Managing Preterm Labor in Multiple Gestations
Treating the Whole Patient
Not infrequently, preterm labor in a multiple gestation pregnancy requires the prolonged hospitalization of the mother, who may be a busy professional woman or the parent of other small children. Spending 5–10 weeks in a hospital is a long, frustrating time, replete with boredom and anxiety.
At my institution, a clinical nurse specialist who was concerned with the psychosocial effect of hospitalization on the women in our unit proposed what has become a highly successful multidimensional program: Mom Matters. The program offers support, diversion, and empathy in the form of wheelchair outings, Internet access, flexible visitation for family members (including children), manicures, pedicures, movies, and get-togethers.
The success of our program and the gratitude expressed by the mothers on our service have convinced me that this is a kind and therapeutic approach worth considering and implementing elsewhere.
The Future
The road to safe and effective therapy for preterm labor has been a long and frustrating one. I am hopeful that researchers are now on the right track, focusing on subtle indications of infection and other potential causes of preterm labor.
In multiple gestations, of course, preterm labor is often caused simply because there are too many fetuses in the womb. Uterine overdistension will not be an easy problem to overcome, except by reducing multiple gestations. Many of our colleagues in reproductive endocrinology have gotten the message that implanting too many embryos is unwise and unethical.
I believe that in the coming years, we will gain a better understanding of organic causes of preterm labor, permitting us to customize therapy according to individual circumstances of each pregnancy.
A twin pregnancy at 25 weeks' gestation shows discordancy for fetal size. The patient presented in preterm labor and will be followed closely. Courtesy Dr. Washington Hill
A Practical Perspective on a Complicated Problem
The health of any country is judged by the survival of its infants. The United States spends 15% of its gross national product on health care, yet it ranks 21st in the world in its infant mortality rate of 8 deaths per 1,000 live births, according to the World Health Organization. The two main contributors to this death rate are prematurity and birth defects.
Aggressive research programs are aimed at trying to understand the pathophysiology of preterm birth, and clinical interventions have been introduced in an attempt to reduce this unacceptably high rate of preterm birth.
Washington Clark Hill, M.D., the guest expert for the Master Class this month, has long studied preterm labor in the context of both singleton and multiple gestations. He has published comprehensive overviews of research on the complications of tocolysis and the prevention and treatment of preterm labor.
A graduate of Temple University School of Medicine in Philadelphia, Dr. Hill did his residency training at William Beaumont Army Medical Center in El Paso, Tex., before completing a fellowship in maternal-fetal medicine at the University of California, San Francisco.
He is director of the perinatal center and the division of maternal-fetal medicine at the Sarasota (Fla.) Memorial Hospital. Dr. Hill brings a clinical and practical perspective to this complicated problem. His insights will allow us to disentangle fact from fiction and what works from what doesn't.
