• Like
Preterm Birth Interventions_James Litch_10.16.13
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

Preterm Birth Interventions_James Litch_10.16.13

  • 1,128 views
Published

 

Published in Health & Medicine
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
1,128
On SlideShare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
76
Comments
0
Likes
2

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide
  • "Prevention of Preterm Birth and Complications: So What?    Evidence for interventions and opportunites for action"
     
    This presentation will present a practical approach to the prevention of preterm birth and complication by focussing on the evidence that supports a priority list of ready interventions and approaches to implementation, that leverage existing program investments, policy environments and resources.
  • 5, 10 and 85%
  • Maternal, fetal, newborn and child health are all linked. Prematurity and stillbirth interventions, many of which are directed toward the mother, will help improve all of these health outcomes. (click) These connected outcomes require a new, interdisciplinary approach.
  • The point of this slide - We’ve made great strides in improved management in NICU care in industrialized countries --- but basic services for late preterm deliveries would address the majority of preterm-related deaths
  • The point of this slide - We’ve made great strides in improved management in NICU care in industrialized countries --- but basic services for late preterm deliveries would address the majority of preterm-related deaths
  • Feeding difficulties since the coordinated suck and swallow process only starts at 34 weeks gestation. Preterm babies need help to feed and are more likely to aspirate.
    Severe infections are more common, and premature babies are at higher risk of dying once they get an infection. The majority of babies who die from neonatal sepsis are preterm.
    Respiratory Distress Syndrome due to lung immaturity and lack of surfactant in the alveoli, resulting in collapsing lungs that take extra pressure to inflate. Below 32 weeks gestation, the majority of babies develop RDS, although this risk can be reduced by antenatal corticosteroids injections to women at risk or preterm labor, or in preterm labor.
    Jaundice is more common in premature babies since the immature liver cannot easily metabolize bilirubin, and once jaundiced, the preterm baby’s brain is at higher risk since their blood-brain barrier is less well developed to protect the brain.
    Brain injury in preterm babies is most commonly intraventricular hemorrhage, occurring in the first few days after birth in about 1 in 5 babies under 2,000 g and is often linked to severity of RDS and hypotension. Less commonly, preterm babies may have hypoxic brain injury with white matter loss which differs from that seen in the brain of term babies (Volpe, 2009).
    Necrotizing enterocolitis is a rarer condition affecting the intestinal wall of very premature babies, with a typical X-ray image of gas in the bowel wall. Formula feeding increases the risk tenfold compared to babies who are fed breast milk alone (Schanler, 2001).
    Retinopathy of prematurity due to abnormal proliferation of the blood vessels around the retina of the eye, which is more severe if the baby is given too high levels of oxygen.
    Anemia of prematurity, which often becomes apparent at a few weeks of age due to delay in producing red blood cells as the bone marrow is immature.
  • Feeding difficulties since the coordinated suck and swallow process only starts at 34 weeks gestation. Preterm babies need help to feed and are more likely to aspirate.
    Severe infections are more common, and premature babies are at higher risk of dying once they get an infection. The majority of babies who die from neonatal sepsis are preterm.
    Respiratory Distress Syndrome due to lung immaturity and lack of surfactant in the alveoli, resulting in collapsing lungs that take extra pressure to inflate. Below 32 weeks gestation, the majority of babies develop RDS, although this risk can be reduced by antenatal corticosteroids injections to women at risk or preterm labor, or in preterm labor.
    Jaundice is more common in premature babies since the immature liver cannot easily metabolize bilirubin, and once jaundiced, the preterm baby’s brain is at higher risk since their blood-brain barrier is less well developed to protect the brain.
    Brain injury in preterm babies is most commonly intraventricular hemorrhage, occurring in the first few days after birth in about 1 in 5 babies under 2,000 g and is often linked to severity of RDS and hypotension. Less commonly, preterm babies may have hypoxic brain injury with white matter loss which differs from that seen in the brain of term babies (Volpe, 2009).
    Necrotizing enterocolitis is a rarer condition affecting the intestinal wall of very premature babies, with a typical X-ray image of gas in the bowel wall. Formula feeding increases the risk tenfold compared to babies who are fed breast milk alone (Schanler, 2001).
    Retinopathy of prematurity due to abnormal proliferation of the blood vessels around the retina of the eye, which is more severe if the baby is given too high levels of oxygen.
