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Understanding Late Preterm Birth

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Preterm Births by Gestational Age. United States, 1990, 2004, ... such as infections, high blood pressure, gestational diabetes, obesity. more multiple births ... – PowerPoint PPT presentation

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Title: Understanding Late Preterm Birth


1
Understanding Late Preterm Birth
  • Background Information for
  • March of Dimes Staff and Volunteers
  • Using the Late Preterm Birth Brain Card
  • Dolores T. Smith, Pennsylvania State Director of
    Program Services
  • dsmith_at_marchofdimes.com

2
Objectives
  • Review the definition and epidemiology of late
    preterm birth
  • Describe how late preterm birth is impacting on
    overall rates of preterm birth
  • Discuss major reasons why late preterm birth
    rates are increasing in the US
  • Summarize some recent research findings about the
    impact of late preterm birth
  • Present the rationale and appropriate use of the
    March of Dimes Late Preterm Birth Brain Card

3
Preterm Birth Rates United States, 1983, 1993,
2003, 2005
gt 1 out of 8 births or 520,000 babies were born
preterm in 2005
Percent
HP 2010 Objective
gt30 Increase
Preterm is less than 37 completed weeks
gestation. Source National Center for Health
Statistics, final natality data Prepared by March
of Dimes Perinatal Data Center, 2007
4
Preterm Births by Gestational Age United States,
1990, 2004, 2005
Percent of live births
late preterm
Source CDC/NCHS National Vital Statistics System
5
Definitions based on the Last Menstrual Period
  • Preterm live birth between 20 weeks and before
  • 37 completed weeks of gestation (140-259 days)
  • Late Preterm preterm birth at 34 weeks 0/7 days
    to 36 weeks 6/7 days (239-259 days)
  • Term live birth between 37 weeks 0/7 days to
  • 41 weeks 6/7 days (260-294 days)
  • Post-term live birth from 42 weeks 0/7 days
  • (295 days)

Engle WE. Semin Perinatol 302-6, 2006
6
Preterm Births by Week of Gestation United
States, 2004
Late preterm 71
Source National Center for Health Statistics,
2004 final natality data Prepared by March of
Dimes Perinatal Data Center, 2007
7
marchofdimes.com/peristats
8
Rates of Late Preterm Births (34-36 wks) for All
States, 2004
2004 US Late Preterm Birth Rate 8.9
Source March of Dimes Peristats
Source www.marchofdimes.com/peristats
9
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10
Why are Late Preterm Rates Rising? Changing
culture of childbearing
  • More high risk pregnancies
  • advanced maternal age, advanced paternal age
  • more complications such as infections, high blood
    pressure, gestational diabetes, obesity
  • more multiple births
  • women unable to get pregnant before now conceive
  • more women now pregnant with serious health
    problems advised not to get pregnant in the past
  • high risk behaviors including substance abuse
    (smoking, drinking, illicit drug use)
  • Public preferences/autonomy
  • date of delivery scheduled for convenience
  • cesarean delivery on maternal request (CDMR)

11
Why are Late Preterm Rates Rising? Changing
culture of obstetrical practice
  • Clinical management (more interventions)
  • more provider suggested scheduled deliveries
  • escalating rates of labor inductions
  • escalating rates of cesarean deliveries
  • if cesarean rates increase, rates of late preterm
    birth usually increase
  • Litigious environment, defensive medicine
  • 9 out of 10 obstetricians named in at least one
    law suit
  • on average 2.6 suits/career
  • 2006 ACOG liability survey
  • earlier delivery to prevent adverse outcomes such
    as fetal demise

12
Why are Late Preterm Rates Rising? Changing
culture of obstetrical practice
  • Few evidence-based interventions after 34 weeks
  • window to administer antenatal steroids to women
    in preterm labor is 24-34 weeks
  • increase in neonatal survival to almost 100 at
    34 weeks
  • Health care delivery system issues
  • reimbursement based on provider performing the
    delivery, not necessarily the provider of the
    prenatal care
  • inadequate coverage of anesthesia or other staff
    during some days of the week
  • administrative or defensive medicine driven
    decisions
  • to not offer procedures such as vaginal birth
    after cesarean (VBAC)

13
ACOG Evidence-Based Guidelines
  • No elective induction or elective cesarean
    delivery before 39 weeks unless evidence of fetal
    lung maturity
  • To assess fetal lung maturity an amniocentesis is
    usually done to collect amniotic fluid for
    testing
  • as for any invasive procedure there are potential
    risks

ACOG Practice Bulletin No. 10, November, 1999.
14
NICHD Invitational Conference on Late Preterm
(Near term) Birth
  • In July 2005 NICHD convened an invitational
    conference with March of Dimes support to address
    growing concerns about infants born 3 to 6 weeks
    before their due date.
  • Representatives from the March of Dimes and all
    three Prematurity Campaign partners (ACOG, AWHONN
    and AAP), SMFM, clinicians, basic science and
    clinical researchers and policy members
    participated.
  • Papers were presented to address the myriad of
    issues related to late preterm births. The
    papers were peer reviewed and published in two
    supplements of Seminar in Perinatology in the
    spring of 2006 and a summary article in
    Pediatrics in September 2006.

