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Official reprint from UpToDate®

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Management of pregnant women after resolution of

an episode of acute idiopathic preterm labor
Authors: Steve Caritis, MD, Hyagriv N Simhan, MD, MS
Section Editor: Charles J Lockwood, MD, MHCM
Deputy Editor: Vanessa A Barss, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jun 2019. | This topic last updated: Mar 15, 2019.

INTRODUCTION

The management of pregnancies after resolution of a suspected episode of acute

idiopathic preterm labor (PTL) lacks high quality evidence on which to base
recommendations. No large randomized trials have compared combinations of
management strategies.

This topic will present our approach to management of women who do not deliver and do
not have advanced cervical dilation after resolution of an acute episode of suspected
idiopathic PTL. The evaluation and management of women with suspected acute PTL
are discussed separately. (See "Preterm labor: Clinical findings, diagnostic evaluation,
and initial treatment" and "Inhibition of acute preterm labor".)

ANTENATAL CORTICOSTEROIDS

Women at 23+0 to 33+6 weeks of gestation anticipated to be at increased risk for

preterm birth in the next seven days should receive an initial course of antenatal
corticosteroids to reduce neonatal morbidity and mortality if preterm delivery occurs.
Administration of an initial course of antenatal corticosteroids at 34+0 to 36+6 weeks of
gestation is somewhat controversial; however, there is consensus that tocolysis should
not be used to delay delivery for completion of a course of steroids at this gestational

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age. The use of antenatal corticosteroids at various gestational ages and the indications
for rescue/salvage/booster therapy in patients who have received a previous course of
therapy are discussed in detail separately. (See "Antenatal corticosteroid therapy for
reduction of neonatal respiratory morbidity and mortality from preterm delivery".)

CONTINUATION OF PROGESTERONE SUPPLEMENTATION

For women who had been receiving supplemental progesterone to reduce the risk of
preterm birth because of a history of prior preterm birth or the finding of a sonographic
short cervix, we continue their same regimen of progesterone supplementation after
resolution of an episode of suspected PTL. We continue therapy because this was the
approach taken in one of the seminal trials that demonstrated the efficacy of
progesterone supplementation [1]. (See "Progesterone supplementation to reduce the
risk of spontaneous preterm birth", section on 'Pregnancies likely to benefit from
progesterone supplementation'.)

We would not newly initiate progesterone supplementation in women who were not
candidates for therapy before their episode of preterm labor. (See 'Initiation of
progesterone supplementation' below.)

DURATION OF HOSPITALIZATION

After resolution of an episode of suspected acute PTL with intact membranes, we

consider several factors when determining the duration of hospitalization.

● Women who are ≥34 weeks of gestation with suspected acute PTL generally do not
receive tocolytic therapy because 34 weeks defines the threshold at which perinatal
morbidity and mortality are too low to justify the potential maternal and fetal
complications and costs associated with inhibition of preterm labor and short-term
delay of delivery (see "Inhibition of acute preterm labor", section on 'Lower and
upper gestational age limits'). However, they may receive a course of antenatal
corticosteroid therapy. (See "Antenatal corticosteroid therapy for reduction of
neonatal respiratory morbidity and mortality from preterm delivery", section on '34+0
or more weeks'.)

These patients can be discharged when the episode of suspected PTL resolves, as
long as tests of fetal well-being are reassuring (eg, reactive nonstress test) and
there are no additional complications that warrant hospitalization (eg, fever,

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abruption, preterm prelabor rupture of membranes, pregnancy-related

hypertension).

For patients with advanced cervical dilation/effacement and/or a history of rapid

labor, the travel time to a hospital with appropriate levels of obstetric and neonatal
care services needs to be considered. Many of these patients will need to remain in
the hospital because of the risk of delivery in a less than optimal setting if they are
discharged.

● In women <34 weeks of gestation with suspected acute PTL, the duration of
hospitalization is made on a case-by-case basis, depending on patient-specific
factors including gestational age, cervical status, past obstetric history, distance
between their residence and the hospital, and coexisting obstetric and medical
problems [2,3]. Patients who receive antenatal corticosteroids generally remain in
the hospital until the course has been completed (eg, 24 hours after the second
dose of betamethasone), but this decision can be individualized.

The only randomized trial designed to determine whether hospitalization of women after
resolution of an episode of PTL increased the proportion of deliveries ≥36 weeks
compared with women discharged home did not find a benefit [4]. In this trial, 101
women with singleton gestations, intact membranes, mean cervical dilation 2.7 cm, and
a diagnosis of arrested PTL between 24+0 and 33+4 weeks of gestation were randomly
assigned to hospitalization until 34+0 weeks or discharged home upon completion of a
course of dexamethasone. Tocolytics were not administered; contractions ceased with
conservative management alone (hydration, meperidine). In both groups, approximately
70 percent of women delivered at ≥36 weeks of gestation. However, this trial was
underpowered, and the findings are not generalizable to the more clinically relevant
population of women with arrested PTL after tocolytic therapy [5].

