Hospitalization for Women With Arrested Preterm Labor

Activity restriction for women with arrested preterm labor: a randomized controlled trial

BACKGROUND

In the past, some pregnant women have been recommended to be in activity restriction because of the presumed increased risk of preterm birth due to the increased release of catecholamines, which might stimulate myometrial activity, during exercise and aerobic activity.

OBJECTIVE

This study aimed to test the hypothesis that in women with singleton pregnancy and arrested preterm labor, activity restriction would reduce the rate of preterm birth at <37 weeks of gestation.

STUDY DESIGN

This was a parallel-group nonblinded randomized trial conducted at a single center in Italy. Eligible patients were those with a diagnosis of arrested preterm labor, defined as not delivering after 48 hours of hospitalization for threatened preterm labor, with transvaginal ultrasound cervical length ≤25 mm, no other symptoms of possible uterine contractions, and cervical dilatation <3 cm at pelvic examination. Inclusion criteria were singleton pregnancies between 24 0/7 and 33 6/7 weeks of gestation. Participants were randomized in a 1:1 ratio to either activity restriction at the time of discharge or no activity restriction. Women in the intervention group were recommended activity restriction, defined as the following: pelvic rest, prohibition of sexual activity, and reduction of work and/or nonwork activity. The primary endpoint was preterm birth at <37 weeks of gestation.

RESULTS

A total of 120 participants were included in the trial; 60 patients were enrolled in the activity restriction group and 60 in the control group. Preterm birth at <37 weeks of gestation occurred in 15 of 60 women (25.0%) in the activity restriction group and 23 of 60 women (38.3%) in the control group (relative risk, 0.65; 95% confidence interval, 0.38-1.12). There was no significant between-group difference in the incidence of preterm birth at <32 weeks and in neonatal outcomes, but the trial was not powered for these outcomes.

CONCLUSION

In singleton gestations with arrested preterm labor, activity restriction, including pelvic rest, prohibition of sexual activity, and reduction of work and/or nonwork activity, does not result in a lower rate of preterm birth at <37 weeks. Given the evidence on the lack of benefits, use of activity restriction in this population should be discouraged.

Beneficial Effects of Maternal Physical Activity during Pregnancy on Fetal, Newborn, and Child Health: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives

The objective of this work is to synthesize current knowledge about the effects of maternal physical activity during pregnancy on children's health. During the prenatal and postnatal periods, maternal physical activity has protective effects against the risks of macrosomia, obesity, and other associated cardiometabolic disorders. Even though longitudinal studies in humans are still necessary to validate them, these effects have been consistently observed in animal studies. A remarkable effect of maternal physical activity is its positive role on neurogenesis, language development, memory, and other cognitive functions related to learning.

Cervical pessary in singleton gestations with arrested preterm labor: a randomized clinical trial

BACKGROUND

Cervical pessary has been proven to be effective in reducing the rate of preterm birth in asymptomatic women with singleton gestations and short cervical length in the midtrimester of pregnancy; however, the efficacy of this device in women with arrested preterm labor is still a subject of debate.

OBJECTIVE

This study aimed to test the hypothesis that the use of a cervical pessary in women with singleton pregnancy and arrested preterm labor would reduce the risk of preterm birth at <37 weeks of gestation.

STUDY DESIGN

This study is a parallel group, nonblinded, randomized trial. Participants included in the study were women with a diagnosis of arrested preterm labor between 24 0/7 and 33 6/7 weeks of gestations. The participants were randomized to either the cervical pessary group or no pessary group in a 1:1 ratio. The primary endpoint was preterm birth at <37 weeks of gestation. A sample size of 120 participants was determined, but the trial was concluded before the completion of enrollment.

RESULTS

A total of 61 women with singleton pregnancies and arrested preterm labor at 24 0/7 to 33 6/7 weeks of gestation were enrolled in the trial. Of the 61 women, 32 were randomized to the cervical pessary group and 29 to the control group. Preterm birth at <37 weeks of gestation occurred in 14 women (43.8%) in the pessary group and 6 women (20.7%) in the control group (relative risk, 2.98; 95% confidence interval, 0.96-9.30).

CONCLUSION

In this underpowered trial, among women with singleton pregnancies and arrested preterm labor, compared with no pessary use, the use of a cervical pessary does not result in a lower rate of preterm birth at <37 weeks of gestation.

Patterns and outcomes of preterm hospital admissions during pregnancy in NSW, 2001-2008

OBJECTIVE

To assess the frequency and outcomes of preterm hospital admissions during pregnancy, with a focus on transfers to higher levels of care.

DESIGN

Population-based cohort study using linked population data.

SETTING AND SUBJECTS

Women who were admitted to hospital in weeks 20-36 of pregnancy (preterm) and gave birth to a liveborn singleton infant in New South Wales during 2001-2008.

MAIN OUTCOME MEASURE

Numbers of preterm admissions of pregnant women who were discharged without giving birth, were transferred to higher care, or who gave birth.

RESULTS

110,439 pregnancies (16.0%) involved at least one preterm admission. After their initial preterm admission, 71.9% of women were discharged, 6.3% were transferred and 21.8% gave birth. Median gestational age at admission was 33 weeks and median time to discharge, transfer or giving birth was 1 day. Most women who were transferred or who gave birth had been admitted for preterm rupture of membranes or preterm labour. Of the women who were admitted or were transferred with suspected preterm labour, only 29% and 38%, respectively, gave birth. Compared with other admitted women, women having a first birth, public patients and those living in areas of low socioeconomic status were more likely to be transferred or to give birth. As gestational age increased, the proportion of women transferred decreased and the proportion giving birth increased. Infants born after maternal transfer had lower gestational age and more adverse outcomes than those born without maternal transfer.