    Anemia of prematurity, which often becomes apparent at a few weeks of age due to delay in producing red blood cells as the bone marrow is immature.
  • 34% reduction in respiratory distress syndrome
    46% reduction in Intraventricular Hemorrhage
    54% reduction in necrotilizing entercolitis
    31% reduction in neonatal death
    Near universal coverage of ACS across 75 priority countries may result in a 40% reduction of newborn deaths arising from complications of prematurity
  • *While both dexamethsaone and betamethasone are safe and effective, Dexamethasone is preferred as it is slightly safer overall, is associated with a greater reduction of IVH and is cheaper than betamethasone
  • n high-income countries, it is standard practice to give antibiotics to women with pre-term, pre-labour rupture of membranes (pPROM) to delay birth and reduce the risk of infection. In low and middle-income settings, where some 2 million neonatal deaths occur annually due to complications of pre-term birth or infection, many women do not receive antibiotic therapy for pPROM.
    To review the evidence for and estimate the effect on neonatal mortality due to pre-term birth complications or infection, of administration of antibiotics to women with pPROM, in low and middle-income countries.
    We performed a systematic review to update a Cochrane review. Standardized abstraction forms were used. The quality of the evi- dence provided by individual studies and overall was assessed using an adapted GRADE approach.
    Eighteen RCTs met our inclusion criteria. Most were from high-income countries and provide strong evidence that antibiotics for pPROM reduce the risk of respiratory distress syndrome [risk ratio (RR)1⁄40.88; confidence interval (CI) 0.80, 0.97], and early onset postnatal infection (RR 1⁄4 0.61; CI 0.48, 0.77). The data are consistent with a reduction in neonatal mortality (RR 1⁄4 0.90; CI 0.72, 1.12).
    Antibiotics for pPROM reduce complications due to pre-term deliv- ery and post-natal infection in high-income settings. There is mod- erate quality evidence that, in low-income settings, where access to other interventions (antenatal steroids, surfactant therapy, ventila- tion, antibiotic therapy) may be low, antibiotics for pPROM could prevent 4% of neonatal deaths due to complications of prematurity and 8% of those due to infection.
  • There is high-quality evidence that antibiotics for pPROM reduce the risk of complications due to pre- maturity and risk of neonatal infection in high-income settings. The evidence for a reduction in neonatal mortality is less strong. Our meta-analysis of 14 trials estimates a 10% reduction in all-cause neonatal mortality but with a wide CI that included no effect. However, there is a dearth of data from low-income countries, where newborns have less access to other forms of care including antenatal ster- oids, surfactant therapy, ventilation and even antibi- otic treatment for infection. In the absence of these other interventions, the use of antibiotics for pPROM will certainly prevent neonatal deaths by preventing RDS, which is the most common cause of death due to complications of prematurity. Similarly, in settings in which newborns do not have easy access to anti- biotic therapy for neonatal infections, the prevention of sepsis cases through the use of antibiotics for pPROM will certainly prevent infection deaths.
  • Common complications and conditions of preterm babies born before 33 weeks’ gestation include low blood pressure during the first days of life, the need for respiratory support due to immature lungs and the need for blood transfusions. Intraventricular haemorrhage (bleeding into the brain) and necrotising enterocolitis (severe infection of the bowel) can be life threatening events. Suggested advantages of delaying clamping of the umbilical cord and subsequent increased placental transfusion include larger blood volume for the preterm baby, better adaption to extrauterine life; higher haemoglobin for the baby; less anaemia for the baby and better iron stores, less need for blood transfusion, less respiratory distress (Linderkamp 1978), and less requirement for respiratory support (Holland 1991; Hudson 1990; Kinmond 1993).
    Potential disadvantages include delay in resuscitation, hypothermia, poly- cythaemia, hyperbilirubinaemia needing treatment (Saigal 1972) and a possible risk of intraventricular haemorrhage (Hofmeyr 1988). If there are benefits for preterm infants in the first few days and weeks of life, it would also be important to assess whether these short-term benefits are reflected in improved long-term out- come.
    There are different potential comparative effects of early rather than delayed cord clamping for term and preterm infants. For ex- ample, in term infants increasing placental transfusion by delaying cord clamping may increase respiratory morbidity after birth (Yao 1974). As a consequence the issue of timing of cord clamping is reviewed separately for preterm and term infants.
