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Fetal Fibronectin Testing for Suspected Preterm Labour An emerging standard of care (Note: Please feel free to use your own background design)

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Presentation on theme: "Fetal Fibronectin Testing for Suspected Preterm Labour An emerging standard of care (Note: Please feel free to use your own background design)"— Presentation transcript:

1 Fetal Fibronectin Testing for Suspected Preterm Labour An emerging standard of care (Note: Please feel free to use your own background design)

2 Fetal Fibronectin Testing for Suspected Preterm Labour Objectives Discuss incidence of preterm labour provincially and nationally Describe the benefits of fetal fibronectin testing Outline insert province approach to this emerging standard of care Provide detailed clinical decision making and procedures for fFN testing

3 Preterm Labour (< 37 weeks) 1 in 5 pregnant women exhibit signs and symptoms of preterm labour. 3-4 % of births occur before 34 weeks Up to 70% of women identified as “high- risk” deliver at term. Maximum clinical judgment sensitivity for del <1week from admission was <50% with minimal cervical dilatation (< 3 cm.).

4 Preterm Birth Preterm birth rate is defined as the number of live births with a gestational age less than 37 weeks completed weeks gestation >7.6% (all Provinces) of all pregnancies result in preterm birth Sources: ACOG Technical Bulletin,1995, No. 206; National Vital Statistics Report 2000;48(3). St John EB et al. Am J Obstet Gynecol. 2000;182:170-175. Macones, Am J ObGyn, Vol 181, 12/99

5 Rate of Preterm Delivery by Province/Territory (excluding Ontario) 2000

6 Add own provincial data

7 The Challenge… The preterm birth rate has not decreased in the last thirty years!!!

8 Source: CPSS Report 2003 p. 74 20 percent increase

9 How do we identify who is at Risk? Risk Factors Cervical Length Fetal Fibronectin Symptoms of PTL Preterm Birth

10 Tocolytics Education Targeting High Risk Women Bedrest Home Uterine Monitoring Frequent Digital Exam HydrationPopulation Based strategies Prevention/Intervention Strategies

11 Risk Assessment Markers Biophysical markers Measurement of cervical length Biochemical markers Fetal fibronectin (fFN) Salivary estriol (E 3 ) Corticotropin-releasing hormone (CRH) Interleukin-6 (IL-6)

12 Potential Benefits of An Evidence- Based, Risk Assessment Marker Identify women who are truly at risk. Identify and reassure women who are not at risk. Avoid separation of mother from her family. Avoid unnecessary expense of extended assessment time, admission time, transport to a tertiary centre. Avoid unnecessary tocolytic and steriod use. Improved resource utilization. Potential research benefits e.g. focus tocolytic trials on women who will potentially benefit.

13 Fetal Fibronectin (fFN) is not new in obstetrics practice 1 st literature appeared in 1985; as an oncogene marker. 1 st OB-specific literature appeared in 1991 in New England J. of Medicine by Lockwood, et al. >200 peer reviewed OB articles now published, 3 meta analyses, 9 Canada-specific abstracts presented at SOGC. Canada specific data documents reduced medication use, reduced hospital day stays, reduced transports Canadian data is from level III hospitals, rural and remote hospitals. Fetal Fibronectin ( ƒ FN)

14 What is Fetal Fibronectin (ƒFN) Glycoprotein found in extracellular matrix of amniotic membranes. Binds chorion to decidua. Normally found in cervico-vaginal secretions until 22 weeks gestation and again near the time of labour. Released into cervical/vaginal fluid in response to inflammation or separation of amniotic membranes from decidua. Presence after 24 weeks is indicative of imminent labour Fetal (ƒFN) immunoassay detects concentrations of fetal fibronectin protein in cervicovaginal fluids. Presence of >50 ng/mL considered positive.

