Preterm labor and birth management: NICE guidelines
The National Institute for Healthcare and Excellence (NICE) has released its latest guidelines on the management of Preterm labor and birth. The guideline covers recommendations for care of women at increased risk of, or with symptoms and signs of, preterm labor (before 37 weeks), and women having a planned preterm birth. The guideline appeared on the National Institute for Healthcare and Excellence's website.
This guideline includes new and updated recommendations on:
Prophylactic vaginal progesterone and prophylactic cervical cerclage
Offer a choice of prophylactic vaginal progesterone or prophylactic cervical cerclage to women who have both:
- A history of spontaneous preterm birth (up to 34+0 weeks of pregnancy) or mid-trimester loss (from 16+0 weeks of pregnancy onwards)
- Results from a transvaginal ultrasound scan carried out between 16+0 and 24+0 weeks of pregnancy that shows a cervical length of 25 mm or less.
- Discuss the risks and benefits of both options with the woman, and make a shared decision on which treatment is most suitable.
Consider prophylactic vaginal progesterone for women who have either:
- A history of spontaneous preterm birth (up to 34+0 weeks of pregnancy) or mid-trimester loss (from 16+0 weeks of pregnancy onwards) or
- Results from a transvaginal ultrasound scan carried out between 16+0 and 24+0 weeks of pregnancy that show a cervical length of 25 mm or less.
When using vaginal progesterone, start treatment between 16+0 and 24+0 weeks of pregnancy and continue until at least 34 weeks.
Consider prophylactic cervical cerclage for women when results of a transvaginal ultrasound scan carried out between 16+0 and 24+0 weeks of pregnancy show a cervical length of 25 mm or less, and who have had either:
- Preterm prelabour rupture of membranes (P‑PROM) in a previous pregnancy or
- A history of cervical trauma.
If prophylactic cervical cerclage is used, ensure that a plan is in place for removal of the suture.
Magnesium sulfate for neuroprotection
For women between 23+0 and 23+6 weeks of pregnancy who are in established preterm labor or having a planned preterm birth within 24 hours, discuss with the woman (and her family members or carers as appropriate) the use of intravenous magnesium sulfate for neuroprotection of the baby, in the context of her individual circumstances.
Offer intravenous magnesium sulfate for neuroprotection of the baby to women between 24+0and 29+6 weeks of pregnancy who are:
- In established preterm labor
- Having a planned preterm birth within 24 hours.
Consider intravenous magnesium sulfate for neuroprotection of the baby for women between 30+0 and 33+6 weeks of pregnancy who are:
- In established preterm labor
- Having a planned preterm birth within 24 hours.
Give a 4 g intravenous bolus of magnesium sulfate over 15 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours (whichever is sooner).
For women on magnesium sulfate, monitor for clinical signs of magnesium toxicity at least every 4 hours by recording pulse, blood pressure, respiratory rate, and deep tendon (for example, patellar) reflexes.
If a woman has or develops oliguria or other signs of renal failure:
- Monitor more frequently for magnesium toxicity
- Think about reducing the dose of magnesium sulfate
Diagnosing, and caring for women with, preterm prelabour rupture of membranes
In a woman reporting symptoms suggestive of P‑PROM, offer a speculum examination to look for pooling of amniotic fluid and:
- If pooling of amniotic fluid is observed, do not perform any diagnostic test but offer care consistent with the woman having P‑PROM
- If pooling of amniotic fluid is not observed, performing an insulin-like growth factor binding protein‑1 test or placental alpha-microglobulin‑1 test of vaginal fluid.
If the results of the insulin-like growth factor-binding protein‑1 or placental alpha-microglobulin‑1 test are positive, do not use the test results alone to decide what care to offer the woman, but also take into account her clinical condition, her medical and pregnancy history and gestational age, and either:
- Offer care consistent with the woman having P‑PROM
- Re-evaluate the woman's diagnostic status at a later time point.
If the results of the insulin-like growth factor-binding protein‑1 or placental alpha-microglobulin‑1 test are negative and no amniotic fluid is observed:
- Do not offer antenatal prophylactic antibiotics
- Explain to the woman that it is unlikely that she has P‑PROM, but that she should return if she has any further symptoms suggestive of P‑PROM or preterm labor.
Do not use nitrazine to diagnose P‑PROM.
Do not perform diagnostic tests for P‑PROM if labor becomes established in a woman reporting symptoms suggestive of P‑PROM.
Diagnosing preterm labor
Explain to women reporting symptoms of preterm labor who have intact membranes (and their family members or carers as appropriate):
- About the clinical assessment and diagnostic tests that are available
- How the clinical assessment and diagnostic tests are carried out
- What the benefits, risks and possible consequences of the clinical assessment and diagnostic tests are, including the consequences of false-positive and false-negative test results taking into account gestational age.
Offer a clinical assessment to women reporting symptoms of preterm labor who have intact membranes. This should include:
- Clinical history taking
- The observations described for the initial assessment of a woman in labor in the NICE guideline on intrapartum care
- A speculum examination (followed by a digital vaginal examination if the extent of cervical dilatation cannot be assessed).
If the clinical assessment suggests that the woman is in suspected preterm labor and she is 29+6 weeks pregnant or less.
If the clinical assessment suggests that the woman is in suspected preterm labor and she is 30+0 weeks pregnant or more, consider transvaginal ultrasound measurement of cervical length as a diagnostic test to determine the likelihood of birth within 48 hours. Act on the results as follows:
- If the cervical length is more than 15 mm, explain to the woman that it is unlikely that she is in preterm labor and:
- Think about alternative diagnoses
- Discuss with her the benefits and risks of going home compared with continued monitoring and treatment in hospital
- Advise her that if she does decide to go home, she should return if symptoms suggestive of preterm labor persist or recur
- If the cervical length is 15 mm or less, view the woman as being in diagnosed preterm labor and offer treatment as described in sections 1.8 and 1.9. [2015]
Consider fetal fibronectin testing as a diagnostic test to determine the likelihood of birth within 48 hours for women who are 30+0 weeks pregnant or more if transvaginal ultrasound measurement of cervical length is indicated but is not available or not acceptable. Act on the results as follows:
- If fetal fibronectin testing is negative (concentration 50 ng/ml or less), explain to the woman that it is unlikely that she is in preterm labor and:
- Think about alternative diagnoses
- Discuss with her the benefits and risks of going home compared with continued monitoring and treatment in hospital
- Advise her that if she does decide to go home, she should return if symptoms suggestive of preterm labor persist or recur
- If fetal fibronectin testing is positive (concentration more than 50 ng/ml), view the woman as being in diagnosed preterm labor and offer treatment as described in sections 1.8 and 1.9. [2015]
If a woman is suspected preterm labor who is 30+0 weeks pregnant or more does not have transvaginal ultrasound measurement of cervical length or fetal fibronectin testing to exclude preterm labor, offer treatment consistent with her being in diagnosed preterm labor.
Do not use transvaginal ultrasound measurement of cervical length and fetal fibronectin testing in combination to diagnose preterm labor.
Ultrasound scans should be performed by healthcare professionals with training in, and experience of, transvaginal ultrasound measurement of cervical length.
For guidance on the use of other biomarker tests used for the diagnosis of preterm labor, see the NICE diagnostics guidance on biomarker tests to help diagnose preterm labor in women with intact membranes.
Furthermore, the guideline also provided recommendations which included
- Tocolysis
- Maternal corticosteroids
- Fetal monitoring
- Mode of birth and clamping the cord
- Information and support
To read full guideline, please click on the link
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