    For developing countries, with limited resources and a high risk of transmitting infection through blood transfusion, the potential value of a reduced need for blood transfusion would be of particular interest. In more developed countries, 60% to 80% of preterm infants less than 32 completed weeks’ gestation (Brune 2002; Ringer 1998)
  • This updated review now includes data from 15 trials involving more than 700 mother and baby pairs. Most trials compared alter- native timings for cord clamping. For the three primary outcomes of infant death, severe intraventricular haemorrhage, and periven- tricular leukomalacia the confidence intervals for the risk ratio are wide and so there is insufficient evidence for reliable conclusions about the differential effects of these alternative policies for care at birth. No study has yet reported the fourth primary outcome of neurodevelopment at age two to three years.
    More placental transfusion, rather than less placental transfusion, is associated with fewer blood transfusions for anaemia and for low blood pressure. More placental transfusion also appears to protect against intraventricular haemorrhage (all grades), although the clinical significance of this is unclear as there are too few data for any reliable conclusions about the comparative effect on se- vere intraventricular haemorrhage (grades three or four) and no trials have assessed neurodevelopment of the children at age two to three years. Necrotising enterocolitis and sepsis also appear to be reduced, but these outcomes are only reported for a limited number of studies in the review. There is no clear difference in the effect on Apgar scores, or temperature on admission to special care unit; although again, these outcomes were not reported for all trials.
    Overall, even when taking all trial results together, most outcomes had wide confidence intervals and so results should be interpreted with caution. Nevertheless, later umbilical cord clamping to allow
    Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and 15 infant outcomes (2012 Cochrane Review)Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
    more placental transfusion at preterm birth appears to be associ- ated with a reduction in the risk ratio of intraventricular haemor- rhage (all grades) and the need for transfusion, either for anaemia or for low blood pressure and less risk for necrotising enterocolitis. These effects may be related to an improvement in the circulating neonatal blood volume, and better control of blood pressure, fol- lowing greater placental transfusion.
    Surprisingly, as one of the rationales for early clamping is to allow the infant to be transferred to a resuscitaire for respiratory support, there are few data on respiratory outcomes. No study reported on spontaneous onset of respiration. A clinical concern about delayed umbilical cord clamping is the potential for the baby to get cold and develop hypothermia. This did not occur in the three trials that report temperature and there is no clear evidence that Apgar scores are significantly different.
    One small study has evaluated milking of the cord (Hosono 2008) which reports positive effects on haemoglobin after birth, better blood pressure and less need for donor blood transfusion. It is too early to say whether this method would be better compared with delaying cord clamping, even though some obstetricians and midwives might prefer it. Future large studies could compare the various methods of achieving placental transfusion such as delayed cord clamping and milking of the cord.
  • Common complications and conditions of preterm babies born before 33 weeks’ gestation include low blood pressure during the first days of life, the need for respiratory support due to immature lungs and the need for blood transfusions. Intraventricular haemorrhage (bleeding into the brain) and necrotising enterocolitis (severe infection of the bowel) can be life threatening events. Suggested advantages of delaying clamping of the umbilical cord and subsequent increased placental transfusion include larger blood volume for the preterm baby, better adaption to extrauterine life; higher haemoglobin for the baby; less anaemia for the baby and better iron stores, less need for blood transfusion, less respiratory distress (Linderkamp 1978), and less requirement for respiratory support (Holland 1991; Hudson 1990; Kinmond 1993).
    Potential disadvantages include delay in resuscitation, hypothermia, poly- cythaemia, hyperbilirubinaemia needing treatment (Saigal 1972) and a possible risk of intraventricular haemorrhage (Hofmeyr 1988). If there are benefits for preterm infants in the first few days and weeks of life, it would also be important to assess whether these short-term benefits are reflected in improved long-term out- come.
    There are different potential comparative effects of early rather than delayed cord clamping for term and preterm infants. For ex- ample, in term infants increasing placental transfusion by delaying cord clamping may increase respiratory morbidity after birth (Yao 1974). As a consequence the issue of timing of cord clamping is reviewed separately for preterm and term infants.
