents a
05:13
probability of 30 percent of preterm
05:16
birth or subsequent pregnancy greater
05:18
than two previous preterm births
05:20
increases this to 70 percent twin
05:23
gestation x’ has a probability of
05:25
preterm birth of 50% and triplets are
05:27
higher this approaches 75 to 95 percent
05:30
uterine malformations such as a unicorn
05:32
uterus increased the probability of
05:35
preterm birth to 30% looking at maternal
05:38
age for a risk factor for preterm birth
05:40
in the United States from 2013 to 2015
05:43
you can see that for the age groups of
05:46
less than 20 20 to 29 and 30 to 39 the
05:49
percentage of preterm births was pretty
05:52
much steady around 9 to 10 percent
05:54
however looking at women over 40 years
05:56
old this increased greatly to 14.3%
06:00
looking more closely at multiple
06:03
gestation and preterm birth and the
06:04
Connecticut in the United States you can
06:06
see that singleton pregnancies have a
06:08
preterm birth rate of 7.8% as compared
06:11
to sixty point three percent for
06:13
multiple gestation x’ in this time
06:15
period of 2015 you can see that multiple
06:18
gestation is accounted for 3.5% of the
06:20
live births in the United States and 4.1
06:23
percent of the live births in
06:24
Connecticut tobacco smoking is also a
06:28
risk factor for preterm birth there are
06:30
some very interesting trends for
06:31
Connecticut in the United States from
06:33
2006 to 2017 what we can see is that
06:37
overall the percentage of women smoking
06:39
during
06:40
agency has decreased over time and also
06:43
that Connecticut has had a lower
06:44
percentage of women smoking during
06:45
pregnancy compared to the nation also
06:49
looking at BMI and its association with
06:51
preterm birth it can be seen that a low
06:53
BMI is associated with an increased risk
06:56
for spontaneous preterm birth looking at
06:58
a BMI less than 19 the percentage of
07:01
spontaneous preterm birth is sixteen
07:03
point six percent you can see this drop
07:05
to eleven point three percent for BMI of
07:07
nineteen to twenty four point nine eight
07:09
point one percent for normal BMI of 25
07:12
to 29 point nine seven point one percent
07:14
for obesity at thirty to thirty four
07:17
point nine and down to five point two
07:19
for a BMI over thirty-five going with
07:22
this indicated preterm birth is about
07:24
the same but does seem to be slightly
07:26
higher for the BMI of 30 to 34 point
07:28
nine for a long period of time there are
07:31
no tests available to predict premature
07:33
birth
07:34
there are now two recent advances in
07:36
predicting premature birth
07:38
these are fetal fibronectin and cervical
07:41
length measurement we will look at them
07:42
separately first field of fibronectin
07:46
fetal Carrboro nekton is a intracellular
07:50
matrix of the surveys it can be found in
07:52
between the chorion and the decidua as
07:55
shown in the picture it is secreted with
07:58
cervical changes and if absent from the
08:00
vagina there is a very low risk for
08:02
preterm birth FFN is low from 24 to 34
08:06
weeks gestational age it is helpful for
08:08
symptomatic patients therefore that are
08:11
greater than 24 weeks in gestation the
08:13
value of the FFN really isn’t as
08:15
negative predictive value if an F of n
08:17
is negative there is a 98% chance that
08:19
the patient will not deliver in the next
08:21
two weeks and therefore there’s no need
08:23
to spend additional money or resources
08:24
on that patient
08:25
unfortunately the positive predictive
08:27
value is not as helpful and when the
08:30
test is positive there’s a 50% chance
08:32
that the patient will deliver in the
08:33
next two weeks looking at a graph of f
08:37
FN at 24 weeks and the risk for preterm
08:40
birth it is important to keep in mind
08:42
that the cutoff for the FN being
08:44
positive or negative is important in
08:46
terms of how well it performs in
08:48
predicting preterm birth with the black
08:51
line the cutoff for FF n is zero
08:54
with the redline the cutoff for FN is 1
08:58
to 50 with the blue mind the cutoff is
09:01