OUTPATIENT FOLLOW-UP

We schedule an office visit or telephone/telemedicine contact one week after the patient
leaves the hospital and usually weekly thereafter for both singleton and twin
pregnancies. These visits provide an opportunity to discuss signs and symptoms of PTL
and to check for cervical change in the absence of symptoms that may warrant a change
in management. For example, a woman whose cervix was 2 cm dilated on hospital
discharge at 25 weeks but 4 cm dilated on follow-up at 28 weeks may warrant a rescue
course of steroids. (See "Antenatal corticosteroid therapy for reduction of neonatal

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respiratory morbidity and mortality from preterm delivery", section on 'Evidence for
salvage, rescue, booster therapy'.)

In patients who remain stable and have a closed, uneffaced cervix, it may be safe to
resume the usual frequency of prenatal care visits. No data are available.

PHYSICAL ACTIVITIES

Ordinary ambulatory activity — We do not advise bed rest for women with a recent
episode of PTL given the lack of evidence of efficacy in prematurity reduction and the
known significant risks of prolonged immobility [6]. A systematic review found inadequate
evidence either supporting or refuting the use of bed rest at home or in-hospital to
prevent preterm birth in singleton pregnancies at high risk of preterm birth (1 trial, n
>1200 women) [7]. Another systematic review found inadequate evidence to support a
policy of routine hospitalization for bed rest in multiple pregnancy (7 trials, n >700
women) [8]. On the other hand, there is clear evidence that bed rest has potential harms:
It promotes loss of trabecular bone density, increases venous thromboembolism risk,
produces musculoskeletal deconditioning, and places significant psychosocial strain on
individuals and families [9-16].

Exercise — After an episode of suspected preterm labor, we advise women against

lifting greater than 20 pounds but allow them to continue most activities of daily living.

We agree with the general consensus that women at high risk for preterm birth should
limit recreational exercise, particularly strength training and heavy lifting, in pregnancy
[17,18]. This is a prudent approach because most trials of recreational exercise in
pregnancy have excluded women at increased risk for PTL or who developed PTL
during the trial; therefore, it is difficult to assess the effect of recreational exercise on
pregnancy outcome in these women.

Returning to work — We also suggest that women at high risk for preterm birth avoid
returning to work if their work involves working more than 40 hours per week, night
shifts, prolonged standing (eg, more than a total of 8 hours or more than 4 continuous
hours per 24-hour period), and heavy physical work, as this activity level has been
variably associated with PTL and preterm birth [19-22]. However, the effect of
occupational work on preterm birth is difficult to analyze because occupational activities
are complex constructs involving duration of work, shift effects, psychological and
physical stress, lifting (frequency and amount of weight), length of time standing, etc,
and thus cannot readily be characterized in a simple way. (See "Exercise during

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pregnancy and the postpartum period" and "Working during pregnancy" and "Preterm
birth: Risk factors, interventions for risk reduction, and maternal prognosis".)

Sexual activity — We tell patients with an arrested episode of PTL that they should
consider avoiding sexual activity if they experience an increased frequency or intensity of
contractions after sexual intercourse. There is no strong evidence that sexual activity
affects the risk of preterm birth or onset of labor in healthy women. However, it is
theoretically possible that a small subgroup of susceptible women may develop PTL with
sexual activity because both prostaglandins in semen and orgasm can increase
myometrial activity [23-26]. (See "Preterm birth: Risk factors, interventions for risk
reduction, and maternal prognosis", section on 'Coitus'.)

Travel — It is unlikely that car, train, or even airline travel significantly increases the risk
of PTL or preterm birth; however, women who wish to travel need to consider the risk of
pregnancy complications away from their usual source of medical care, as well as the
availability of medical resources and their medical insurance coverage at their
destination [27-30]. (See "Prenatal care: Patient education, health promotion, and safety
of commonly used drugs", section on 'Travel'.)

INEFFECTIVE AND UNPROVEN INTERVENTIONS

Maintenance tocolysis — After acute inhibition of PTL, systematic reviews of

randomized trials have consistently found that, compared with placebo/no treatment,
maintenance tocolysis with nifedipine, terbutaline (orally or via pump), or magnesium
sulfate does not prolong pregnancy, prevent preterm birth, or improve neonatal outcome
[31-34]. However, most trials were small and had study design limitations. Tocolytic
drugs may have a role in providing symptomatic relief with respect to intensity and
frequency of contractions, but the risk of serious adverse events, especially with
prolonged terbutaline pump or magnesium sulfate therapy, outweighs any potential
benefit [35-37].

