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Department of Obstetrics and Gynecology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
Department of Pediatrics, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 13 October 2013
Received in revised form 18 May 2014
Accepted 22 May 2014
Objective: Late preterm prematurity has been related to poorer neonatal outcomes. However, research
has focused on the neonatal outcomes of late preterm infants, maternal characteristics of these births
have been less evaluated. The aim of the study was to compare maternal risk factors and obstetric
complications in late preterm births (LPTB) and term births. These factors were also assessed comparing
spontaneous LPTB with medically-indicated LPTB.
Study design: We conducted a retrospective cohort study with two groups. All singleton LPTB occurred at
our University Hospital between January 1, 2009 and December 31, 2010 were included in the rst cohort
(n = 171). A comparison cohort of term births was congured in a ratio 2:1 (n = 342). Well-dated
pregnancies without congenital malformations, congenital infections or chromosome abnormalities
were eligible. LPTB were classied into two groups, spontaneous LPTB and medically-indicated LPTB
following delivery indications. Statistical analysis of categorical variables was performed using either x2
or Fishers exact. Continuous variables were compared using the Students t-test.
Results: Women with LPTB had more medical conditions than women with term births (29% vs 15.7%;
P = 0.002). Prior preterm births (9.7% vs 2%; P < 0.001), prior adverse obstetric outcomes (6.9% vs 2.3%;
P < 0.001), and obstetric complications were also more frequent in LPTB than in term births. However, no
differences were found in maternal medical conditions when spontaneous LPTB and medically-indicated
LPTB were compared. Women with medically-indicated LPTB were older (33.69 vs 31.07; P = 0.003) and
mainly nulliparous (75.8% vs 49.4%; P = 0.002). Obstetric complications were more frequent in medicallyindicated LPTB than in spontaneous LPTB.
Conclusions: Maternal risk factors and obstetric complications are signicantly higher in LPTB than in
term births. These factors should be considered to identify women at risk for either spontaneous or
medically-indicated LPTB.
2014 Elsevier Ireland Ltd. All rights reserved.
Keywords:
Late preterm birth
Maternal risk factors
Obstetric complications
Prematurity
Introduction
Prematurity rates have increased in recent years mainly due to
an increase in late preterm births (LPTB) [13], dened as births
occurring between 34 0/7 and 36 6/7 weeks. This group currently
represents nearly 75% of preterm births (PTB). Several factors have
been suggested to contribute to the increase in prematurity rates.
One proposed explanation is that changes in maternal factors, such
as the rise of maternal age at pregnancy and assisted reproduction
techniques, may have increased the number of high-risk pregnancies, which are at higher risk of prematurity [2]. Another possible
explanation is that pregnancies at risk for an adverse perinatal
outcome are often delivered before term. This could be due to a
more comprehensive understanding of fetal adaptation mechanisms to threatening situations [4,5]. The enhancements in
obstetric surveillance and neonatal care have also been cited as
partially responsible for the increase in prematurity rates [2].
Late preterm prematurity has been related to poorer neonatal
outcome [69]. Teune et al. [9] performed a systematic review,
comparing neonatal morbidity in LPTB to term births. The
authors reported higher rates of respiratory distress syndrome,
intraventricular hemorrhage, necrotizing enterocolitis and neonatal death in late preterm infants. Long-term outcomes, such as
mortality in the rst year of life, neurological development and
http://dx.doi.org/10.1016/j.ejogrb.2014.05.030
0301-2115/ 2014 Elsevier Ireland Ltd. All rights reserved.
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C.C. Trilla et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 179 (2014) 105109
Fig. 1. Diagram of included and excluded patients. This gure shows the study prole. Causes for patient exclusion are also detailed.
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Table 1
Maternal clinical characteristics of the late preterm and term groups.