50 to 200 and the green line is greater
09:05
than 200 so certainly as the
09:08
concentration of your cutoff for F of n
09:10
increases it is more predictive of the
09:12
risk for preterm birth and that women
09:14
who have such high cut-offs such as the
09:17
Green Line certainly at risk for preterm
09:19
birth in a Cochrane review of studies
09:22
evaluating the use of fetal fibronectin
09:25
testing producing the risk of preterm
09:26
birth what they found was in the top
09:28
graph that using FF n did reduce the
09:31
risk of preterm birth less than 37 weeks
09:33
however in reducing the risk of preterm
09:36
birth less than 32 weeks FF n was not
09:39
successful this can be seen in the
09:40
bottom graph and the use of FF n did not
09:44
improve the gestational age at delivery
09:46
in this Cochrane review now moving on to
09:50
a cervical length measurement in a study
09:53
published by James in the New England
09:54
Journal Medicine in 1996 they correlated
09:57
the length of the cervix with the risk
09:59
of preterm birth and you can see that
10:00
the mean cervical eighth was 3.5
10:02
centimeters and that the risk factor for
10:05
preterm birth was approximately 2 to 3
10:07
percent when the cervix was this long as
10:09
the service gradually became shorter and
10:12
shorter and shorter are moving to the
10:14
left side of the graph the relative risk
10:16
for preterm birth increased greatly in
10:18
fact for a woman with a cervical length
10:20
of one point two centimeters the
10:22
relative risk for preterm birth was over
10:25
14 this led to recommendations to screen
10:27
women with a cervical length measurement
10:29
using a transvaginal ultrasound to
10:31
predict the risk of preterm birth while
10:33
this may not be applied generally across
10:35
all populations certainly all women who
10:37
have risk factors for preterm birth are
10:39
recommended to undergo cervical
10:41
screening what that looks like an
10:44
ultrasound is shown in this picture in
10:46
this first picture the vaginal
10:48
ultrasound probe is pressed too far into
10:50
the vagina and compresses the cervix you
10:52
can see the cervix in the middle of the
10:54
screen as the greyish mass in the middle
10:56
of the ultrasound screen with the white
10:59
line running through it representing the
11:00
end of cervical canal as the vaginal
11:04
probe is pulled out slightly from the
11:06
vagina you can begin to see some
11:08
the amniotic fluid near the internal
11:10
offering up as a black triangle with
11:14
some pressure on the fundus of the
11:16
uterus being transmitted through the
11:17
pregnancy down to the cervix you can see
11:19
now a black funneling of the inner
11:22
portion of the cervix the cervical
11:25
length is then measured as the white
11:27
line of the part of the service that is
11:29
closed and this is called the functional
11:31
length of the cervix in this image that
11:34
the cervical length is two point six
11:35
centimeters and this is slightly
11:37
shortened we will end this video by
11:40
discussing progesterone for the
11:42
prevention of preterm birth there is
11:45
recent evidence to suggest that
11:46
progesterone maintains uterine
11:48
quiescence progesterone inhibits the
11:50
production of prostaglandins it also
11:52
inhibits the production of contraction
11:54
associated protein genes such as
11:57
oxytocin and prostaglandin receptors gap
12:00
junctions and ion channels it down
12:03
regulates the production of calcium
12:05
channels and therefore decreases uterine
12:08
contractions looking at some of the
12:10
historical Studies on the use of
12:12
progesterone for the Prevention of
12:14
recurrent preterm birth this goes back
12:16
to the 1970s when pepper Nick and
12:18
colleagues published a placebo
12:19
controlled trial of 99 women in the
12:21
third trimester who were given 17 alpha
12:24
hydroxy progesterone capri and they
12:26
found that this was efficacious for
12:27
preventing preterm birth in 1975 Johnson
12:30
at all published in the New England
12:32
Journal of Medicine that initiating 17
12:35
hydroxy progesterone in the second
12:36
trimester prevented preterm birth from