    For developing countries, with limited resources and a high risk of transmitting infection through blood transfusion, the potential value of a reduced need for blood transfusion would be of particular interest. In more developed countries, 60% to 80% of preterm infants less than 32 completed weeks’ gestation (Brune 2002; Ringer 1998) require transfusion
  • Feeding difficulties since the coordinated suck and swallow process only starts at 34 weeks gestation. Preterm babies need help to feed and are more likely to aspirate.
    Severe infections are more common, and premature babies are at higher risk of dying once they get an infection. The majority of babies who die from neonatal sepsis are preterm.
    Respiratory Distress Syndrome due to lung immaturity and lack of surfactant in the alveoli, resulting in collapsing lungs that take extra pressure to inflate. Below 32 weeks gestation, the majority of babies develop RDS, although this risk can be reduced by antenatal corticosteroids injections to women at risk or preterm labor, or in preterm labor.
    Jaundice is more common in premature babies since the immature liver cannot easily metabolize bilirubin, and once jaundiced, the preterm baby’s brain is at higher risk since their blood-brain barrier is less well developed to protect the brain.
    Brain injury in preterm babies is most commonly intraventricular hemorrhage, occurring in the first few days after birth in about 1 in 5 babies under 2,000 g and is often linked to severity of RDS and hypotension. Less commonly, preterm babies may have hypoxic brain injury with white matter loss which differs from that seen in the brain of term babies (Volpe, 2009).
    Necrotizing enterocolitis is a rarer condition affecting the intestinal wall of very premature babies, with a typical X-ray image of gas in the bowel wall. Formula feeding increases the risk tenfold compared to babies who are fed breast milk alone (Schanler, 2001).
    Retinopathy of prematurity due to abnormal proliferation of the blood vessels around the retina of the eye, which is more severe if the baby is given too high levels of oxygen.
    Anemia of prematurity, which often becomes apparent at a few weeks of age due to delay in producing red blood cells as the bone marrow is immature.
  • Feeding difficulties since the coordinated suck and swallow process only starts at 34 weeks gestation. Preterm babies need help to feed and are more likely to aspirate.
    Severe infections are more common, and premature babies are at higher risk of dying once they get an infection. The majority of babies who die from neonatal sepsis are preterm.
    Respiratory Distress Syndrome due to lung immaturity and lack of surfactant in the alveoli, resulting in collapsing lungs that take extra pressure to inflate. Below 32 weeks gestation, the majority of babies develop RDS, although this risk can be reduced by antenatal corticosteroids injections to women at risk or preterm labor, or in preterm labor.
    Jaundice is more common in premature babies since the immature liver cannot easily metabolize bilirubin, and once jaundiced, the preterm baby’s brain is at higher risk since their blood-brain barrier is less well developed to protect the brain.
    Brain injury in preterm babies is most commonly intraventricular hemorrhage, occurring in the first few days after birth in about 1 in 5 babies under 2,000 g and is often linked to severity of RDS and hypotension. Less commonly, preterm babies may have hypoxic brain injury with white matter loss which differs from that seen in the brain of term babies (Volpe, 2009).
    Necrotizing enterocolitis is a rarer condition affecting the intestinal wall of very premature babies, with a typical X-ray image of gas in the bowel wall. Formula feeding increases the risk tenfold compared to babies who are fed breast milk alone (Schanler, 2001).
    Retinopathy of prematurity due to abnormal proliferation of the blood vessels around the retina of the eye, which is more severe if the baby is given too high levels of oxygen.
    Anemia of prematurity, which often becomes apparent at a few weeks of age due to delay in producing red blood cells as the bone marrow is immature.
  • Feeding difficulties since the coordinated suck and swallow process only starts at 34 weeks gestation. Preterm babies need help to feed and are more likely to aspirate.
    Severe infections are more common, and premature babies are at higher risk of dying once they get an infection. The majority of babies who die from neonatal sepsis are preterm.
    Respiratory Distress Syndrome due to lung immaturity and lack of surfactant in the alveoli, resulting in collapsing lungs that take extra pressure to inflate. Below 32 weeks gestation, the majority of babies develop RDS, although this risk can be reduced by antenatal corticosteroids injections to women at risk or preterm labor, or in preterm labor.
    Jaundice is more common in premature babies since the immature liver cannot easily metabolize bilirubin, and once jaundiced, the preterm baby’s brain is at higher risk since their blood-brain barrier is less well developed to protect the brain.