A randomized trial in over 500 patients that compared atosiban (an oxytocin antagonist)
with placebo for maintenance therapy after an episode of PTL also found that active
therapy did not reduce preterm birth before 28, 32, or 37 weeks of gestation, although
the time to first recurrence of labor was prolonged (33 days with atosiban versus 28 days
with placebo) [38,39].

Antibiotic prophylaxis — There is no convincing evidence of benefit from prophylactic

antibiotic therapy for women with PTL with intact membranes and no evidence of

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infection. In a 2007 systematic review and meta-analysis of randomized trials of

asymptomatic, nonlaboring women at high risk of preterm birth assigned to prophylactic
antibiotic therapy or placebo, antibiotic therapy did not reduce preterm birth, irrespective
of criteria used to assess risk, the antimicrobial agent administered, or the gestational
age at time of treatment [40]. A subsequent meta-analysis of trials of routine antibiotic
prophylaxis in different types of pregnant women (eg, unselected women, women at high
risk of preterm birth by past histories, women who were predominantly HIV positive)
affirmed these findings [41].

Although group B streptococcus (GBS) chemoprophylaxis is recommended for women

with active PTL, it is discontinued once the patient is no longer at imminent risk of
preterm birth, even if the GBS rectovaginal culture is positive, as continued therapy is
not beneficial [42]. Guidelines for GBS prophylaxis are reviewed separately. (See
"Neonatal group B streptococcal disease: Prevention", section on 'Special populations'.)

Initiation of progesterone supplementation — For women who were not candidates

for progesterone supplementation before their episode of suspected PTL, we do not
begin progesterone as an adjunct to tocolysis or as part of maintenance therapy after
resolution of the episode, regardless of cervical length, because available data suggest
that it is not beneficial. The evidence for this approach is reviewed separately. (See
"Progesterone supplementation to reduce the risk of spontaneous preterm birth", section
on 'Treatment or cotreatment of threatened or established preterm labor' and
"Progesterone supplementation to reduce the risk of spontaneous preterm birth", section
on 'Maintenance therapy after threatened preterm labor'.)

Cervical pessary — The first clinical trial to evaluate use of a cervical pessary versus
routine care in women with singleton pregnancies and short cervical length after an
episode of arrested PTL reported a trend in reduction in spontaneous preterm birth <34
weeks (10.7 versus 13.7 percent with routine care, relative risk [RR] 0.78, 95% CI
0.45-1.38) and statistically significant reductions in spontaneous preterm birth <37
weeks (14.7 versus 25.1 percent, RR 0.58, 95% CI 0.38-0.90) and preterm prelabor
rupture of membranes (2.3 versus 8.0 percent, RR 0.28, 95% CI 0.09-0.84); however,
neonatal morbidity and mortality were similar in both groups [43]. These results are
promising, but the number of spontaneous preterm births in the trial was relatively small
(43 <34 weeks, 70 <37 weeks). A subsequent smaller trial, which was halted early for
futility, observed no reduction in preterm birth <32, 34, or 37 weeks [44].

No serious side effects have been reported [45,46]. The major side effect is vaginal
discharge, which occurs in most patients. Nevertheless, until a benefit in neonatal

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outcome is established, we suggest only utilizing pessaries in the context of a clinical

trial. (See "Cervical insufficiency", section on 'Pessary'.)

Antepartum fetal surveillance — After resolution of an episode of suspected PTL, we

do not perform antenatal fetal assessment (nonstress tests, biophysical profile) or serial
ultrasound examinations for fetal growth assessment unless a medical or obstetric
indication exists for these tests. PTL alone is not an indication for antepartum fetal
surveillance since the risk of fetal demise is not increased. (See "Overview of
antepartum fetal surveillance".)

Fetal fibronectin testing — We do not use fetal fibronectin (fFN) testing to monitor
asymptomatic women who are clinically stable after an episode of acute PTL, whether or
not they have had a previous fFN test. There are no studies on the use of fFN testing
after an episode of PTL to further stratify preterm birth risk status and guide
management. (See "Preterm labor: Clinical findings, diagnostic evaluation, and initial
treatment", section on 'Fetal fibronectin for selected patients'.)

Home uterine activity monitoring — We agree with the American College of

Obstetricians and Gynecologists and other expert organizations that recommend not
using home uterine activity monitors to monitor women at increased risk for PTL or
recurrent PTL [47,48]. In a 2017 systematic review and meta-analysis of trials of
standard care with versus without home uterine activity monitoring, the intervention had
no impact on maternal and perinatal outcomes such as perinatal mortality or preterm
birth [49].

