Hospitalization for Preterm Labor

Abstract & Commentary

By John C. Hobbins, MD, Professor and Chief of Obstetrics, University of Colorado Health Sciences Center, Denver, is Associate Editor for OB/GYN Clinical Alert

Dr. Hobbins reports no financial relationship to this field of study.

Synopsis: Compared with hospitalization, outpatient management of women with arrested preterm labor and intact membranes had no effect on the rate of preterm birth.

Source: Yost NP, et al. Hospitalization for women with arrested preterm labor: a randomized trial. Obstet Gynecol. 2005;106:14-18.

There is a strong tendency today to continue to hospitalize patients diagnosed to have arrested preterm labor. A randomized trial was designed to answer the question of whether this practice was necessary, and the results were recently published in the July issue of Obstetrics and Gynecology.

Yost and colleagues randomized 108 women who were admitted with painful preterm contractions at 24 to 33 weeks gestation and with cervical dilation of 2-4 centimeters. All women were given steroids, but not started on tocolytics. One group (54) was discharged with a prescription for decreased activity (but not bedrest). Hospitalization was continued until 34 weeks in the other group.

There was no difference in the time of delivery (36 vs 36.5 weeks), pregnancy prolongation (38.6 days vs 37 days), or percentage that reached 36 weeks (71% vs 70%) between nonhospitalized and hospitalized patients. Interestingly, 15 patients (29%) left the hospital against medical advice after an average of 10 days.

Yost et al’s conclusion was that continued hospitalization had no benefit, but they admitted that they stopped the study prior to achieving the statistical power to conclusively demonstrate the lack of efficacy of hospitalization. They terminated the study because:

  1. It took 6 years to recruit the patients in the study, and it might take another 4 years to complete the study.
  2. There was no difference in outcome.
  3. They needed to move on to another study to assess the benefit of progesterone in prolonging pregnancy.

Commentary

In a companion editorial, Robert Goldenberg, one of the leading experts on clinical trials, pointed out that the study was underpowered statistically, and even suggested that it might have been doomed from the start.1 However, although he indicated that the data should do little "to influence care," he then went on to allude to other evidence that hospitalization, bedrest, and even "intense maternal observation" have failed to demonstrate benefit in other preterm labor studies; and, in one study, the intensely observed patients even had a higher rate of respiratory distress syndrome (compared to the controls).

For years, it was in vogue to restrict the activity of patients with twins, and many practitioners were even advocating bedrest in the latter stages of pregnancy for these patients.2-4 However, pooled data from randomized trials, pitting hospitalized twin patients’ outcomes with those of controls pursuing ad-lib activity, suggest a higher rate of preterm birth and prolonged neonatal stays in twins on bed rest.

Some will question whether adding tocolytics would have made a difference in the study results. However, there has not been a study to demonstrate the benefit of tocolytics, except perhaps to prolong pregnancy long enough to get steroids on board.

What is quite clear is that hospitalization is extremely expensive. In a previous OB/GYN Clinical Alert, I indicated that one day of hospitalization on our antepartum service had a baseline cost of about $900.5 This has now risen to about $1,700. The average stay for the hospitalized patients in the above study was 30 days, so the average total cost of just occupying a bed for those patients would have been $51,000 per patient. Although Dallas Hospital costs may be less than ours, this alone would have been enough to stop the study when Yost et al found no difference in outcome after 6 years.

References

  1. Goldenberg RL. Arrested preterm labor: do the data support home or hospital care? Obstet Gynecol. 2005;106:3-5.
  2. Sosa C, et al. Bed rest in singleton pregnancies for preventing preterm birth. The Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003581. DOI: 10.1002/14651858.CD003581.pub2.
  3. Hobel CJ, et al. The West Los Angeles Preterm Birth Prevention Project I. Program impact on high-risk women. Am J Obstet Gynecol. 1994;170:54-62.
  4. Goulet C, et al. A randomized clinical trial of care for women with preterm labour: home management versus hospitalized management. CMAJ. 2001;164:985-991.
  5. Hobbins J. Does cervicovaginal fetal fibronectin really play a role in the diagnosis of preterm labor? OB/GYN Clinical Alert. 2005;22:17-18.