    Brain injury in preterm babies is most commonly intraventricular hemorrhage, occurring in the first few days after birth in about 1 in 5 babies under 2,000 g and is often linked to severity of RDS and hypotension. Less commonly, preterm babies may have hypoxic brain injury with white matter loss which differs from that seen in the brain of term babies (Volpe, 2009).
    Necrotizing enterocolitis is a rarer condition affecting the intestinal wall of very premature babies, with a typical X-ray image of gas in the bowel wall. Formula feeding increases the risk tenfold compared to babies who are fed breast milk alone (Schanler, 2001).
    Retinopathy of prematurity due to abnormal proliferation of the blood vessels around the retina of the eye, which is more severe if the baby is given too high levels of oxygen.
    Anemia of prematurity, which often becomes apparent at a few weeks of age due to delay in producing red blood cells as the bone marrow is immature.
  • Feeding difficulties since the coordinated suck and swallow process only starts at 34 weeks gestation. Preterm babies need help to feed and are more likely to aspirate.
    Severe infections are more common, and premature babies are at higher risk of dying once they get an infection. The majority of babies who die from neonatal sepsis are preterm.
    Respiratory Distress Syndrome due to lung immaturity and lack of surfactant in the alveoli, resulting in collapsing lungs that take extra pressure to inflate. Below 32 weeks gestation, the majority of babies develop RDS, although this risk can be reduced by antenatal corticosteroids injections to women at risk or preterm labor, or in preterm labor.
    Jaundice is more common in premature babies since the immature liver cannot easily metabolize bilirubin, and once jaundiced, the preterm baby’s brain is at higher risk since their blood-brain barrier is less well developed to protect the brain.
    Brain injury in preterm babies is most commonly intraventricular hemorrhage, occurring in the first few days after birth in about 1 in 5 babies under 2,000 g and is often linked to severity of RDS and hypotension. Less commonly, preterm babies may have hypoxic brain injury with white matter loss which differs from that seen in the brain of term babies (Volpe, 2009).
    Necrotizing enterocolitis is a rarer condition affecting the intestinal wall of very premature babies, with a typical X-ray image of gas in the bowel wall. Formula feeding increases the risk tenfold compared to babies who are fed breast milk alone (Schanler, 2001).
    Retinopathy of prematurity due to abnormal proliferation of the blood vessels around the retina of the eye, which is more severe if the baby is given too high levels of oxygen.
    Anemia of prematurity, which often becomes apparent at a few weeks of age due to delay in producing red blood cells as the bone marrow is immature.
  • Feeding difficulties since the coordinated suck and swallow process only starts at 34 weeks gestation. Preterm babies need help to feed and are more likely to aspirate.
  • Feeding difficulties since the coordinated suck and swallow process only starts at 34 weeks gestation. Preterm babies need help to feed and are more likely to aspirate.
  • The point of this slide - We’ve made great strides in improved management in NICU care in industrialized countries --- but basic services for late preterm deliveries would address the majority of preterm-related deaths

Transcript

  • 1. Prevention of Preterm Birth and Complications: Evidence for Interventions and Opportunities for Action James A. Litch, MD, DTMH Director, Perinatal Interventions Program Global Alliance for Prevention of Prematurity and Stillbirth (GAPPS) Clinical Assistant Professor Department of Global Health Department of Epidemiology University of Washington jlitch@yahoo.com
  • 2. Outline • • • • Definitions and numbers Strategic approach Interventions to manage preterm birth Interventions for care the preterm newborn • Interventions to prevent preterm birth • Ready for Implementation?