Maternal characteristic
Late preterm
(n = 145)
Term (n = 299)
P value
32.19 5.33
31.84 5.10
0.511
Maternal age, (years)a
Nulliparity, n (%)
88 (60.7)
187 (62.5)
0.755
Prior uterine surgery, n (%)
16 (11.1)
24 (8)
0.295
History of preterm birth, n (%)
14 (9.7)
6 (2)
<0.001*
History of adverse obstetric
7 (2.3)
0.031*
10 (6.9)
outcome, n (%)
13 (9)
Articial reproductive
16 (5.4)
0.156
technique, n (%)
47 (15.7)
0.002*
Composite maternal
42 (29)
morbidity, n (%)
Hypertensive disorder, n (%)
4 (2.8)
1 (0.3)
Endocrinological disease, n (%)
11 (7.6)
16 (5.4)
Prothrombotic condition, n (%)
11 (7.6)
5 (1.7)
Congenital heart disease, n (%)
2 (1.4)
1 (0.3)
Infectious condition, n (%)
2 (1.4)
4 (1.3)
Cervical conization, n (%)
1 (0.7)
2 (0.7)
Other, n (%)
16 (11.1)
18 (6)
*
a
107
734 6/7) weeks, 25.6% (n = 40) at 35 (35 0/735 6/7) weeks, and
53.1% (n = 77) at 36 (36 0/736 6/7) weeks.
Maternal clinical characteristics of LPTB and term births are
described in Table 1. No differences were found with regard to
maternal age, parity, ART or prior uterine surgery. History of PTB
and prior adverse obstetric outcome were more frequent in LPTB
than in full-term pregnancies (9.7% vs 2%; P < 0.001, and 6.9% vs
2.3%; P < 0.05, respectively). Composite maternal morbidity rate
was also signicantly higher in women with LPTB (29% vs 15.7%;
P < 0.01). Endocrinological disorders were the most frequent
medical disorders in both LPTB and term groups, followed by
prothrombotic conditions.
The obstetric characteristics of LPTB and term groups are
summarized in Table 2. Rates of all reviewed pregnancy-related
complications were signicantly higher in the LPTB group. IUGR
and intrahepatic cholestasis of pregnancy were the obstetric
complications most frequently observed in LPTB (15.2% and 10.3%,
respectively), whereas gestational diabetes was the most frequent
complication in term births (4.3%). Women who delivered at late
preterm period were more likely to require admission to the High
Risk Obstetric Unit, antenatal corticosteroid and tocolytic treatments. As regards the mode of delivery, more than 40% of late
preterm infants were delivered by caesarean section (42.8% vs
21.4%; P < 0.001).
Composite maternal morbidity, obstetric complications, history
of PTB, prior adverse obstetric outcome and ART were included in
the multivariate analysis. Only composite maternal morbidity (OR
1.86; 95% CI, 1.113.09), obstetric complications (OR 3.83; 95% CI,
2.446.04), and history of PTB (OR 5.08; 95% CI, 1.8014.31),
remained signicantly associated with LPTB (data not showed in
tables).
Of the 145 LPTB analyzed, 57% (n = 83) were spontaneous and
43% (n = 62) were medically-indicated. In the spontaneous group
13 neonates were born at 34 weeks, 27 at 35 weeks, and 43 at 36
weeks. In the medically-indicated group 15 neonates were
delivered at 34 weeks, 13 at 35 weeks, and 34 at 36 weeks.
Distribution by gestational age at delivery showed no differences
between groups (P = 0.207). Medically-indicated LPTB were mainly
due to an obstetric complication, and only two cases occurred
exclusively as a result of a maternal situation (one elective delivery
at 36 weeks in a woman with a high-risk prothrombotic condition,
and one elective delivery at 36 weeks in a woman with severe
gastroenteritis). Three pregnancies were complicated by PPROM
before 34 0/7 weeks (one case at 26 weeks, and two cases at 33
weeks). Conservative management was adopted after excluding
chorioamnionitis, and labour was induced at 34 weeks. These cases
Table 2
Obstetric characteristics of the late preterm and term groups.
