Understanding Late Preterm Birth

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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

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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

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Preterm Birth RatesUnited 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
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Preterm Births by Gestational AgeUnited States,
1990, 2004, 2005
Percent of live births
late preterm
Source CDC/NCHS National Vital Statistics System
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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
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Preterm Births by Week of GestationUnited
States, 2004
Late preterm 71
Source National Center for Health Statistics,
2004 final natality data Prepared by March of
Dimes Perinatal Data Center, 2007
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marchofdimes.com/peristats
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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
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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)

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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

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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)

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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.
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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
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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
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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.
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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.
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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
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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.

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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.

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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.

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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