Evidence
Report on the Management of Preterm Labor
Funded by the Agency for Healthcare Research and Quality (AHRQ,
formerly AHCPR) under Contract Number 290-97-0011, Task Order No. 4
Period of Performance: September 30, 1998 to January 10, 2000
Publications
The following publication resulted from this task:
Berkman ND, Thorp JM, Jr., Hartmann KE, Lohr KN, Idicula AE, McPheeters
M, Gavin NI, Carey TS, Tolleson-Rinehart S, Jackman AM, Hasselblad
V, Puckett EC. Management of Preterm Labor. Volume 1. Evidence
Report and Appendices. Volume 2. Evidence Tables. Evidence Report/Technology
Assessment No. 18. AHRQ Publication No. 01-E012. Rockville, Md. Agency
for Healthcare Research and Quality, December 2000.
The full report may be downloaded: www.ahrq.gov/clinic/evrptfiles.htm
A summary report is available: www.ahrq.gov/clinic/pretermsum.htm
All evidence reports are published by AHRQ as part of its series of
evidence reports and are available from the Agency in Rockville, MD
(www.ahrq.gov/clinic/epcix.htm).
Overview
RTI, in collaboration with the five health professions schools and the
Cecil G. Sheps Center for Health Services Research at the University
of North Carolina (UNC), operates the RTI-UNC Evidence-based Practice
Center (EPC) for the Agency for Healthcare Research and Quality, or
AHRQ (formerly, AHCPR). AHRQ sponsored this task order to develop an
evidence report that examines effective strategies for identifying,
treating, and monitoring women with preterm labor. The topic was nominated
by the American College of Obstetricians and Gynecologists (ACOG).
The evidence report focuses on four main clinical questions: (1) the
appropriate criteria for diagnosing preterm labor, specifically with
respect to the use of three biologic markers and their positive and
negative predictive value; (2) the efficacy and effectiveness of tocolytics
(pharmaceutical agents that arrest preterm labor symptoms); (3) the
efficacy and effectiveness of antibiotics (with respect to covert infections
that might prompt preterm labor); and (4) efficacy of home uterine activity
monitoring (a device used to detect uterine contractions that may not
be discernable by the mother).
Specifically, the RTI/UNC EPC investigated three biologic markers:
fetal fibronectin (fFN), endovaginal ultrasound (EVUSD), and salivary
estriol; because of a lack of relevant studies on the last-named, the
review focused only on fFN and EVUSD. Also studied were five classes
of tocolytics: beta-mimetics, calcium channel blockers, magnesium sulfate,
nonsteroidal anti-inflammatory agents (NSAIDs) and ethanol. Tocolytic
studies were further subdivided based on whether treatment was used
as a first-line regimen (while a woman was experiencing uterine contractions
considered to be symptoms of preterm labor) or maintenance therapy (treatment
following an episode of preterm labor to maintain uterine quiescence).
The numerous antibiotics were reviewed as one group. Lastly, we reviewed
the literature on home uterine activity monitoring for women in preterm
labor.
Approach
The RTI/UNC EPC conducted an exhaustive review of the literature published
in English, French, and German. Included were studies in which women
were considered by the authors to be in preterm labor. The definition
of preterm labor varied across studies. Studies in which all of the
subjects had preterm premature rupture of membranes, medically indicated
preterm delivery, or multiple gestations were excluded.
The work included the following steps:
- identifying and working with a Technical Expert Advisory Group
(TEAG) for guiding the project
- refining key clinical questions and creating causal pathways to
guide the literature searches
- developing a formal literature search strategy based on explicit
inclusion and exclusion criteria
- abstracting data from selected articles and other materials ("gray
literature") using data abstraction instruments created specifically
for the project
- reviewing, critiquing and grading the body of literature
- developing "bubble charts" of the frequency and severity
of harms of the pharmacologic interventions resolving differences
in findings and interpretation of results
- conducting meta-analyses on first-line tocolytics, maintenance
tocolytics, antibiotics and home uterine activity monitoring literatures
using an appropriate subsample of randomized controlled trials included
in the review
- creating evidence tables and a draft evidence report
- revising the draft report following extensive external peer review
by a panel of experts
- developing separate reports to advise AHRQ on recommendations for
future research and how best to ensure that all relevant professional
groups, researchers, and other interested parties learn of these findings
- preparing a manuscript for submission to a peer-reviewed general
medical journal.
Findings
Full report
has been posted on the AHRQ web site.
A summary is
also available on the AHRQ web site.
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URL: http://www.rti.org/epc/preterm.html
Revised: March 22, 2001
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