  • 3. Definitions and Numbers
  • 4. Born Too Soon Report What is preterm birth? Definition of preterm birth: Babies born alive before 37 completed weeks of pregnancy Source: Chap 5, Born Too Soon erm ret p te era od ks m nd wee a ate <37 L to 32 % 84 Very preterm 28 to <32 weeks 10% Ex < 2 trem 5% 8 w ely ee pre ks ter m
  • 5. Born Too Soon Report Annual births by gestation age Source: Analysis using data from Blencowe et al., 2012; Cousens et al., 2011; Liu et al., 2012 Source: Chap 5, Born Too Soon
  • 6. Strategic Approach
  • 7. Connected MNCH Outcomes ConnectedMNCH Outcomes Require aan Interdisciplinary Approach Requires New, Interdisciplinary Approach Preterm birth and stillbirth are Maternal Maternal inextricably linked with maternal, newborn, child and RH health. Child Prematurit preterm births and stillbirths will y& accelerate efforts toward Stillbirth Interventions aimed at reducing Child Prematurity & Stillbirth Fetal achieving MDGs 4 and 5. Newborn Newborn Reproductive Health
  • 8. Three-phase Approach to Preterm Birth Image from Healthy Newborn Network Technical Guidance for Program Implementation http://www.healthynewbornnetwork.org/resource/technical-guidance-program-implementation
  • 9. Preterm Birth as a direct cause of neonatal deaths – change between 2000 to 2010
  • 10. Causes of Death Due to Preterm Birth Underlying Pathology Cause of Death Lung immaturity Hypoxia Acute respiratory distress syndrome (ARDS) Inability to tolerate labor Birth asphyxia Poor temperature regulation Hypothermia Infection Sepsis Pneumonia Poor feeding Hypoglycemia Dehydration Pour weight gain
  • 11. Additional risks specific to preterm newborns • Hypoglycemia/dehydration/under-nutrition from feeding difficulties - coordinated suck and swallow process only starts at 34 weeks • Thermal instability - surface area to mass and metabolic issues • Severe infections more common, and higher risk of dying infection • Respiratory Distress Syndrome due to lung immaturity and lack of surfactant • Jaundice - immature liver cannot easily metabolize bilirubin, and brain is at higher risk since their blood-brain barrier is less well developed. • Brain injury is most commonly intraventricular hemorrhage, occurring in the first few days after birth in about 1 in 5 babies <2,000 g. • Necrotizing enterocolitis affecting the intestinal wall of very premature babies. Formula feeding increases risk tenfold compared to BF milk alone (Schanler, 2001). • Retinopathy of prematurity if given too high levels of oxygen.
  • 12. Interventions and Evidence
  • 13. Essential Newborn Care plus Extra Care for Preterm Babies
  • 14. Evidenced-based Interventions to Improve Preterm Survival • ENC – thermal care, hygeine/handwashing, immediate breast feeding and resuscitation • Antenatal corticosteroids • Antibiotics for preterm prelabor rupture of the membranes (pPROM) • Delayed cord clamping • Chlorhexidine to chord • Kangaroo Mother Care (prolonged skin to skin contact) • Surfactant therapy • Optimal feeding
  • 15. Evidenced-based Interventions to Prevent Preterm Birth • Birth spacing • Family planning • Treatment of infectious diseases (STI, malaria, HIV) • Substance abuse / smoking cessation • Domestic violence
  • 16. What works?
  • 17. Born Too Soon Report Potential for lives saved through steroid injections for women in preterm labor Respiratory complications due to lung immaturity (RDS) are the commonest cause of death in preterm babies. Single course of antenatal steroids to women in preterm labour: •31% Mortality reduction (RR 0.69, 95% CI 0.58 to 0.81) for babies in settings where ventilation (+/-surfactant) is standard of care (Cochrane review) •53% reduction in mortality in 4 studies in middle income countries (RR 0.47, 95% CI 0.35 to 0.64) Dexamethasone is low cost (<$1) and available in many settings but low coverage in low and middle income settings One of the 13 priority medicines listed by UN Commodities Commission Could save about 400,000 babies each year if reached 95% of women in preterm labor (LiST analysis) Source: Chap 6 , Born too soon,
  • 18. ACS: Clinical Guidelines • WHO recommended treatment – Single dose for pregnant women who are: • between 26 and 35 weeks gestational age, and • At risk of preterm delivery within 7 days – Dexamethasone 6 mg IM 4 doses 12 hours apart* – Betamethasone 12 mg IM, 2 doses 24 hours apart • • • Insufficient evidence to justify multiple courses or a single rescue course of ANC at this time Partial or incomplete regimen may provide some benefit Major barrier to implementation is identifying women at risk or preterm labor in time to administer drug Hofmeyer GJ. Antenatal corticosteroids for women at risk of preterm birth: RHL commentary. The WHO Reproductive Health Library; Geneva, WHO. Bonanno C, Wapner RJ. Antenatal Corticosteroids an the management of preterm birth: are we back where we started? 2012 Obstet Gynecol Clin N Am; 39:47-3-62.
