Preterm+Birth+Prevention

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** CCRMC OBGYN **** Prenatal Guideline ** Consultation available 24 hours per day from OB on-call at 925-370-5608 or via page/amion, via inbasket to OB dept member or by calling Perinatologist at 510-444-0790 during the day and 510-204-1572 after hours. Consultation appointments or transfer of care to more experienced prenatal clinician available at major clinics sites—see consultation guidelines for more information.

** Preterm Birth Prevention for Patients with Prior Preterm Birth **
 * __1. Verify prior birth preterm__**
 * Get records or look in ccLINK if prior delivery at CCRMC
 * Query history in months as well as weeks—e.g. 32 weeks is often put in ccLINK OB history when patient says “8 months” and baby was really 3-4 weeks before due date at 36 or 37 weeks EGA
 * Query history of birth weight and time in hospital to verify consistent with prematurity


 * __2. Verify birth spontaneous and not iatrogenic—if iatrogenic, prevention NOT indicated__**
 * Delivery not induced for medical indications
 * Delivery not a fetal demise prior to birth


 * __3. Assess for possible cervical insufficiency warranting cerclage or evaluation for cerclage__**
 * Painless dilation often with bulging bag
 * PPROM and found to be unexpectedly dilated without contractions
 * Most common 16-28 weeks EGA


 * __Primary treatment for prevention of recurrent preterm birth is weekly hydroxyprogesterone caproate injections 250mg week 16-36 of pregnancy__**. Treatment decreases risk preterm delivery by about 1/3. There is not a known risk to the fetus.
 * __Criteria for alpha hydroxyl progesterone caproate (Makena) injections:__**
 * Prior spontaneous preterm delivery < 34 weeks strongly recommend injections
 * Preterm delivery 34-36 weeks offer injections--usually chosen by mother if baby had prematurity related morbidity
 * Prior PPROM < 34-36 weeks
 * Not beneficial in studies of patients with multiple gestations for primary prophylaxis

Makena (hydroxyprogesterone caproate) using a “bed” icon weekly from 16-36 weeks for 20 doses Our pharmacy orders a compounded version and not the very expensive brand version. Schedule injections in treatment room and at prenatal visits so that they happen weekly. Some sites also like want paper copy of prescription to send to MHC Outpatient pharmacy. Evidence of benefit is for injections. There is some evidence for progesterone (Prometrium) 200mg per vagina daily for incidental short cervix < 2cm on ultrasound before 24 weeks. If a patient who would normally use progesterone injections declines due to injection this could be considered as an unproven alternative.
 * __How to Order__**
 * __Alternative treatment__**

Although multiple gestation pregnancies are at higher risk for preterm delivery, hydroxyprogesterone injections have not been beneficial in prevention of preterm delivery in studies and are not advised.