FIGO good practice recommendations for reducing preterm birth and improving child outcomes

In this issue of International Journal of Gynecology & Obstetrics, the FIGO (International Federation of Gynecology and Obstetrics) Working Group for Preterm Birth provides nine FIGO good practice recommendations. The project started and developed from the FIGO Working Group meetings in London, December 2019, and at the Society of Maternal Fetal Medicine meeting in Dallas, February 2020. The idea was to try to highlight the most important lowhanging fruits for reducing preterm births and improving child outcomes after preterm birth. Each document was drafted initially by selected Working Group members and discussed on multiple occasions. Consensus was reached as to the breadth and depth necessary for healthcare providers and FIGO member societies. Materials used to construct the recommendations include those from WHO, governmental healthcare agencies, professional societies, and global collaborative networks (e.g. Cochrane). The Working Group naturally sought randomized clinical trials in highimpact peerreviewed journals, and robust analysis. The latter included literature based on aggregate data, but ideally individual patient data. When consensus was reached, Working Group recommendations were in alignment with FIGO policy. Documents were stratified into three categories with recommendations provided: populationbased registries1– 3; prevention by maternal treatment4– 6; and fetal treatment imminent to delivery.7– 9


| P OPUL ATI ON -BA S EDPRE VENTI ON OFPRE TERMB IRTH
The FIGO Working Group for Preterm Birth recognizes that reducing preterm birth at the population level requires the ability to track changes in the general population to determine frequency and causes known to be associated with preterm birth. Useful data must be accessible, accurate, and timely. Three FIGO Working Group recommendations address population-based methods for preterm birth prevention. [1][2][3] Frøen, Bianchi, Moller, and Jacobsson 1 speak for the Working Group in advocating not only universal healthcare coverage but also sustained access to quantitative preventive strategies to fulfill the global Sustainable Development Goals for women's, children's and adolescents' health. 10 The authors recommend strengthening health information systems to ensure timely access to actionable highquality data. This good practice recommendations document states that "every individual counts and should be counted individually", in particular mother-child dyads, from pre-conception to pediatrics, and later in life. A second recommendation calls for strengthening investments in digital registries, enabling integration with reproductive, maternal, newborn, and child health services adhering to targeted WHO recommendations.
In a second good practice recommendations document, Valencia, Mol, and Jacobsson 2 address the 30%-35% of preterm deliveries believed to be iatrogenic-related. The Working Group recommends efforts to identify the contribution of iatrogenic preterm delivery to the overall preterm birth rate and encourages health authorities to establish preventive measures accordingly. For example, achieving a reduction in preterm deliveries is also possible by reducing cesarean deliveries, given the later risk of related pregnancy complications (e.g. uterine rupture or placenta accreta). The document also recommends avoiding multiple embryo transfers in assisted reproductive technologies (ART). Once considered necessary in order to achieve an acceptable pregnancy rate, there is less need at present for multiple embryo transfer to achieve suitable pregnancy rates.
Single embryo transfer (SET) is now recommended: 50%-60% pregnancy rates can be achieved with SET accompanied by ancillary diagnostic tests. A third recommendation calls for access to adequate pregnancy dating and clinical practice guidelines that minimize nonmedically-indicated preterm delivery.
The topic of the third FIGO good practice recommendations document in the population category has already been alluded to-namely, the reduction of preterm births by SET in ART. Mol, Jacobsson, Grobman, and Moley 3 acknowledge that ART has enabled infertile couples to achieve pregnancy. SET is, as previously noted, 2 recommended as the best approach to ensure a healthy neonate. Nevertherless, even a singleton ART pregnancy carries more complications than a singleton pregnancy after spontaneous conception; FIGO recommends that couples and individuals should be advised of this. Minimal embryo manipulation during cell culture is also recommended. Attention is called to the increased risks of birth defects (odds ratio 1.3), and increased rate of pregnancy complications in ART. The extent to which these increases reflect the underlying reason for infertility will require investigation and communication with patients.

| MATERNALTRE ATMENTTOPROLONG G E S TATI O N
The second set of good practice recommendations deals with therapeutically extending gestational length to decrease preterm birth rate. [4][5][6] This strategic approach has existed for decades. One topical

| OBS TE TRIC ALMANAG EMENT IMMINENTTODELIVERYOFNEONATE
The third category of approaches to reduce preterm birth involves obstetrical management imminent to preterm delivery. Speaking on behalf of the Working Group, Norman, Shennan, Jacobsson and Stock reviewed RCTs that encompassed 27 trials involving administration of betamethasone, dexamethasone or hydrocortisone; control arms received either no treatment or placebo. 7 Significant benefit was seen in reduction of perinatal death, respiratory distress (RR 0.58, 95% CI 0.45-0.75), and necrotizing enterocolitis (0.50; 95% CI 0.32-0.97) (15). The FIGO Working Group recommended that when active neonatal care was appropriate, prenatal corticosteroid should be administered to the mother between 24 + 0/7 and 34 + 0/7 weeks in a singleton pregnancy. This recommendation held also for multiple pregnancies. Administration of corticosteroids was not recommended routinely for women imminent for preterm birth between 34 + 0/7 to 36 + 6/7 weeks or for elective cesarean delivery at term. Dosage recommendations were made: two intramuscular 12 mg doses of betamethasone acetate/phosphate 24 h apart, or two intramuscular 12 mg doses of dexamethasone 24 h apart. The Working Group reviewed inconsistencies between the ACT Cluster randomized clinical trial, 15 which failed to reduce neonatal mortality, and the ACTION trial, 16 which did show benefit, and clarified that prenatal corticosteroid should be also used in a low-resource setting.
An important recommendation is also that prenatal corticosteroids should not be given "just in case", but reserved for women for women with an imminent preterm birth delivery based on the woman's symptoms or an accurate predictive test.
Working Group authors Shennan, Suff, and Jacobsson addressed the value of administration of magnesium sulfate for fetal neuroprotection. 8 This good practice recommendations document emphasizes that 25% of cerebral palsy cases occur before 34 weeks, implying correlation with preterm birth. The Working Group agreed with Cochrane reviews, 17 concluding that cerebral palsy was reduced (RR 0.68; 95% CI 0.54-0.87) when MgSO 4 was administered before 34 weeks. MgSO 4 was recommended from viability to 30 weeks.
If resources allow, MgSO 4 can be considered from viability to 34 weeks, and should be administered within 24 h of delivery and as close to 4 h before delivery as possible. The recommended initial dose of MgSO 4 is 4-6 g, followed by 1 g/h intravenous maintenance thereafter. Monitoring clinical signs is necessary at least every 4 h: pulse, blood pressure, respiratory rate, and deep tendon reflexes.
Bianchi, Jacobsson, and Mol authored the good practice recommendations for delayed umbilical cord clamping. 9 A thorough rationale is provided. Improved neonatal hematologic indices and reduced hospital mortality have been shown when performed at various timelines (<34 weeks; <28 weeks). The Working Group concluded, however, that insufficient evidence exists to set a precise duration of delay, but current evidence supports not clamping the cord before 30 s for preterm births. Future trials could compare different lengths of delay. Until then, a period of 30 s to 3 min seems justified for term-born babies.