  • 19. Born Too Soon Report Potential for lives saved through antibiotics for premature prelabor rupture of the membranes (pPROM) - In high-income countries, it is standard practice to give antibiotics to women with pre-term, pre-labour rupture of membranes (pPROM) to delay birth and reduce the risk of infection. - In LMICs use of antibiotic therapy for pPROM is not common - Reviewed 18 RCTs (most from HIC) that provide strong evidence that antibiotics for pPROM: - Reduced risk of RDS [risk ratio (RR) = 0.88; confidence interval (CI) 0.80, 0.97], - Reduced risk of early onset postnatal infection (RR = 0.61; CI 0.48, 0.77). - Reduction in neonatal mortality (RR = 0.90; CI 0.72, 1.12). - In LMICs where access to other interventions (antenatal steroids, surfactant therapy, ventilation, antibiotic therapy) may be low, antibiotics for pPROM could prevent 4% of neonatal deaths due to complications of prematurity and 8% of those due to infection. Could save about 12% of PT babies each year if reached 95% of women in preterm labor (LiST analysis) Cousens S, et al. Antibiotics for preterm pre-labor rupture of membranes. International Journal of Epidemiology 2010;39:i134–i143.
  • 20. Antibiotics for premature prelabor rupture of the membranes (PROM) Lack of data from low-income countries, where newborns have less access to appropriate PT care. In the absence advance PT interventions, the use of antibiotics for pPROM will certainly prevent neonatal deaths by preventing RDS. Similarly, in settings with poor access to antibiotic therapy for neonatal infections, the prevention of sepsis cases through the use of antibiotics for pPROM will certainly prevent infection deaths. Cousens S, et al. Antibiotics for preterm pre-labor rupture of membranes. International Journal of Epidemiology 2010;39:i134–i143.
  • 21. Delayed chord clamping Wait 2-3 minutes, or until chord stops pulsating, while keeping baby below level of placenta There are different potential comparative effects of early rather than delayed cord clamping for term and preterm infants. In term infant, increasing placental transfusion by delaying cord clamping may increase respiratory morbidity after birth (Yao 1974). What about for PTB less than 37 weeks? Born Too Soon: The Global Action Report on Preterm Birth. World Health Organization. Geneva, 2012 Roberts d, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Reviews 2006. 3.
  • 22. Born Too Soon Report Potential for decrease morbidity and transfusions through delayed chord clamping for PTB < 37 weeks Fifteen studies (738 infants) were eligible for inclusion. Participants were between 24 and 36 weeks’ gestation at birth. The maximum delay in cord clamping was 180 seconds. Delaying cord clamping, compared to immediate clamping, was associated with: - Fewer infants requiring transfusions for anaemia (seven trials, 392 infants; risk ratio (RR) 0.61, 95% confidence interval (CI) 0.46 to 0.81) - Less intraventricular haemorrhage (ultrasound diagnosis all grades) 10 trials, 539 infants (RR 0.59, 95% CI 0.41 to 0.85) - Lower risk for necrotising enterocolitis (five trials, 241 infants, RR 0.62, 95% CI 0.43 to 0.90) For primary outcomes of infant death, severe intraventricular hemorrhage and periventricular leukomalacia there were no clear differences identified between groups Decreased complications and reduced transfusion needs if reached 95% of preterm newborns Source: Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and 15 infant outcomes (2012 Cochrane Review)
  • 23. Delayed chord clamping for PTB < 37 weeks • • • Developing countries, with limited resources and a high risk of transmitting infection through blood transfusion Potential value of a reduced need for blood transfusion. In more developed countries, 60% to 80% of preterm infants less than 32 completed weeks’ gestation (Brune 2002; Ringer 1998) require transfusion Born Too Soon: The Global Action Report on Preterm Birth. World Health Organization. Geneva, 2012 Roberts d, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Reviews 2006. 3.
