UH OB Network MLC 4 Clinical Practice Guideline
Indicated Pre-Term Birth
Purpose of Guidelines:
To reduce elective preterm birth by better defining indications for indicated preterm birth.
These guidelines are adapted from the 2011 SMFM guidelines for indicated preterm birth
which were based on the understanding that for some maternal and fetal diagnoses,
preterm birth optimizes pregnancy outcome. Given the unique situations individual
patients present with, the evidence to help determine the best timing for delivery may be
difficult to find and generalize. These guidelines for common conditions are based on
SMFM review of available evidence and expert opinion. These are guidelines, and do not
apply to every patient.
Scope of Policy:
Clinical Personnel
Grade of Recommendations:
Grade of recommendations are based on the following: recommendations or conclusions
or both are based on good and consistent scientific evidence. (A) limited or inconsistent
scientific evidence (B) primarily consensus and expert opinion (C) the recommendations
regarding expeditious delivery for imminent fetal jeopardy were not given a grade. The
recommendations regarding severe preeclampsia is based largely on expert opinion;
however, higher-level evidence is not likely to be forth coming because this condition is
believed to carry significant maternal risk with limited potential fetal benefit from expectant
management after 34 wks.
Conditions:
Grade of Recommendation:
Placental and Uterine Issues:
 Placenta Previa (stable):
36-37 wk:
B
 Suspected placenta accrete, increta,
34-35 wk:
B
or perceta with placenta previa
 Prior classical cesarean (upper segment 36-37wk:
B
uterine incision)
 Prior myomectomy necessitating
37-38 wk:
B
Cesarean delivery (may require earlier delivery, similar to prior classical cesarean, in situations with more
extensive or complicated myomectomy)
INDICATED PRE-TERM BIRTH GUIDELINES
Owner: Mac Action Team
Origin & Approval Date: 12/21/2011
Revised: 11/15
Page 1 of 4
Uncontrolled document – printed version only reliable for 24 hours
Conditions:
Fetal Issues:
 Fetal growth restriction-singleton
Grade of Recommendation:
38-39 wk:
B
 Otherwise uncomplicated, no concurrent findings
34-37 wk:
 Concurrent conditions (oligohydramnios, abnormal Doppler
studies, maternal risk factors, co-morbidity)
Expeditious delivery regardless of gestational age:
 Persistent abnormal fetal surveillance suggesting imminent fetal
jeopardy
Fetal Issues:
 Fetal growth restrictions-twin gestation
36-38wk:
B
 Dichorionic-diamniotic twins with isolated fetal
growth restriction
32-36 wk:

Monochorionic-diamniotic twins with isolated
fetal growth restriction (depending on
severity of IUGR
32-34 wk:

Concurrent conditions (oligohydramnios, abnormal
Doppler studies, maternal risk, co-morbidity)
Expedious delivery regardless of gestational age:
 Persistent abnormal fetal surveillance suggesting
imminent fetal jeopardy
 Fetal congenital malformations:
34-39wk:
B
 Suspected worsening of fetal organ damage
 Potential for fetal intracranial hemorrhage (eg, vein of
Galen aneurysm, neonatal alloimmune thrombocytopenia)
 When delivery prior to labor is preferred (eg, EXIT procedure)
 Previous fetal intervention
 Concurrent maternal disease (eg, preeclampsia, chronic




 Multiple gestations: dichorionic-:
diamniotic
 Multiple gestations: monochorionic-:
diamniotic
hypertension)
Potential for adverse maternal effect from fetal condition
Expedious delivery regardless of gestational age:
When intervention is expected to be beneficial
Fetal complications develop (abnormal fetal surveillance,
new-onset hydrops fetalis, progressive or new onset organ
injury)
Maternal complications develop (eg mirror syndrome)
38wk:
B
34-37wk:
B
INDICATED PRE-TERM BIRTH GUIDELINES
Owner: Mac Action Team
Origin & Approval Date: 12/21/2011
Revised: 11/15
Page 2 of 4
Uncontrolled document – printed version only reliable for 24 hours
Conditions:
Fetal Issues:
 Multiple gestations: dichorionicdiamniotic or monochorionicdiamniotic with single fetal death
 Multiple gestations: monochorionicdiamniotic
Conditions:
 Multiple gestations: monochorionicmonoamniotic with single fetal death
 Oligohydramnios-isolated and
persistent
Grade of Recommendation:
B
If occurs at or after 34 wk, consider delivery
(recommendation limited to pregnancies at or after 34 wk;
if occurs before 34 wk, individualize based on
concurrent maternal or fetal conditions)
34-36 wk:
B
Grade of Recommendation:
B
Consider delivery; individualized according to gestational
age and concurrent complications
36-37 wk:
Maternal Issues:
 Chronic hypertension-no medication
38-39 wk:
 Chronic hypertension-controlled on
37-39 wk:
medication
 Chronic hypertension-difficult to control 36-37 wk:
(requiring frequent medication adjustments)
 Gestational hypertension
37-39 wk:
 Preeclampsia-severe
B
B
B
B
B
C
At diagnosis (recommendation limited to pregnancies at
or after 34 wk)
 Preeclampsia-mild
37 wk:
B
 Diabetes-pregestational well
B
Controlled
*delivery prior to 39 wks not recommended
 Diabetes-pregestational with
37-39 wk: B
vascular disease
 Diabetes-pregestational, poorly controlled 34-39 wk: B (individualized to situation)
 Diabetes-gestational well controlled
B
on diet
* delivery prior to 39 wks not recommended
 Diabetes-gestational well controlled
B
on medication
*delivery prior to 39 wks not recommended
 Diabetes-gestational poorly controlled
34-39 wk: B (individualized to situation)
on medication
Obstetric Issues:
 Prior stillbirth-unexpected
*delivery prior to 39 wks not recommended
(Consider amniocentesis for fetal pulmonary
B
C
maturity if delivery planned at less than 39 wk)
 Spontaneous preterm birth: preterm
premature rupture of membranes
34 wk:
INDICATED PRE-TERM BIRTH GUIDELINES
Owner: Mac Action Team
Origin & Approval Date: 12/21/2011
Revised: 11/15
Page 3 of 4
Uncontrolled document – printed version only reliable for 24 hours
B (recommendation limited to
pregnancies at or after 34 wk)
Conditions:
Grade of Recommendation:
Obstetric Issues:
 Spontaneous preterm birth: active
preterm labor
C (delivery if progressive labor or
additional maternal or fetal
indication)
 * Gestational age is in completed weeks; thus, 34 wks includes 34 0/7 wks through 34 6/7 wks.
References:
Modified from : American College of Obstetrics and Gynecologists Vol. 118, No. 2, Part 1, August 2011
Spong et al: Timing of Indicated Late-Preterm and Early-Term Birth
Nancy J. Cossler, M.D.
Chief, System Quality for Obstetrics
University Hospitals
Linda Wildey, RN, MSN, NE-BC
Director, Women and Perinatal Services
University Hospitals
REVISION ELECTRONICALLY APPROVED: 11/11/2015
REVISION EFFECTIVE DATE: 12/7/2015
INDICATED PRE-TERM BIRTH GUIDELINES
Owner: Mac Action Team
Origin & Approval Date: 12/21/2011
Revised: 11/15
Page 4 of 4
Uncontrolled document – printed version only reliable for 24 hours