Practice Bulletin No 171 Summary Management Of.52 (ACOG

interim update
The American College of

Obstetricians and Gynecologists
WOMEN’S HEALTH CARE PHYSICIANS
P RACTICE BULLET IN SUMMARY

clinical management guidelines for obstetrician – gynecologists
Number 171, October 2016 (Replaces Practice Bulletin Number 159, January 2016)
For a comprehensive overview of management of preterm labor, the full-text Scan this QR code
version of this Practice Bulletin is available at http://dx.doi.org/10.1097/ with your smart
phone to view the
AOG.0000000000001711.
full-text version of
this Practice Bulletin.
Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the American College
of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics in collaboration with Hyagriv
N. Simhan, MD, MS.
The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These guidelines should not be
construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient,
resources, and limitations unique to the institution or type of practice.
INTERIM UPDATE: This Practice Bulletin is updated to reflect a limited, focused change in the gestational age at which
to consider antenatal corticosteroids, including administration during the late preterm period and rescue course timing.
For complete details on these updates, please see the full-text version.
Management of Preterm Labor

Preterm birth is the leading cause of neonatal mortality and the most common reason for antenatal hospitalization
(1–4). In the United States, approximately 12% of all live births occur before term, and preterm labor preceded
approximately 50% of these preterm births (5, 6). Although the causes of preterm labor are not well understood, the
burden of preterm births is clear—preterm births account for approximately 70% of neonatal deaths and 36% of infant
deaths as well as 25–50% of cases of long-term neurologic impairment in children (7–9). A 2006 report from the
Institute of Medicine estimated the annual cost of preterm birth in the United States to be $26.2 billion or more than
$51,000 per premature infant (10). However, identifying women who will give birth preterm is an inexact process.
The purpose of this document is to present the various methods proposed to manage preterm labor and to review the
evidence for the roles of these methods in clinical practice. Identification and management of risk factors for preterm
labor are not addressed in this document.
Clinical Management Questions

Which tests can be used to stratify risk for preterm delivery in patients who present with preterm
contractions?
Which patients with preterm labor are appropriate candidates for intervention?
Should women with preterm contractions but without cervical change be treated?
Does the administration of antenatal corticosteroids improve neonatal outcomes?
What is the role for magnesium sulfate for fetal neuroprotection?
Does tocolytic therapy improve neonatal outcomes?
Should tocolytics be used after acute therapy?
VOL. 128, NO. 4, OCTOBER 2016 OBSTETRICS & GYNECOLOGY 931
Copyright ª by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Is there a role for antibiotics in preterm labor?
Is there a role for nonpharmacologic management of women with preterm contractions or preterm
labor?
Is preterm labor managed differently in women with multiple gestations?
Recommendations and A single course of corticosteroids may be considered

starting at 23 weeks of gestation for pregnant women
Conclusions who are at risk of preterm delivery within 7 days,
The following recommendations and conclusions irrespective of membrane status.
are based on good and consistent scientific evi- A single repeat course of antenatal corticosteroids
dence (Level A): should, therefore, be considered in women who are
less than 34 weeks of gestation, who are at risk of
A single course of corticosteroids is recommended preterm delivery within the next 7 days, and whose
for pregnant women between 24 weeks and prior course of antenatal corticosteroids was admin
34 weeks of gestation who are at risk of delivery istered more than 14 days previously. Rescue course
within 7 days. corticosteroids could be provided as early as 7 days
Accumulated available evidence suggests that magne from the prior dose, if indicated by the clinical
sium sulfate reduces the severity and risk of cerebral scenario.
palsy in surviving infants if administered when birth is Bed rest and hydration have not been shown to be
anticipated before 32 weeks of gestation. Hospitals effective for the prevention of preterm birth and
that elect to use magnesium sulfate for fetal neuropro should not be routinely recommended.
tection should develop uniform and specific guidelines
for their departments regarding inclusion criteria, The positive predictive value of a positive fetal
treatment regimens, concurrent tocolysis, and monitor fibronectin test result or a short cervix alone is poor
ing in accordance with one of the larger trials. and should not be used exclusively to direct manage
ment in the setting of acute symptoms.
The evidence supports the use of first-line tocolytic
treatment with beta-adrenergic agonist therapy, cal
cium channel blockers, or NSAIDs for short-term
prolongation of pregnancy (up to 48 hours) to allow
Proposed Performance
for the administration of antenatal steroids. Measure
Maintenance therapy with tocolytics is ineffective The proportion of women with preterm labor at less than
for preventing preterm birth and improving neonatal 34 weeks of gestation who receive corticosteroid therapy
outcomes and is not recommended for this purpose.
Antibiotics should not be used to prolong gestation
or improve neonatal outcomes in women with pre Studies were reviewed and evaluated for quality according
term labor and intact membranes. to the method outlined by the U.S. Preventive Services
Task Force. Based on the highest level of evidence found
The following recommendations and conclusions in the data, recommendations are provided and grad ed
according to the following categories:
are based on limited and inconsistent scientific
Level A—Recommendations are based on good and con
evidence (Level B): sistent scientific evidence.
For women with ruptured membranes or multiple Level B—Recommendations are based on limited or
inconsistent scientific evidence.
gestations who are at risk of delivery within 7 days,
a single course of corticosteroids is recommended Level C—Recommendations are based primarily on con
sensus and expert opinion.
between 24 weeks and 34 weeks of gestation.
932 Practice Bulletin No. 171 Summary OBSTETRICS & GYNECOLOGY

Copyright October 2016 by the American College of Obste-
tricians and Gynecologists. All rights reserved. No part of this
publication may be reproduced, stored in a retrieval system,
posted on the Internet, or transmitted, in any form or by any
means, electronic, mechanical, photocopying, recording, or
otherwise, without prior written permission from the publisher.
Requests for authorization to make photocopies should be
directed to Copyright Clearance Center, 222 Rosewood Drive,
Danvers, MA 01923, (978) 750-8400.
The American College of Obstetricians and Gynecologists
409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920
Official Citation
Management of preterm labor. Practice Bulletin No. 171. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2016;
128:e155–64.
VOL. 128, NO. 4, OCTOBER 2016 Practice Bulletin No. 171 Summary 933


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What are the main methods proposed to manage preterm labor?

What is the role of corticosteroids in managing preterm labor?

interim update

The American College of

P RACTICE BULLET IN SUMMARY

Management of Preterm Labor

Clinical Management Questions

VOL. 128, NO. 4, OCTOBER 2016 OBSTETRICS & GYNECOLOGY 931

Copyright ª by The American College of Obstetricians

Recommendations and A single course of corticosteroids may be considered

932 Practice Bulletin No. 171 Summary OBSTETRICS & GYNECOLOGY

Copyright ª by The American College of Obstetricians

Copyright ª by The American College of Obstetricians

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