Management, Utilization, and Outcomes of Preterm Labor in an Integrated Health Care System

Abstract

Objective Fetal fibronectin (fFN) testing and transvaginal ultrasound (TVUS) are diagnostic tools used to predict impending spontaneous preterm birth (sPTB) among women presenting with preterm labor (PTL). We evaluated the association between fFN testing or TVUS cervical length (CL) measurement in predicting sPTB, respiratory distress syndrome (RDS), neonatal intensive care unit (NICU) admission, and sPTB-related costs.

Study Design We conducted a retrospective cohort study using data from the Kaiser Permanente Southern California electronic health system (January 1, 2009–December 31, 2020) using diagnostic and procedure codes, along with a natural language processing algorithm to identify pregnancies with PTL evaluations. PTL evaluation was defined as having fFN and/or TVUS assessment. Outcomes were ascertained using diagnostic, procedural, and diagnosis-related group codes. Multivariable logistic regression assessed the association between fFN and/or TVUS results and perinatal outcomes.

Results Compared with those without PTL evaluations, those with positive fFN tests had higher adjusted odds ratio (adj.OR) for sPTB (2.95, 95% confidence interval [CI]: 2.64, 3.29), RDS (2.34, 95% CI: 2.03, 2.69), and NICU admission (2.24, 95% CI: 2.01, 2.50). In contrast, those who tested negative had lower odds for sPTB (adj.OR: 0.75, 95% CI: 0.70, 0.79), RDS (adj.OR: 0.67, 95% CI: 0.61, 0.73), and NICU admission (adj.OR: 0.74, 95% CI: 0.70, 0.79). Among those with positive fFN results, the odds of sPTB was inversely associated with CL. Health care costs for mothers and neonates were lowest for those with fFN testing only.

Conclusion This study demonstrates that positive fFN results were associated with an increased odds of sPTB, RDS, and NICU admission and the association with sPTB was inversely proportional to CL. Additionally, negative fFN results were associated with decreased odds of sPTB, RDS, and NICU admissions. fFN testing may predict these and other sPTB-related adverse outcomes hence its utility should be explored further. Moreover, fFN testing has some cost savings over TVUS.

Key Points

• Patients with positive fFN tests had higher odds of sPTB, RDS, and NICU admission.

• Inverse relationship between sPTB and CL among those with positive fFN tests was observed.

• Health care costs for mothers and neonates were lowest for those with fFN testing only.

Keywords

preterm labor - fetal fibronectin - transvaginal ultrasound - preterm birth - respiratory distress syndrome - neonatal intensive care - natural language processing