  • 24. Resuscitation for preterm baby - Premature births have higher risk of hypoxic brain injury and retinopathy from oxygen administration. - Some 10% of newborns require assistance to begin breathing, more for preterm babies - ¾ of these require only basic resuscitation with bag and mask or tube and mask to initiate breathing - Assisted ventilation with room air is equivalent to using oxygen (Saugstad et al, 2006) - Premature babies at great risk for RDS and may require ventilation support with CPAP
  • 25. Emollient ointment for preterm newborn - Topical application of emollient ointment (sunflower oil or Aquaphor/Petrolatum 41%) - Reduces water loss, dermatitis and risk of sepsis (Soll and Edwards, 2000) - Limited hospital-based trials in Egypt and Bangladesh (reduced mortality) - High potential and has application in facilities and homes
  • 26. Chlorhexidine topical application - Topical application of 7.1% chlorhexidine digluconate solution/gel to chord before 24 hours of birth (continue up to 7 days) - Reduces chord stump infection and risk of sepsis (Tielsch et al, 2007, Scoofi et al, 2012, Arifeen et al, 2012) - Community trials in Asia and Africa - Greater reduction of mortality among preterm newborns (Arifeen et al 2012)
  • 27. Clean birth practices for preterm newborn - Consistent hand washing and maintaining a clean environment - Premature births have higher risk of sepsis. - Included in: - Continuous skin to skin care package (KMC) - Clean birth kits
  • 28. Born Too Soon Report Potential for lives saved through continuous skin-to-skin care Baby is tied skin to skin with mother 24 hours a day for days/weeks providing: •thermal care •increased breastfeeding, better weight gain •links to additional supportive care, if needed, and •earlier discharge Mortality reduction 51% for babies < 2000 gm, in facilities, clinically stable and started within one week compared to incubator care Effective entry point for care of preterm babies Could save about 450,000 babies each year if reached 95% of preterm babies (LiST analysis) Chap 5, Born too Soon. Impact data from Lawn et al ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications. Int J Epid: 2010, Conde Aguedelo Cochrane review 2011
  • 29. Feeding Support - Early initiation of breast feeding within one hour after birth reduces (Edmond et al, 2006) - Premature newborns benefit nutritionally, immunologically and developmentally (Callen and Pinelli, 2005) - Formula feeding increases risk of necrotizing enterocolitis and improved neurodevelopmental outcome (Edmond et al, 2007; Hurst, 2007) - Extra feeding support with a cup, spoon or other device (especially <34 weeks) - Support mother expressing milk or provide donor milk - Milk banking is option in some areas of Africa
  • 30. Likely to work – but lacking evidence for preterm lives saved - Birth preparedness Danger signs awareness Monitoring of labor Transportation / referral arrangements Mother/Baby friendly care (patient centered respectful care) Postnatal care vouchers
  • 31. Prevention of preterm birth Care before and between pregnancy Implement: • Family planning strategies, including birth spacing and provision of adolescent-friendly services • Prevention and management of STIs and NCDs • Education and interventions for domestic violence • Promotion of healthy nutrition and addressing life-style risks like smoking and substance abuse Source: Born Too Soon
  • 32. Implementation
  • 33. Where 15 million preterm babies receive care
  • 34. Estimated Lives Saved of Premature Babies in Settings with Universal Coverage of Basic Interventions (without NICU) 520,000 lives (55%) of premature babies could be saved if adequate management of preterm labor and birth. 760,000 lives (80%) saved if family planning included in model. 34
  • 35. Thank you Global Alliance to Prevent Prematurity and Stillbirth (GAPPS) leads a collaborative, global effort to increase awareness and accelerate innovative research and development to make every birth a healthy birth. jlitch@yahoo.com james.litch@seattlechildrens.org 35
  • 36. Important Resources Global report on preterm birth & stillbirth: the foundation for innovative solutions and improved outcomes www.biomedcentral.com/bmcpregnancychildbirth/supplements/ Born Too soon: The Global Action Report on Preterm Birth www.who.int/pmnch/media/news/2012/preterm_birth_report/en/index.html Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health www.who.int/pmnch/topics/part_publications/201112_essential_interventions/en/in
  • 37. Interventions for preterm birth and stillbirth along the continuum of care PTB Intervention PREPREGNANCY •Family planning/ birth spacing •Prevent & treat sexually transmitted infections •Nutrition PREGNANCY •Prevent & treat sexually transmitted infections •Nutrition BIRTH •Antenatal steroids •Antibiotics for pPROM •Delayed chord cutting •Identify preterm babies POSTNATAL/ NEWBORN CHILDHOOD •Essential & Extra care •Chlorhexidine •Kangaroo Mother Care •Management of sick newborns •Neonatal resuscitation •Appropriate oxygen use •Ventilation support •Postnatal followup