50 O B .GYN. NEWS • February 1, 2005 T HE M ASTER C LASS A Practical Perspective on a to reduce this unacceptably high rate of cine at the University of California, San preterm birth. Francisco. Complicated Problem Washington Clark Hill, M.D., the guest ex- He is director of the perinatal center and pert for the Master Class this month, has long the division of maternal-fetal medicine at he health of any country is judged by the survival of studied preterm labor in the context of both the Sarasota (Fla.) Memorial Hospital. Dr. Tits infants. The United States spends 15% of its gross singleton and multiple gestations. He has pub- Hill brings a clinical and practical perspec- national product on health care, yet it ranks 21st in the lished comprehensive overviews of research tive to this complicated problem. His in- world in its infant mortality rate of 8 deaths per 1,000 live on the complications of tocolysis and the pre- sights will allow us to disentangle fact from births, according to the World Health Organization. The vention and treatment of preterm labor. fiction and what works from what doesn’t. two main contributors to this death rate are prematuri- A graduate of Temple University School of ty and birth defects. Medicine in Philadelphia, Dr. Hill did his res- DR. REECE, who specializes in maternal- Aggressive research programs are aimed at trying to idency training at William Beaumont Army BY E. ALBERT fetal medicine, is the vice chancellor and understand the pathophysiology of preterm birth, and Medical Center in El Paso, Tex., before com- REECE, M.D., PH.D, dean of the college of medicine at the clinical interventions have been introduced in an attempt pleting a fellowship in maternal-fetal medi- M.B.A. University of Arkansas in Little Rock. Managing Preterm Labor in Multiple Gestations reterm labor is one of the most im- high. Then, options for the mother should effective treatment for preterm labor. In sition that tocolytic agents work for a short portant and vexing challenges com- be discussed with her and with the neona- fact, the initial administration of bolus in- period—about 48 hours, although Roger B. Pplicating pregnancy. Premature ba- tal intensive care unit at your hospital or the travenous fluids may pose some risk to pa- Newman, M.D., and colleagues have bies account for an estimated 6%-10% of institution to which she will be transferred. tients with multiple gestations. These pa- shown that some multiple gestations can be births, yet they account for 70%-85% of Depending on the circumstances, the tients already have an increased blood prolonged for more than 7 days (Am. J. Ob- neonatal morbidity and mortality. treatment of preterm labor may be un- volume and could develop pulmonary ede- stet. Gynecol. 1989;161:547-55; “Multifetal In multiple gestations, which are in- dertaken for several reasons: ma from fluid overload if tocolytic thera- Pregnancy: A Handbook for Care of the creasingly common as a result of delayed Ǡ To delay delivery until the patient can py is initiated after unnecessary fluids are Pregnant Patient” [Philadelphia: Lippincott childbearing and the use of be transferred to a tertiary administered. Williams & Wilkins, 2000]). assisted reproductive tech- medical center with a high- Each tocolytic agent carries its own ben- nologies, preterm labor is an level neonatal intensive care Progesterone efits, risks, contraindications, and adverse even greater risk. The litera- unit. A study by Paul J. Meis, M.D., and col- effects profile. Numerous sources are ture points to an incidence of Ǡ To delay delivery 24-48 leagues (N. Engl. J. Med. 2003;348:2379- available for this information; for quick preterm labor of 20%-75% in hours for the administration 85) suggests recurrent preterm birth in reference; I recently published a summa- multiple gestations. Al- of corticosteroid therapy. singleton pregnancies can be prevented by ry in chart form (Clin. Obstet. Gynecol. though these figures may be Ǡ To reduce the strength 17 a-hydroxyprogesterone caproate. The 2004;47:216-26). Keep in mind that women somewhat high, I think it is and frequency of uterine jury is still out on whether progesterone with multiple gestations have an elevated safe to say that at least 1 in 10 contractions, enabling the fe- can be useful in managing active or threat- risk of cardiovascular complications, such multiple gestations seen at tus to further develop in the ened preterm labor in a multiple gestation as pulmonary edema resulting from ane- my institution are compli- uterus. pregnancy. mia, lower colloid oncotic pressure, and cated by preterm labor. Not BY WASHINGTON C. Ǡ To minimize hospital Studies are underway that may provide higher blood volume. all of these patients will be HILL, M.D. stays for the mother and the us with more guidance in the use of this I would take a middle-of-the-road ap- admitted or will deliver ear- neonate. agent. However, no