CONCLUSIONS

Preterm hospital admission affects one in six women with singleton pregnancies. Methods that could improve assessment of labour status have a large potential to reduce the burden on maternity services. The increased morbidity for infants born after maternal transfer suggests women with high-risk pregnancies are being appropriately identified.

[Prolonged hospitalization versus home management for women with arrested preterm labour: a before-after study]

OBJECTIVES

To compare gestational age at birth and incidence of preterm birth inferior to 37 weeks of gestation (WG) in single pregnancies with either prolonged hospitalization, or early home discharge after arrested preterm labour.

PATIENTS AND METHODS

Management of preterm labour was changed in our public academic hospital because no evidence of benefits for prolonged hospitalization was found and because adverse effects related to long-term hospitalization were described. In this retrospective before-after study, we compare the attitude A (December 2006 to April 2008), a prolonged hospitalization until 32 or 34WG, with new attitude B (May 2008 to February 2010), an early discharge home if the cervical exam was unchanged since admission.

RESULTS

A total of 140 patients were included: 70 in each group. Initial hospitalization stay was significantly shorter in Group B (respectively, 5.4±5.4 days and 11.4±12.1 days; P<0.05). Preterm spontaneous delivery is 14 (20%) in group A and 21 (28.6%) in Group B (P>0.05). Gestational ages at birth were 33(5/7) and 33(0/7) WG in groups A and B, respectively (P>0.05). If we focus on patients who were discharged home in the two groups (women who did not deliver no matter the hospitalization length), the gestational age at birth (38(4/7) and 38WG; ns) and the prematurity rate inferior to 37WG (17.2% and 22.4%; ns) were statistically similar.

DISCUSSION AND CONCLUSION

This study suggests that shorter hospitalization does not decrease the delivery term, nor does it increase the premature delivery incidence.

Antepartum bed rest for pregnancy complications: efficacy and safety for preventing preterm birth

Preterm birth is the major maternal-child health issue across developed nations and the leading cause of perinatal mortality and morbidity. Of all deaths of infants <1 year of age in the United States in 2005, 68.6% occurred in infants born prior to term. Although the preterm birth rate in European countries is 5-7%, the U.S. preterm birth rate is 12.7%, representing an increase of 9% since 2000. Antepartum bed rest/activity restriction (ABR/AR) has been a mainstay of treatment to prevent preterm birth for the past 30 years prescribed for nearly 1 million women in the United States annually, despite a lack of evidence for its effectiveness. In fact, there is increasing evidence that ABR causes several adverse physiologic and psychological side effects among women and their infants. Unfortunately, these findings have had little impact on clinical practice. This integrative review of literature provides a comprehensive analysis of the evidence for the practice of prescribing ABR and its physiologic, behavioral, and experiential side effects. It also presents a model to guide continuing research about the effects of maternal bed rest as well as evidence supporting the use of home care with bed rest, a different, safe, and feasible model of prenatal care for treating women with pregnancy complications used particularly in other countries. Finally, suggestions to improve the health of high-risk pregnant and postpartum women and their infants are provided.

The recommendation for bed rest in the setting of arrested preterm labor and premature rupture of membranes

OBJECTIVE

The objective of the study was to estimate practice patterns regarding bed rest in women with preterm premature rupture of membranes (PPROM) and arrested preterm labor.

STUDY DESIGN

This was a mail-based survey of all Society for Maternal-Fetal Medicine members in the United States asking whether they would recommend bed rest in the setting of arrested preterm labor or PPROM at 26 weeks. Bed rest was defined as no more than 1-2 hours per day out of bed, with permitted activities including bathroom use, bathing, and brief ambulation inside the home/hospital.

RESULTS

Seventy-one percent and 87% would recommend bed rest for women with cervical dilation and arrested preterm labor and women with PPROM, respectively, even though the majority believed bed rest was associated with minimal or no benefit. Female sex, nonacademic practice, and practice location in the South or West were independently associated with the recommendation for bed rest.

CONCLUSION

Despite the belief that bed rest is associated with minimal or no benefit, most maternal-fetal medicine specialists recommend bed rest for arrested preterm labor and PPROM. Randomized, prospective trials are needed to evaluate the efficacy of bed rest in these settings.

The Mother's House: a new concept in antepartum care

OBJECTIVE

High-risk antepartum patients often require long and costly hospitalization. The Mother's House facility has been used to house antepartum women on hospital property as an alternative to inpatient management. This study looked at the cost effectiveness of this facility.

STUDY DESIGN

A retrospective chart review on occupants (n = 111) of the Mother's House from 2003-2005 was performed. Admission, discharge, and outcome data were collected. A comparison of the cost of management at the Mother's House with the estimated cost of inpatient management was then performed.

RESULTS

A cost savings of $2.1 million was seen over a 3-year period with the use of the Mother's House. Demographic data show that patients with positive drug screens are more likely to fail Mother's House management.

CONCLUSION

The Mother's House is a cost effective alternative to inpatient management of some antepartum patients. Admission criteria should be modified to exclude patients with positive drug screens.