Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Describe the risk factors associated with preterm birth 2. Discuss the clinical evaluation and management of women at risk for preterm birth
Estimated time to complete activity: 0.25 hours
Ashley Comfort, MD, FACOG is the Director of Medical Content, ObG Project.
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Ashley Comfort, MD, has a financial interest in Pfizer and has no other conflicts of interest to disclose.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 3/31/2022 through 3/1/2023, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.25 contact hours.
Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.
Spontaneous preterm birth (PTB) includes preterm labor, preterm rupture of membranes and cervical insufficiency from ≥20w7d to <37w0d of gestation. The PTB rate has significantly increased during the last 2 decades. According to the CDC, PTB rates decreased from 2007 to 2014, partly due to fewer teens and young women giving birth. However, the PTB rate rose for the fifth year in a row in 2019 and sits at approximately 10%. Unfortunately, racial, and ethnic differences in PTB rates remain problematic. The CDC reports that “in 2019, the rate of preterm birth among non-Hispanic black women (14.4%) was about 50% higher than the rate of preterm birth among non-Hispanic white women (9.3%) or Hispanic women (10%).”
Adverse Outcomes and Preterm Birth
The rate of neonatal adverse outcomes decreases with advancing gestational age
While adverse outcomes are therefore greatest <34 weeks (early preterm), higher rates of both short- and long-term complications are seen between 34w0d an 36w6d (late preterm) vs ≥37 weeks
The CDC reported that in 2018, preterm birth and low birth weight accounted for about 17% of infant deaths <1 year
Short cervical length (<25 mm) between 16 and 24 weeks
Low maternal pre-pregnancy weight (BMI <18.5)
Short interpregnancy interval (<18 months)
Note: Surgical procedures (e.g., cold-knife conization, loop electrosurgical excision, or laser ablation) have been postulated to be associated with preterm birth, but data is inconsistent
Clinical Evaluation and Management
Previous Spontaneous PTB (Singleton)
Detailed medical history and prior obstetric history
Progesterone (vaginal or IM) starting at 16w0d to 20w6d “more effective than starting later” | “Although the pharmacokinetic data are reassuring, there are no clinical data on which to make a recommendation regarding use of subcutaneous 17-OHPC in pregnant individuals at risk for preterm birth”
Serial endovaginal cervical length measurements starting at 16w0d and repeated every 1 to 4 weeks until 24w0d
If cervical length ≤25 mm, offer the following
Not on progesterone: Cervical cerclage or vaginal progesterone
On progesterone: Cervical cerclage and continue progesterone
No Previous History of PTB
Low risk for PTB
Clinical utility of universal cervical length screening “remains unsettled”
Cervix should be visualized at the 2nd trimester anatomy exam (18 to 22 weeks) | Transabdominal or endovaginal approach is acceptable
If cervix appears short on transabdominal scan, endovaginal ultrasound is recommended to determine whether progesterone may be of benefit
Serial endovaginal ultrasonography is not indicated in low risk patients
Short cervical length
Vaginal Progesterone: “Although most studies used 200 mg progesterone daily from the time of identification of a cervix shorter than 25 mm at 18 0/7–25 6/7 weeks of gestation until 36–37 weeks of gestation, there are no adequate dosing studies or comparative trials, and there are insufficient data to indicate which formulation and which dose are most effective”
Ultrasound-indicated: Overall, no significant reduction of PTB | May be potential benefit in very short cervix (<10 mm)
Exam-indicated: Dilated cervix on digital/speculum exam at 16w0d to 23w6d “are candidates” for cerclage | Uncertain if amniocentesis to test for infection impacts outcome
Pessary: Not recommended
Multiple gestation with or without history of PTB
Progesterone: No reduction of PTB
Cerclage if cervix <25 mm: May increase risk for PTB
“There is a paucity of information about optimal cervical length screening and treatment approaches for individuals with higher-order multiple gestations”
Pessary is not recommended
History of a Medically Indicated Preterm Delivery
May be increased risk for PTB
“insufficient evidence to support a recommendation that these individuals undergo serial cervical length surveillance in future pregnancies”
Women with singleton pregnancy and history of PTB should be offered progesterone supplementation staring at 16 weeks
Vaginal progesterone is recommended in women without a history of PTB but with short cervix
Screening for fetal fibronectin, bacterial vaginosis and home contraction monitoring are not recommended
Universal cervical length with endovaginal remains unclear | However, cervix should be visualized during the second trimester anatomy scan
Neither progesterone nor cerclage are recommended routinely in multiple gestations
Activity restriction is not recommended to reduce the risk of preterm birth
OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.
Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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