Publication History

Received: 31 January 2024

Accepted: 24 March 2024

Article published online:
07 May 2024

• References

• 1 March of Dimes. 2022 March of Dimes Report Card. , United States. 2022 . Accessed on September 15, 2023 at: https://www.marchofdimes.org/report-card
• 2 Hamilton BE, Martin JA, Osterman MJ, Curtin SC, Matthews TJ. Births: Final Data for 2014. National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System 2015; 64: 1-64
• 3 Goldenberg RL, Jobe AH. Prospects for research in reproductive health and birth outcomes. JAMA 2001; 285 (05) 633-639
• 4 Getahun D, Rhoads GG, Demissie K. et al. In utero exposure to ischemic-hypoxic conditions and attention-deficit/hyperactivity disorder. Pediatrics 2013; 131 (01) e53-e61
• 5 Ferré C, Callaghan W, Olson C, Sharma A, Barfield W. Effects of maternal age and age-specific preterm birth rates on overall preterm birth rates - United States, 2007 and 2014. MMWR Morb Mortal Wkly Rep 2016; 65 (43) 1181-1184
• 6 Braveman PA, Heck K, Egerter S. et al. The role of socioeconomic factors in Black-White disparities in preterm birth. Am J Public Health 2015; 105 (04) 694-702
• 7 Martin JA, Hamilton BE, Osterman MJK. Births in the United States, 2018. NCHS Data Brief 2019; (346) 1-8
• 8 Demissie K, Rhoads GG, Ananth CV. et al. Trends in preterm birth and neonatal mortality among blacks and whites in the United States from 1989 to 1997. Am J Epidemiol 2001; 154 (04) 307-315
• 9 Slattery MM, Morrison JJ. Preterm delivery. Lancet 2002; 360 (9344) 1489-1497
• 10 Ananth CV, Getahun D, Peltier MR, Smulian JC. Placental abruption in term and preterm gestations: evidence for heterogeneity in clinical pathways. Obstet Gynecol 2006; 107 (04) 785-792
• 11 Getahun D, Fassett MJ, Longstreth GF. et al. Association between maternal inflammatory bowel disease and adverse perinatal outcomes. J Perinatol 2014; 34 (06) 435-440
• 12 Peltier MR, Fassett MJ, Arita Y. et al. Women with high plasma levels of PBDE-47 are at increased risk of preterm birth. J Perinat Med 2020
• 13 Kramer MS, Goulet L, Lydon J. et al. Socio-economic disparities in preterm birth: causal pathways and mechanisms. Paediatr Perinat Epidemiol 2001; 15 (Suppl. 02) 104-123
• 14 Savitz DA, Blackmore CA, Thorp JM. Epidemiologic characteristics of preterm delivery: etiologic heterogeneity. Am J Obstet Gynecol 1991; 164 (02) 467-471
• 15 Peltier MR, Koo HC, Getahun D, Menon R. Does exposure to flame retardants increase the risk for preterm birth?. J Reprod Immunol 2015; 107: 20-25
• 16 Ananth CV, Getahun D, Peltier MR, Salihu HM, Vintzileos AM. Recurrence of spontaneous versus medically indicated preterm birth. Am J Obstet Gynecol 2006; 195 (03) 643-650
• 17 Adams MM, Elam-Evans LD, Wilson HG, Gilbertz DA. Rates of and factors associated with recurrence of preterm delivery. JAMA 2000; 283 (12) 1591-1596
• 18 Ananth CV, Peltier MR, Getahun D, Kirby RS, Vintzileos AM. Primiparity: an ‘intermediate’ risk group for spontaneous and medically indicated preterm birth. J Matern Fetal Neonatal Med 2007; 20 (08) 605-611
• 19 Centers for Disease Control and Prevention (CDC). State-specific variation in rates of twin births–United States, 1992-1994. MMWR Morb Mortal Wkly Rep 1997; 46 (06) 121-125
• 20 Haight SC, Hogue CJ, Raskind-Hood CL, Ahrens KA. Short interpregnancy intervals and adverse pregnancy outcomes by maternal age in the United States. Ann Epidemiol 2019; 31: 38-44
• 21 Andersen SL, Olsen J, Wu CS, Laurberg P. Low birth weight in children born to mothers with hyperthyroidism and high birth weight in hypothyroidism, whereas preterm birth is common in both conditions: a Danish National Hospital Register Study. Eur Thyroid J 2013; 2 (02) 135-144
• 22 Wing DA, Fassett MJ, Getahun D. Acute pyelonephritis in pregnancy: an 18-year retrospective analysis. Am J Obstet Gynecol 2014; 210 (03) 219.e1-219.e6
• 23 Getahun D, Ananth CV, Oyelese Y, Peltier MR, Smulian JC, Vintzileos AM. Acute and chronic respiratory diseases in pregnancy: associations with spontaneous premature rupture of membranes. J Matern Fetal Neonatal Med 2007; 20 (09) 669-675
• 24 ACOG Committee on Practice Bulletins. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologist. Number 43, May 2003. Management of preterm labor. Obstet Gynecol 2003; 101 (5 Pt 1): 1039-1047
• 25 Honest H, Bachmann LM, Gupta JK, Kleijnen J, Khan KS. Accuracy of cervicovaginal fetal fibronectin test in predicting risk of spontaneous preterm birth: systematic review. BMJ 2002; 325 (7359) 301
• 26 Navathe R, Saccone G, Villani M. et al. Decrease in the incidence of threatened preterm labor after implementation of transvaginal ultrasound cervical length universal screening. J Matern Fetal Neonatal Med 2019; 32 (11) 1853-1858
• 27 Berghella V, Baxter JK, Hendrix NW. Cervical assessment by ultrasound for preventing preterm delivery. Cochrane Database Syst Rev 2013; 2013 (01) CD007235
• 28 Crane JM, Hutchens D. Transvaginal sonographic measurement of cervical length to predict preterm birth in asymptomatic women at increased risk: a systematic review. Ultrasound Obstet Gynecol 2008; 31 (05) 579-587
• 29 Leitich H, Egarter C, Kaider A, Hohlagschwandtner M, Berghammer P, Husslein P. Cervicovaginal fetal fibronectin as a marker for preterm delivery: a meta-analysis. Am J Obstet Gynecol 1999; 180 (05) 1169-1176
• 30 American College of Obstetricians and Gynecologists. Committee Opinion No 700: Methods for estimating the due date. Obstet Gynecol 2017; 129 (05) e150-e154
• 31 Koebnick C, Langer-Gould AM, Gould MK. et al. Sociodemographic characteristics of members of a large, integrated health care system: comparison with US Census Bureau data. Perm J 2012; 16 (03) 37-41
• 32 Xie F, Khadka N, Fassett MJ. et al. Identification of preterm labor evaluation visits and extraction of cervical length measures from electronic health records within a large integrated health care system: algorithm development and validation. JMIR Med Inform 2022; 10 (09) e37896
• 33 Andrade SE, Scott PE, Davis RL. et al. Validity of health plan and birth certificate data for pregnancy research. Pharmacoepidemiol Drug Saf 2013; 22 (01) 7-15
• 34 Smith N, Iyer RL, Langer-Gould A. et al. Health plan administrative records versus birth certificate records: quality of race and ethnicity information in children. BMC Health Serv Res 2010; 10: 316
• 35 Getahun D, Rhoads GG, Fassett MJ. et al. Accuracy of reporting maternal and infant perinatal service system coding and clinical utilization coding. J Med Stat Inform 2013; 1: 3 . Accessed April 16, 2024 at: http://www.hoajonline.com/medicalstat/2053-7662/1/3
• 36 Berghella V, Saccone G. Fetal fibronectin testing for prevention of preterm birth in singleton pregnancies with threatened preterm labor: a systematic review and metaanalysis of randomized controlled trials. Am J Obstet Gynecol 2016; 215 (04) 431-438
• 37 Lucovnik M, Chambliss LR, Garfield RE. Costs of unnecessary admissions and treatments for “threatened preterm labor”. Am J Obstet Gynecol 2013; 209 (03) 217.e1-217.e3
• 38 American College of Obstetricians and Gynecologists. Medically indicated late-preterm and early-term deliveries: ACOG Committee Opinion, Number 818. Obstet Gynecol 2021; 137 (02) e29-e33
• 39 Spong CY, Mercer BM, D'Alton M, Kilpatrick S, Blackwell S, Saade G. Timing of indicated late-preterm and early-term birth. Obstet Gynecol 2011; 118 (2 Pt 1): 323-333