NICHD Invitational Conference, July 2005
15
Late Preterm is Still Premature
  • Late preterm infants (34-36 weeks) typically
    receive routine care in well-baby nurseries and
    are presumed low risk
  • Problems may not be noticed until illness is more
    advanced and symptoms are evident.
  • Late Preterm infants are much more likely than
    term infants to have
  • NICU Admission
  • Depression at birth (low Apgar scores)
  • Respiratory Distress, including respiratory
    failure
  • Hypoglycemia
  • Feeding problems
  • Temperature Instability
  • Apnea

NICHD Invitational Conference, July 2005
16
Fetal Brain Development and Growth
  • Lower functions mature first the cerebral cortex
    is last to develop
  • The brain at 35 weeks weighs only 2/3 what it
    will weigh at term
  • The immature control of the late preterm brain
    can be evidenced by problems with periodic
    breathing, apnea, decreased HR variability, REM
    sleep and feeding difficulties.
  • Volume of the cerebellum at 34 weeks is only 55
    of that at term
  • Cerebellar function is related to fine motor
    control, coordination, motor sequencing,
    cognition and language, social function and
    learning

Adams- Chapman I. Clin Perinatol 33 947-964,
2006 Kinney HC. Semin Perinatol 30 81-88, 2006.
17
Fetal Brain Development and Growth
  • Volume of the white matter increases 5-fold from
    35-41 weeks
  • Cerebral cortex volume at 34 weeks is only 53 of
    term volume
  • Cerebral cortex is the seat of higher order
    functions cognition, perception, reason, motor
    control
  • The brain organizes during late preterm period
    there is huge development of synapses, axon
    growth, dendrites, and neurotransmitters

Adams- Chapman I. Clin Perinatol 33 947-964,
2006 Kinney HC. Semin Perinatol 30 81-88, 2006.
18
Infant Mortality among Late Preterm and Term
Singletons, United States, 1995 - 2002
Rate per 1,000 live births
Late preterm is between 34 and 36 weeks gestation
Source National Center for Health Statistics,
period linked birth/infant death data Prepared by
March of Dimes Perinatal Data Center, 2007
19
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20
Appropriate Use of the Brain Card
  • There are many situations where an earlier
    delivery is the optimal management for the
    pregnant woman and/or her baby- do not use nor
    encourage use of the brain card for these
    patients.
  • Only use the brain card if the pregnancy is
    normal/healthy and it is safe for the mother and
    baby to be delivered at full term.
  • The card is just informational and is intended
    for use in healthy pregnancies where there are no
    known medical or obstetrical reasons to warrant
    an indicated early delivery.

21
Appropriate Use of the Brain Card
  • The card is to be used interactively by a
    provider educating a patient. It should NOT be
    simply handed to pregnant women.
  • Be sensitive to concerns by some providers that
    the card could make it more difficult to convince
    a woman where earlier delivery is optimal that
    the benefits outweigh concerns about fetal brain
    growth and development.
  • Always remember that the decision of when to
    deliver is made by the physician/health care
    provider and the pregnant patient.
  • The card may be used for educating pregnant women
    who are considering an elective induction or
    elective cesarean delivery for convenience before
    39 weeks.

22
Appropriate Use of the Brain Card
  • The card can be used in conjunction with other
    health promotion messages about pregnancy.
  • For example, for women who smoke during pregnancy
    and are at greater risk of preterm birth, the
    information provided about brain growth may help
    them decide that smoking cessation is important
    to help reduce the risk of preterm birth.
  • The card can be particularly useful in educating
    women that may have limited knowledge about
    pregnancy and fetal development especially first
    time and adolescent moms.
  • Reach out to health care providers in your area
    so they are aware that they can obtain this
    resource for their patients.

23
Questions and Ordering
  • To order more brain cards contact the fulfillment
    center
  • Item 37-2229-07
  • Call 1-800-367-6630 or email mod_at_pbd.com
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