12:38
1980 there was a study that showed that
12:40
this was not efficacious for preventing
12:42
preterm birth in twins and a 1989
12:45
meta-analysis said that this was still
12:47
unclear more recent studies were
12:50
published in 2003 and the papers shown
12:54
here by Mesa dal as one of the landmark
12:56
studies around progesterone for the
12:58
Prevention of preterm birth this was run
13:00
out of the National Institutes of child
13:03
and health development and the maternal
13:04
fetal medicine University and this was a
13:06
randomized double-blind
13:07
placebo-controlled trial women were
13:09
enrolled at 16 to 20 weeks and were
13:11
either given placebo or
13:13
250 milligrams of 17 hydroxy
13:16
progesterone
13:16
all through weekly injections and the
13:19
primary outcome for the study of a
13:20
spontaneous preterm birth less than 37
13:24
2980 women are eligible for the study
13:26
1039 met entry criteria and 463
13:30
consented for the trial in cutting to
13:34
the chase delivery before 37 weeks was
13:36
greatly reduced by the use of
13:38
progesterone by a total of 34 percent
13:42
delivery before 35 weeks gestational age
13:45
was reduced by 33 percent and delivery
13:50
before 32 weeks gestational AIDS was
13:52
decreased by 42 percent all of these
13:55
results were statistically significant
13:58
in a separate study by dave fonseca at
14:01
all this is also pops in 2003 they
14:04
looked at you do vaginal progesterone in
14:07
a randomized double-blind
14:07
placebo-controlled study out of Brazil
14:10
they looked at 142 high-risk singleton
14:13
pregnancies and these patients were
14:15
either given 100 milligrams of vaginal
14:17
progesterone or placebo daily the
14:21
vaginal suppositories
14:22
contained 100 milligrams of natural
14:24
progesterone and it was applied nightly
14:26
from 24 to 34 weeks what they found was
14:30
that there was again a decreased risk of
14:32
preterm birth less than 37 weeks in the
14:35
progesterone group 28.5% for placebo
14:39
13.8% for progesterone there was also a
14:42
decreased incidence of preterm birth
14:43
less than 34 weeks 18.6% for placebo and
14:47
2.8 percent for progesterone and these
14:49
were significantly different looking at
14:52
the cumulative deliveries you can see
14:54
that the progesterone group had more
14:56
undelivered patients compared to the
14:58
placebo group this again was too
15:00
distantly sniffing in brief summary of
15:03
progesterone
15:04
it appears that randomized studies show
15:06
benefit to using 17 hydroxy progesterone
15:09
in vaginal progesterone in patients with
15:11
a short cervix or with a history of
15:13
preterm birth rain in my studies so far
15:15
showed no benefit in using progesterone
15:17
for patients with twins triplets or if a
15:21
stitch called a cerclage is placed in
15:23
the cervix so importantly what we can do
15:27
as providers and decreasing preterm
15:29
birth is to recommend our patients to
15:31
stop smoking improve their BMI and
15:34
nutrition and take a good history
15:36
spontaneous preterm birth and find women
15:39
with short services and offer them
15:41
progesterone the take-home messages here
15:44
are that all women are at risk for
15:46
preterm labor and birth the rate of
15:48
preterm labor in birth is rising mostly
15:50
due to indicated preterm births we know
15:52
now that 700c progesterone and vaginal
15:55
progesterone may be beneficial in
15:56
certain populations and really everybody
15:58
should just stop smoking so wrapping it
16:02
up I think we did meet our goals and
16:03
objectives they were to discuss the
16:05
burden of prematurity review the trends
16:07
in Connecticut and national preterm
16:08
birth data understand the risk factors
16:10
and drivers of preterm birth describe
16:13
the tests available to predict preterm
16:14
birth and review the use of progesterone
16:16
to prevent recurrent preterm birth thank
16:19
you for watching this video we hope you
16:21
found it helpful good luck with their
16:23
studies and we’ll be seeing you soon in
16:24
class


Duration 5:32


 

Introductory Women's HealthCare