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and

regions around the world are provided separately. (See "Society guideline links: Preterm
labor and birth".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to
6th grade reading level, and they answer the four or five key questions a patient might
have about a given condition. These articles are best for patients who want a general
overview and who prefer short, easy-to-read materials. Beyond the Basics patient

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education pieces are longer, more sophisticated, and more detailed. These articles are
written at the 10th to 12th grade reading level and are best for patients who want in-depth
information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you
to print or e-mail these topics to your patients. (You can also locate patient education
articles on a variety of subjects by searching on "patient info" and the keyword(s) of
interest.)

● Beyond the Basics topics (see "Patient education: Preterm labor (Beyond the
Basics)")

SUMMARY AND RECOMMENDATIONS

● Women at 23+0 to 33+6 weeks of gestation anticipated to be at increased risk for

preterm birth in the next seven days should receive an initial course of antenatal
corticosteroids.

Administration of an initial course of antenatal corticosteroids at 34+0 to 36+6 weeks

of gestation is somewhat controversial; however, there is consensus that tocolysis
should not be used to delay delivery for completion of a course of steroids at this
gestational age.

The indications for rescue/salvage/booster therapy are discussed in detail

separately. (See "Antenatal corticosteroid therapy for reduction of neonatal
respiratory morbidity and mortality from preterm delivery".)

● For women who were receiving supplemental progesterone for prevention of

preterm birth because of a history of prior preterm birth or the finding of a
sonographic short cervix, we continue their same regimen of progesterone
supplementation after resolution of an episode of suspected preterm labor (PTL).
(See 'Continuation of progesterone supplementation' above.)

We suggest not newly initiating progesterone therapy as an adjunct to tocolysis or

as part of maintenance therapy after a resolved episode of PTL (Grade 2C).
Treatment does not appear to be effective in this setting. (See "Progesterone
supplementation to reduce the risk of spontaneous preterm birth", section on
'Maintenance therapy after threatened preterm labor'.)

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Many women who are stable after an episode of PTL can be managed as
outpatients, as long as tests of fetal well-being are reassuring and there are no
additional obstetric/medical complications that warrant hospitalization. For patients
with advanced cervical dilation/effacement and/or a history of rapid labor, the travel
time to a hospital with appropriate levels of obstetric and neonatal care services
needs to be considered. (See 'Duration of hospitalization' above.)

● We schedule an office visit or telephone/telemedicine contact one week after the

patient leaves the hospital and usually weekly thereafter to check for symptoms of
recurrent PTL and asymptomatic cervical dilation/effacement. We do not perform
antenatal fetal surveillance testing unless a medical or obstetric indication exists for
these tests. PTL alone is not an indication for antepartum fetal surveillance since the
risk of fetal demise is not increased. (See 'Outpatient follow-up' above and
'Antepartum fetal surveillance' above.)

● We do not advise bed rest for women with a recent episode of PTL given the lack of
evidence of efficacy for prolonging gestation or reducing preterm birth and the
known significant risks of prolonged immobility. They may continue typical activities
of daily living.

We agree with the general consensus that women at high risk for preterm birth
should limit recreational exercise and avoid returning to work if their work involves
working more than 40 hours per week, night shifts, prolonged standing, or heavy
physical work (eg, lifting ≥20 pounds), as this activity level has been variably
associated with PTL and preterm birth. (See 'Ordinary ambulatory activity' above
and 'Exercise' above and 'Returning to work' above.)

● We advise patients with a resolved episode of preterm labor that they should
consider avoiding sexual activity if they experience an increased frequency or
intensity of contractions after sexual intercourse. (See 'Sexual activity' above.)

● It is unlikely that car, train, or airline travel significantly increases the risk of PTL or
preterm birth; however, women who wish to travel need to consider the risk of
pregnancy complications away from their usual source of medical care, the
availability of medical resources, and their medical insurance coverage at their
destination. (See 'Travel' above.)

● Maintenance tocolysis, antibiotic prophylaxis, home uterine monitoring, and

fibronectin testing do not improve outcomes after an episode of arrested preterm
labor. (See 'Ineffective and unproven interventions' above.)

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● In women with a short cervix after an episode of PTL, neither a benefit nor serious
harm from use of a cervical pessary has been established. We suggest only utilizing
pessaries in this setting in the context of a clinical trial. (See 'Cervical pessary'
above.)

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Topic 6795 Version 37.0

Contributor Disclosures
Steve Caritis, MD Grant/Research/Clinical Trial Support: AMAG Pharmaceuticals [Preterm birth
(17-OHPC)]. Hyagriv N Simhan, MD, MS Nothing to disclose Charles J Lockwood, MD,
MHCM Nothing to disclose Vanessa A Barss, MD, FACOG Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found,
these are addressed by vetting through a multi-level review process, and through requirements for
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