Preterm Labour: Managing Risk in Clinical Practice
http://www.100md.com
《新英格兰医药杂志》
Preterm births have continued to increase despite years of research into the causes, epidemiology, and management of preterm labor. In the United States, the rate of preterm births now exceeds 12 percent. There are many hypotheses to explain this increase. Assisted reproductive technology has contributed to a substantial increase in multiple gestations. As compared with singletons, multiples are at higher risk for early delivery and are disproportionately represented among infants born extremely preterm. Another contributing factor is the willingness of obstetricians to elect delivery of infants of women in whom medical, fetal, or obstetrical complications occur preterm. The majority of cases of iatrogenic prematurity occur after 32 weeks of gestation, when neonatal outcomes are generally favorable. Regardless of the cause, the burden of prematurity for the infant, the family, and health care systems and society is enormous. Preterm infants are at risk for immediate complications, including severe respiratory distress, intraventricular hemorrhage, necrotizing enterocolitis, and sepsis. Among survivors, particularly those born extremely premature, the consequences can extend into a lifetime.
Norman and Greer, in their textbook Preterm Labour, have attempted to summarize the risk factors, biology, treatment, and outcomes of women in preterm labor. They have solicited chapters from experts in obstetrics, pediatrics, anesthesiology, epidemiology, and law, in the United Kingdom and Ireland. Generally, the chapters are succinct, well written, and informative. Those on the biology and genetics of prematurity are exceptional. The review of neonatal outcomes, with the emphasis on family counseling and the active participation of parents in decision making, is important. The data presented will be particularly helpful to physicians in small units, where site-specific outcome data may be based on only a few cases.
The chapters on the prevention and treatment of preterm labor, premature rupture of the membranes, and specific complications are less insightful. The editors' goal was to provide evidence-based practice guidelines, but there are insufficient data from large, randomized, controlled trials to establish the benefits of any particular therapy to prevent preterm birth — or, more important, to improve neonatal outcomes. I think that the controversy regarding therapy, including the limitations of making treatment recommendations on the basis of consensus, could have been developed further in the book.
The authors appear to be enthusiastic regarding the use of new technology, including assays for fetal fibronectin and transvaginal ultrasonography, to identify women at risk. Although both of these techniques may enhance the identification of such women, the purported benefit is the identification of those who are not destined to deliver preterm, thus avoiding the use of potentially hazardous therapies. The other major limitation to this approach is the lack of proven benefit from interventions to reduce preterm birth in women with risk factors.
The last three chapters, which discuss the use of resources and the medicolegal issues involved in perinatal medicine, have limited generalizability to physicians beyond the United Kingdom and Ireland. However, they are well written, and they highlight the universal complexity for physicians in dealing with potentially conflicting responsibilities to the mother and the fetus, as well as the legal and moral issues surrounding abortion.
Norman and Greer have done an admirable job of summarizing the issues involved in preterm labor and the management of the care of preterm infants. The book is easy to read and offers an international perspective, which I found particularly interesting.
Debra Ann Guinn, M.D.
Northwest Perinatal Center
Portland, OR 97229
dguinn@whallc.com(Edited by Jane Norman and)
Norman and Greer, in their textbook Preterm Labour, have attempted to summarize the risk factors, biology, treatment, and outcomes of women in preterm labor. They have solicited chapters from experts in obstetrics, pediatrics, anesthesiology, epidemiology, and law, in the United Kingdom and Ireland. Generally, the chapters are succinct, well written, and informative. Those on the biology and genetics of prematurity are exceptional. The review of neonatal outcomes, with the emphasis on family counseling and the active participation of parents in decision making, is important. The data presented will be particularly helpful to physicians in small units, where site-specific outcome data may be based on only a few cases.
The chapters on the prevention and treatment of preterm labor, premature rupture of the membranes, and specific complications are less insightful. The editors' goal was to provide evidence-based practice guidelines, but there are insufficient data from large, randomized, controlled trials to establish the benefits of any particular therapy to prevent preterm birth — or, more important, to improve neonatal outcomes. I think that the controversy regarding therapy, including the limitations of making treatment recommendations on the basis of consensus, could have been developed further in the book.
The authors appear to be enthusiastic regarding the use of new technology, including assays for fetal fibronectin and transvaginal ultrasonography, to identify women at risk. Although both of these techniques may enhance the identification of such women, the purported benefit is the identification of those who are not destined to deliver preterm, thus avoiding the use of potentially hazardous therapies. The other major limitation to this approach is the lack of proven benefit from interventions to reduce preterm birth in women with risk factors.
The last three chapters, which discuss the use of resources and the medicolegal issues involved in perinatal medicine, have limited generalizability to physicians beyond the United Kingdom and Ireland. However, they are well written, and they highlight the universal complexity for physicians in dealing with potentially conflicting responsibilities to the mother and the fetus, as well as the legal and moral issues surrounding abortion.
Norman and Greer have done an admirable job of summarizing the issues involved in preterm labor and the management of the care of preterm infants. The book is easy to read and offers an international perspective, which I found particularly interesting.
Debra Ann Guinn, M.D.
Northwest Perinatal Center
Portland, OR 97229
dguinn@whallc.com(Edited by Jane Norman and)