Obstetric characteristic
Term (n = 299)
P value
25 (17.4)
24 (16.7)
19 (13.1)
4 (1.3)
1 (0.3)
0 (0)
<0.001*
<0.001*
<0.001*
Obstetric complications
Hypertensive disease, n (%)
Intrauterine growth restriction, n (%)
Intrahepatic cholestasis of pregnancy, n (%)
Gestational diabetes, n (%)
Bleeding in the second half of pregnancy, n (%)
Other, n (%)
11 (7.6)
22 (15.2)
15 (10.3)
14 (9.7)
7 (4.8)
10 (6.9)
6 (2)
5 (1.7)
2 (0.7)
13 (4.3)
4 (1.3)
26 (8.7)
0.007*
<0.001*
<0.001*
0.035*
0.045*
0.582
Mode of delivery
Vaginal delivery, n (%)
Operative vaginal delivery, n (%)
Caesarean section, n (%)
83 (57.2)
18 (21.7)
62 (42.8)
235 (78.6)
77 (32.7)
64 (21.4)
<0.001*
<0.001*
<0.001*
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108
C.C. Trilla et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 179 (2014) 105109
Table 3
Maternal clinical characteristics of the spontaneous and medically-indicated LPTB.
Spontaneous
LPTB (n = 83)
31.07 5.18
Maternal age, (years)a
Nulliparity, n (%)
41 (49.4)
Prior uterine surgery, n (%)
12 (14.5)
History of preterm birth, n
9 (10.8)
(%)
History of adverse obstetric
5 (6)
outcome, n (%)
Articial reproductive
7 (8.4)
technique, n (%)
21 (25.3)
Composite maternal
morbidity, n (%)
1 (1.2)
Hypertensive disorder, n (%)
Endocrinological disease, n
6 (7.2)
(%)
4 (4.8)
Prothrombotic condition, n
(%)
1 (1.2)
Congenital heart disease, n
(%)
2 (2.4)
Infectious condition, n (%)
Cervical conization, n (%)
0 (0)
Other, n (%)
10 (12)
*
a
Obstetric characteristic
Spontaneous
LPTB (n = 83)
Medicallyindicated LPTB
(n = 62)
12 (14.6)
13 (21)
0.003*
0.002*
0.181
0.777
5 (8.1)
0.582
6 (9.7)
21 (33.9)
3 (4.8)
4 (6.5)
7 (11.3)
1 (1.6)
0 (0)
1 (1.6)
6 (9.7)
0.273
13 (15.9)
13 (15.7)
Obstetric complications
0 (0)
Hypertensive disease, n (%)
Intrauterine growth restriction,
2 (2.4)
n (%)
Intrahepatic cholestasis of
1 (1.2)
pregnancy, n (%)
Gestational diabetes, n (%)
6 (7.2)
Bleeding in the second half of
2 (2.4)
pregnancy, n (%)
2 (2.4)
Other, n (%)
Mode of delivery
Vaginal delivery, n (%)
67 (80.7)
Caesarean section, n (%)
16 (19.3)
*
Our study showed that women with LPTB had more medical
disorders, mainly endocrinological and prothrombotic conditions.
However, no differences were observed when spontaneous and
medically-indicated LPTB were compared. We have also identied
other maternal risk factors highly associated with LPTB. According
to our data, the rate of prior PTB was up to 5-fold higher in LPTB,
corroborating ndings from previous studies assessing recurrence
of PTB [14]. However, no differences were noted in prior PTB rate
when we compared spontaneous and medically-indicated LPTB.
The rate of ART was similar in LPTB and term births. One possible
explanation for this nding is that we only included singleton
pregnancies, and risk of prematurity in pregnancies achieved
through ART is mainly associated with multiple pregnancies.
According to our results, prior PTB, history of adverse obstetric
outcome, and the presence of maternal medical conditions were
equally associated with spontaneous and medically-indicated
LPTB. This suggests these factors are not suitable to distinguish
women at risk for spontaneous LPTB from women at risk for
medically-indicated LPTB. As expected, the risk of developing
Maternal characteristics
Table 4
Obstetric characteristics of the spontaneous and indicated LPTB.
P value
0.377
11 (17.7)
6 (9.7)
0.823
0.330
11 (17.7)
20 (32.3)
<0.001*
<0.001*
14 (22.6)
<0.001*
8 (12.9)
5 (8.1)
0.270
0.138
8 (12.9)
0.019*
<0.001*
16 (25.8)
46 (74.2)
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C.C. Trilla et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 179 (2014) 105109
109
practice guidelines should insist on maternal clinical characteristics for a thorough identication of patients at risk for LPTB.
Better assessment of both maternal and fetal risks of obstetric
complications at late preterm period is needed.
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