evidence exists that it proach in choosing an agent or agents for ly, but the very common nature of this Ǡ To reduce the risk of neonatal morbid- is safe and efficacious in multiple gestation tocolysis. For example, oral terbutaline, problem and the potentially lethal conse- ity and mortality by preventing preterm pregnancies, so I quences of premature multiple deliveries delivery, the most dangerous complication suggest its use be re- make this an issue that every physician and of multiple gestation pregnancies. served for patients institution should approach carefully. When I consult with a woman in in clinical trials. First, it is important to consider the de- preterm labor, I go through a list of avail- livery goal of a multiple gestation preg- able options. Unfortunately, a careful re- Antibiotics nancy. Overall, most twins are delivered at view of the literature reveals few really It is tantalizing to 37-38 weeks. For triplets, the gestational good, effective treatments. believe antibiotics age is closer to 34 weeks, and quadruplets Although new ideas emerge every few would be helpful in are born at around 30 weeks. These are years, not many interventional strategies preventing or treat- reasonable numbers applicable to com- have withstood attempts to corroborate re- ing preterm labor. ILL munity practice. sults from single institutions. It may be Many researchers H If a patient arrives in preterm labor, you tempting to “just do something,” but we theorize that in- have to decide what to do, considering her owe it to our patients to stick to scientifi- trauterine infection situation and the capabilities of your local cally valid and efficacious treatments. or fetal infection ASHINGTON . W . hospital and medical staff. It is clear that may be responsible R D premature babies fare best when they are Bed Rest for preterm labor, cared for in the institution where they are Bed rest or activity restriction will not pre- particularly in preg- OURTESY born. If someone needs to be transferred, vent preterm labor. Rest neither lengthens nancies that are not C it should be the mother, not the baby. gestation nor reduces neonatal morbidity in complicated by A twin pregnancy at 25 weeks’ gestation shows discordancy Obviously, if a patient carrying twins multiple gestation pregnancies. In some multiple fetuses. for fetal size. The patient presented in preterm labor and will presents in labor at 35 or 36 weeks, most studies these patients did worse. However, the data be followed closely. obstetricians would be inclined to do very If a patient carrying multiples has a do not show that little to cut short the labor, because—in short cervix and threatened preterm labor, antibiotic treatment is any more effica- oral calcium channel blockers, and oral In- the absence of other complications—these there is some evidence to support getting cious than placebo in prolonging pregnan- docin have been well-studied and widely babies are likely to do well. However, if her off her feet rather than having her con- cy or preventing preterm delivery. used, with varying levels of success. she presents at 29 weeks, it would make tinue working at a very active job. John P. Elliott, M.D., and Tari Radin, sense to be more aggressive. Once a multiple pregnancy is compli- Tocolytics Ph.D., studied a small number of high-or- Can the patient be safely and aggressive- cated by preterm labor, hospitalization The use of tocolytics to decrease or halt der multiple gestations and found similar ly managed for preterm labor in her local may be necessary for observation and im- preterm labor is controversial in multiple levels of serum magnesium in triplets and community? The answer hinges on the plementation of a treatment course. gestations as well as in singleton pregnan- quadruplets and in singleton pregnancies plan for delivery if the treatment fails. Each cies because the drugs pose risks to the after the administration of magnesium hospital and service has to pick a gestational Hydration mother and, in some cases, to the fetus. age at which neonatal survival is acceptably There is no evidence that hydration is an However, the available data support the po- Continued on following page February 1, 2005 • www.eobgynnews.com 51 Continued from previous page terval delivery of the second twin is desired. fers support, diversion, and empathy in the subtle indications of infection and other form of wheelchair outings, Internet ac- potential causes of preterm labor. sulfate for tocolysis (J. Reprod. Med. Treating the Whole Patient cess, flexible visitation for family members In multiple gestations, of course, 1995;40:450-2). However, they concluded Not infrequently, preterm labor in a mul- (including children), manicures, pedicures, preterm labor is often caused simply be- that higher levels of magnesium sulfate tiple gestation pregnancy requires the pro- movies, and get-togethers.