Preterm Labor and Birth: A Nurse’s Perspective

1. Preterm Labor and Birth: A Nurse’s Perspective Barbara Dehn RN, MS, NP Author of Your Personal Guide to Pregnancy www.blueorchidpress.com

2. A pediatric nurse’s experience • While working in pediatrics and in the pediatric intensive care unit (PICU) at Stanford University Hospital, I cared for many children who were born prematurely • These were the fortunate children who survived, grew enough, and were able to be discharged from the Neonatal Intensive Care unit (NICU).

3. Bronchopulmonary dysplasia • Chronic lung disease, a result of being on a mechanical ventilator which can permanently scar the fragile, developing lung tissue • Many of these children develop chronic asthma and are on multiple meds • Any minor cough or cold could bring these children back to the hospital for treatment, including antibiotics, inhaled steroids and possibly mechanical ventilation

4. Necrotizing Enterocolitis • Affects 10% of babies who weigh less than 1 kg (2 lbs) • Increased risk with babies on tube feedings • Bacterial infection in the small intestine that leads to perforations, scarring and necrosis of the tissue • May be treated with antibiotics, sometimes surgery

5. Necrotizing Enterocolitis • Mortality rates are 30 - 40% • Short term conseqences are numerous including: DIC, inability to feed, recurrent strictures, intestinal obstruction • With surgery, most common long term consequence: short gut syndrome. • Portion of the bowel removed, malabsorption and chronic diarrhea are common Kliegman & Walsh,Current Prob Pediatrics, 1987, April; 17 (4): 213-88

6. Intraventricular hemorrhage IVH • IVH and PVH - Periventricular hemorrhage - Bleeding from the delicate cerebral capillaries1 • Increased risk if delivered < 32 weeks • 12-18% of premies2 • Can be triggered by multiple events common in the NICU 1 Annibale, D J & Hill, J. Periventricular Hemorrhage-Intraventricular Hemorrhage, eMedicine, WebMD, 2006. 2Ment et al. Pediatrics. 1994; 93(4):543-50

7. IVH - Long term consequences • Depends on staging of IVH • Grade III - 30-40% have subsequent cognitive or motor disorders • Grade IV - Mortality approaches 80%. • A 90% incidence of severe neurological sequelae including cognitive and motor disturbances exists • Seizures • Cerebral Palsy • Mental Retardation • Hydrocephalus Annibale, D J & Hill, J. Periventricular Hemorrhage-Intraventricular Hemorrhage, eMedicine, WebMD, 2006.

8. Preterm Birth: Risk Factors -Partial list • Immune Status Low SES Infections Poor NutritionStress SmokingMultiples Obesity HTN Age Fibroids Gestational Diabetes Periodontal disease Standing for long periods Recent Pregnancy Previous Preterm Birth

9. Prevention of Recurrent Preterm Delivery • Study by Meis, et al, 2003 showed a significant reduction in preterm delivery for pregnant women with a previous history of preterm birth who received weekly injections of 17 P • Infants of women treated with 17P had significantly decreased rates of NEC and IVH and need for supplemental Oxygen Meis, P J, et al. Prevention of Recurrent Preterm Delivery by 17 Alpha-Hydroxyprogesterone Caproate. NEJM, 348; 24, 2379-2385.

10. Results 17P Placebo Meis, P J, et al. Prevention of Recurrent Preterm Delivery by 17 Alpha- Hydroxyprogesterone Caproate. NEJM, 348; 24, 2379-2385.

11. 17 P • Difficult to initiate in patients • Translates to limited access • Undertreatment of women at risk

12. Current difficulties with 17 P • Protocols vary among institutions • Not widely available • Hospital formulary issues • No FDA approved formulation • Must be compounded • Lack of Quality Assurance

13. Conclusions • 17 P has a favorable safety profile • It has proven efficacy • Currently is under utilized by medical community for a variety of reasons • I strongly recommend FDA approval