Preterm Labor and Birth: A Nurse’s Perspective Barbara Dehn RN, MS, NP Author of Your Personal Guide to Pregnancy www.blueorchidpress.com
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).
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
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
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
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
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.
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
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.
Results 17P Placebo Meis, P J, et al. Prevention of Recurrent Preterm Delivery by 17 Alpha- Hydroxyprogesterone Caproate. NEJM, 348; 24, 2379-2385.
17 P • Difficult to initiate in patients • Translates to limited access • Undertreatment of women at risk
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
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