Optimising maternal-fetal outcomes in preterm labour: a decision analysis.
OBJECTIVE
To compare, using decision analytic techniques, maternal and fetal risk and benefits of three strategies for the management of preterm labour after 32 weeks. These strategies are empiric tocolysis, no tocolysis, or amniocentesis for fetal maturity testing.


METHODS
Published medical literature provided the probabilities, including those for tocolysis efficacy, maternal and neonatal outcomes, and steroid efficacy.


METHODS
Synthesis Separate decision trees were created for hypothetical cohorts of patients presenting with preterm labour at 32, 34, and 36 weeks of gestation to compare strategies. The primary outcome was the total number of expected adverse maternal and neonatal events for each strategy at each gestational age.


RESULTS
At 32 weeks tocolysis yielded the lowest total number of adverse maternal and neonatal events. At 34 weeks, both tocolysis and no tocolysis yielded similar overall outcomes. At 36 weeks most clinical outcomes were good regardless of strategy.


CONCLUSIONS
This analysis supports the empiric use of tocolytics at 32 weeks. At 34 weeks, either tocolysis or no tocolysis appear to be reasonable alternatives. At 36 weeks no tocolysis is probably preferred. This analysis also suggests that amniocentesis should not be employed in the management of preterm labour at these gestational ages.
Macones
G A
GA
Department of Obstetrics and Gynaecology, University of Pennsylvania School of Medicine, Philadelphia, USA.
Bader
T J
TJ
Asch
D A
DA
D000649:Amniocentesis; D003663:Decision Trees; D036861:Delivery, Obstetric; D005260:Female; D006801:Humans; D007752:Obstetric Labor, Premature / Q000628:therapy*; D011247:Pregnancy; D011256:Pregnancy Outcome; D011263:Pregnancy Trimester, Third; D012312:Ritodrine / Q000009:adverse effects; D012680:Sensitivity and Specificity; D013997:Time Factors; D015149:Tocolytic Agents / Q000009:adverse effects
D015149:Tocolytic Agents; D012312:Ritodrine