Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
maternal evaluation and assessment of fetal viability
Initial assessment in a woman who presents with apparent preterm contractions should include a careful review of all data concerning gestational age, as this is related to prognosis. The fibronectin test may reduce preterm birth rates by helping to identify women at high risk of delivery, and by influencing subsequent management.[98]
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Fetal monitoring can be carried out by either intermittent auscultation or continuous cardiotocography, although, at very early gestations, monitoring may be inappropriate.
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The method of potential delivery should also be considered, especially if a caesarean section is likely to be required. There is little evidence to guide these decisions, and they should be made by an experienced obstetrician, in consultation with a neonatologist. If possible, parents should be encouraged to see the neonatal intensive care unit.
In women at critical gestations (23 to 26 weeks), admission to hospital may prevent inadvertent delivery away from neonatal resuscitation facilities.
corticosteroid ± transfer to neonatal unit
Treatment recommended for ALL patients in selected patient group
The two most important interventions that improve outcome in premature labour are antenatal corticosteroids and in utero transfer to a specialist centre when local neonatal services are not adequate.[65][97][127]
All women at risk of preterm delivery within 7 days, who are from 24 to 34 weeks' gestation, should be given one course of betamethasone or dexamethasone.[34][119][128] The Royal College of Obstetricians and Gynaecologists guidelines recommend the use of corticosteroids in women at imminent risk of preterm delivery from 24 to 34+6 weeks’ gestation.[94][130] Dexamethasone may result in lower rates of intraventricular haemorrhage.[97]
Corticosteroids may be considered in women at 22 weeks' gestation who are at risk for imminent delivery.[128][130][131] This option depends on the family's wishes on resuscitation.[128]
Evidence suggests that corticosteroids given later in preterm gestations (i.e., 35 to 36 weeks) may reduce neonatal respiratory complications, but these benefits must be weighed against possible adverse effects.[128][130][132][133]
Optimal clinical benefit of antenatal corticosteroids is likely to be from 24 hours to 7 to 14 days after administration. The use of multiple doses has been linked to intrauterine growth restriction and theoretical concerns of long-term morbidity.[134] However, a single repeat course after 7 days may be beneficial if still at a critical gestation, and a meta-analysis suggests no evidence of harm at 2 to 3 years (in over 4000 children).[135][136][137]
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[Evidence A]
The use of antenatal corticosteroids in low- and middle-income countries has been associated with an increase in overall neonatal mortality, and care must be taken not to extrapolate clinical trial findings to all populations.[138][119]
Transfer is indicated if local facilities for premature neonatal care are not available.
Primary options
betamethasone sodium phosphate/betamethasone acetate: 12 mg intramuscularly every 24 hours for 2 doses
OR
dexamethasone sodium phosphate: 6 mg intramuscularly every 12 hours for 4 doses
tocolytic agent
Additional treatment recommended for SOME patients in selected patient group
Tocolytic agents may prolong gestation by between 2 and 7 days and are recommended for short-term use to provide time for administration of antenatal corticosteroids and transfer to an appropriate neonatal unit.[65][66] One Cochrane review reported low- to moderate-certainty evidence that all tocolytic drug classes assessed were effective in delaying preterm birth for 48 hours and 7 days.[139]
The use of tocolytic drugs must be carefully considered as there is no clear evidence they improve outcome, and their adverse-effect profile should be taken into account when choosing a particular drug.[60]
During administration, maternal pulse rate and blood pressure should be monitored every 30 minutes for the first 4 hours, then every 2 hours for the first 24 hours.
Contraindications include lethal fetal anomaly, chorio-amnionitis, fetal compromise, significant vaginal bleeding, or maternal comorbidity.[60]
Nifedipine (calcium-channel blocker) is a commonly used agent. Calcium-channel blockers may be more effective than other tocolytic agents at reducing deliveries before 34 weeks' gestation, and at reducing neonatal morbidity.
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Nifedipine has adverse effects that are dose dependent, most commonly after a total dose of 60 mg.[140] Atosiban (oxytocin antagonist) and nifedipine have comparable effectiveness to beta agonists with fewer adverse effects, and similar perinatal outcomes.[142][143][144] Atosiban is used in some countries, but is not available in the US. Beta agonists no longer seem the best choice as, although they can prolong gestation, they are more likely to cause maternal adverse effects that lead to discontinuation of therapy, and the US Food and Drug Administration cautions against the off-label use of terbutaline for premature labour.[141]
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Primary options
nifedipine: 30 mg orally (immediate-release) as a loading dose, followed by 10-20 mg every 4-6 hours
OR
atosiban: consult specialist for guidance on dose
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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