# Presentation: 230204

## 
Barbara Dehn RN, MS, NP

Author of 
Your Personal Guide to Pregnancy
www.blueorchidpress.com

- Barbara Dehn RN, MS, NP
- Author of
*Your Personal Guide to Pregnancy*
- www.blueorchidpress.com

- Preterm Labor and Birth: A Nurse’s Perspective

## 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.

## Immune Status     Low SES Infections              Poor NutritionStress                   SmokingMultiples               Obesity 
   HTN		     Age
   Fibroids
   Gestational Diabetes
   Periodontal disease
   Standing for long periods
   Recent Pregnancy
   Previous Preterm Birth

-    HTN		     Age
-    Fibroids
-    Gestational Diabetes
-    Periodontal disease
-    Standing for long periods
-    Recent Pregnancy
-    Previous Preterm Birth

- Preterm Birth: Risk Factors -Partial list

## 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

| Delivery
 < 37 wks | 
   36.3% | 
   54.9% | RR 0.66
95% CI
0.54 - 0.81 |
| --- | --- | --- | --- |
| Delivery
 < 35 wks | 
   20.6% | 
   30.7% | RR 0.67
95% CI
0.48 - 0.93 |
| Delivery
 < 32 wks | 
   11.4% | 
   19.6% | RR 0.58
95% CI
0.37 - 0.91 |

- 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