RTI-UNC Evidence-based Practice Center
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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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