Obstetrical Management of Late Preterm Pregnancy

Jin Hoon Chung

doi:10.14734/PN.2016.27.4.195

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Chung: Obstetrical Management of Late Preterm Pregnancy

Review Article

Perinatology 2016; 27(4): 195-204.

Published online: 31 December 2016

DOI: https://doi.org/10.14734/PN.2016.27.4.195

Obstetrical Management of Late Preterm Pregnancy

Jin Hoon Chung, MD, PhD

Division of Maternal-fetal Medicine, Department of Obstetrics and Gynecology, Cheil General Hospital & Women's Healthcare Center, DanKook University College of Medicine, Seoul, Korea.

Correspondence to: Jin Hoon Chung, MD, PhD. Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cheil General Hospital & Women's Healthcare Center, 17, Seoae ro 1 Gil, Jung gu, Seoul 04619, Korea. Tel: +82-2-2000-7273, Fax: +82-2-2000-7183, sabi0515@hanmail.net

Received 8 September 2016 Revised 1 November 2016 Accepted 8 November 2016

(open-access, http://creativecommons.org/licenses/by-nc/4.0/):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The neonatal risks of late preterm (34 0/7-36 6/7 weeks of gestation) births are well established. Late preterm birth results from spontaneous, indicated, and sometime elective indications. Prediction and prevention of preterm birth is currently largely aimed at identifying women at high risk such as those with previous preterm birth, and targeting intervention at this group. Both cervical length assessment and fibronectin testing permit some modification of the likelihood of preterm birth in this group. Progesterone treatment for the prevention of preterm birth is currently being researched widely, and appears a potentially promising strategy. The burden of prematurity can be decreased if elective late preterm delivery is eliminated. However, there are a number of maternal, fetal, and placental complications in which a late preterm delivery is warranted. The timing of delivery in such cases must balance the maternal and newborn risks of late preterm delivery with the risks of further continuation of pregnancy. Decisions regarding timing of delivery must be individualized. The following is a review of obstetric decision-making for late preterm pregnancies.

Keywords: Fetal lung maturation, Late preterm birth, Prematurity

Figures and Tables

Table 1

Neonatal and Infant Mortality Rates Associated with Late-Preterm and Early-Term Deliveries

Gestational age (weeks)	Neonatal mortality rate (per 1,000 live births)	Relative risk (95% CI)	Infant mortality rate (per 1,000 live births)	Relative risk (95% CI)
34^*	7.1	9.5 (8.4–10.8)	11.8	5.4 (4.9–5.9)
35^*	4.8	6.4 (5.6–7.2)	8.6	3.9 (3.6–4.3)
36^*	2.8	3.7 (3.3–4.2)	5.7	2.6 (2.4–2.8)
37^*	1.7	2.3 (2.1-2.6)	4.1	1.9 (1.8-2.0)
38^*	1.0	1.4 (1.3–1.5)	2.7	1.2 (1.2–1.3)
39	0.8	1.00^†	2.2	1.00^†
40	0.8	1.0 (0.9–1.1)	2.1	0.9 (0.9–1.0)

Data from Reddy UM, Ko CW, Raju TN, Willinger M. Delivery indications at late-preterm gestations and infant mortality rates in the United States. Pediatrics 2009;124:234-40.

Abbrevation: CI, confidence interval.

^*P<0.001.

^†Reference group.

Table 2

Recommendations for Timing of Delivery When Conditions Complicate Pregnancy at or After 34 Weeks of Gestation

Condition	general timing	Suggested specific timing
Placental/Uterine issues
Placenta previa^*	Late preterm/early term	36⁺⁰–37⁺⁶ weeks of gestation
Placenta previa with suspected accrete, increta, or percreta^*	Late preterm	34⁺⁰–35⁺⁶ weeks of gestation
Prior classical cesarean	Late preterm/early term	36⁺⁰–37⁺⁶ weeks of gestation
Prior myomectomy	Early term/term (individualized)	37⁺⁰–38⁺⁶ weeks of gestation
Fetal issue
Growth restriction (singleton)
Otherwise uncomplicated, no concurrent findings	Early term/term	38⁺⁰–39⁺⁶ weeks of gestation
Concurrent conditions (oligohydramnios, abnormal Doppler studies, maternal co-morbidity [eg, preeclampsia, chronic hypertension])	Late preterm/early term	34⁺⁰–37⁺⁶ weeks of gestation
Growth restriction (twins)
DCDA twin with isolated FGR	Late preterm/early term	36⁺⁰–37⁺⁶ weeks of gestation
DCDA twin with concurrent condition (abnormal Doppler studies, maternal co-morbidity [eg, preeclampsia, chronic hypertension])	Late preterm	32⁺⁰–34⁺⁶ weeks of gestation
MCDA twin with isolated FGR	Late preterm	32⁺⁰–34⁺⁶ weeks of gestation
Multiple gestation
DCDA twin	Early term	38⁺⁰–38⁺⁶ weeks of gestation
MCDA twin	Late preterm/early term	34⁺⁰–37⁺⁶ weeks of gestation
Oligohydramnios	Late preterm/early term	36⁺⁰–37⁺⁶ weeks of gestation
Maternal issues
Chronic hypertension
Controlled on no medications	Early term/term	38⁺⁰–39⁺⁶ weeks of gestation
Controlled on medications	Early term/term	37⁺⁰–39⁺⁶ weeks of gestation
Difficult to control	Late term/early term	36⁺⁰– 37⁺⁶ weeks of gestation
Gestational hypertension	Early term	37⁺⁰–38⁺⁶ weeks of gestation
Preeclampsia-severe	Late preterm	At diagnosis after 34⁺⁰ weeks of gestation
Preeclampsia-mild	Early term	At diagnosis after 37⁺⁰ weeks of gestation
Diabetes
Pregestational well-controlled^*	Late preterm, early term birth not indicated
Pregestational with vascular complications	Early term/term	37⁺⁰–39⁺⁶ weeks of gestation
Pregestational, poorly controlled	Late preterm or early term	Individualized
Gestational-well controlled on diet or medications	Late preterm, early term birth not indicated
Gestational- poorly controlled	Late preterm or early term	Individualized
Obstetric issue
PPROM	Late preterm	34⁺⁰ weeks of gestation

Data from American College of Obstetricians and Gynecologists. ACOG committee opinion no. 560: Medically indicated late-preterm and early-term deliveries. Obstet Gynecol 2013;121:908-10.

Abbreviations: DCDA, dichorionic diamniotic; MCDA, monochorionic diamniotic; FGR, fetal growth restriction; PPROM, preterm premature rupture of membranes.

^*Uncomplicated, thus no fetal growth restriction, superimposed preeclampsia, or other complications. If these are present, then the complicating conditions take precedence and earlier delivery may be indicated.

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