15 Fetal Fibronectin (ƒFN)

16 Normal ƒFN Expression by Gestational Age

17 Key Terminology for Evaluating PTD Diagnostics Negative Predictive Value (NPV): Answers the question, “If a woman has a negative test, how likely is she NOT to deliver prematurely?” Positive Predictive Value (PPV): Answers the question, “If a woman has a positive test, how likely is she to deliver prematurely?” Sensitivity: Percent of women who have preterm delivery whom the test correctly identifies Specificity: Percent of women who do NOT have preterm delivery whom the test correctly identifies

18 Utility of ƒFN for Predicting PTB in Symptomatic Women PPV(%) NPV(%) Cx Dilatation(cm) Lockwood, 1991 (n=117) 83 81 None Morrison, 1993 (n=28) 64 93  1 Iams, 1995 (n=192) 60 76  3 Burrus, 1995 (n=37) 79 63  3 Bartnicki, 1996 (n=112) 79 83  2 Peaceman, 1997 (n=725) 43 87  3

19 1/125 Deliver <14 days Women with Threatened Preterm Labour (1/25 deliver <14 days ) ƒFN - (80%) ƒFN + (20%) 1/6 Deliver <14 days Peaceman, AJOG 1997; 177:13-8

20 Nova Scotia Pilot Study April 2002-March 2004 (Armson & Scott et. al.) Prospective cohort study Objectives To determine if introduction of rapid ƒFN testing for suspected PTL will: 1. Reliably predict preterm birth 2. Result in a reduction of: - PTL admissions/maternal transfer rates - length of stay, tocolytic/corticosteroid use - reproductive health care costs without compromising neonatal outcomes

21 Conclusions from Nova Scotia Study A negative ƒFN test for suspected PTL accurately identifies women not likely to deliver within 14 days (98% -99% accurate) A positive ƒFN test identifies women at high risk for preterm birth - 24%  7 days - 28%  14 days - 31%  34 weeks - 48%  37 weeks Diagnostic accuracy of ƒFN superior to clinical criteria for women with suspected preterm labour

22 Conclusions from Nova Scotia Study Criteria for clinical use of ƒFN appear to be broad and inconsistent Clinicians/patients somewhat reluctant to adhere to guidelines of non-intervention for negative ƒFN results, particularly in regional centres. Potential for reduction in maternal transfers, hospital admissions and associated health care costs

23 Results from the Nova Scotia Study Implementation of province-wide Fetal Fibronectin testing currently ongoing Seed funding provided by NS Department of Health Goals To reduce unnecessary maternal transfers and admissions for suspected preterm labour To reduce psychosocial and financial burdens for families

24 BC Study Fetal Fibronectin collected by speculum exam from admitted patients with symptomatic preterm labour Assays were performed in our laboratory. The results were revealed to the clinician within 1 – 8 hours A retrospective chart review was undertaken to assess pregnancy outcome An estimate of the total hospital days saved was developed using the ALOS for patients admitted with a diagnosis of PTL prior to the utilization of the Fetal Fibronectin Assay

25 Of 62 patients tested, outcomes were known for 47 patients. Delivered < 14 days Delivered > 14 days FFN +ve 17 FFN –ve 138 Sensitivity = 50% PPV = 12.5% Specificity = 84% NPV = 97% Results Farquharson, D., Lee, L.,Garg, A. Clinical utilization and cost saving analysis of fetal fibronectin assay in a tertiary care institution. Abstracted presented at 2003 SOGC meeting, Charlottetown.

26 BC Study Results A total of 62 assays were conducted between May 2002 and March 2003 Ages 18 – 39, mean 30 GA on admission: 20 – 33 weeks Length of stay ranged 1 – 44 days, mean 4.7 days Nulliparas: 55 % Multiparas: 45 %

27 BC Study Conclusion Our experience in which Fetal Fibronectin Assay (Adeza TLI) was used as an adjunct to diagnosis and management of preterm labour suggest reduced hospital utilization, and earlier reverse transfer of these patients to their referring institutions without adverse sequelae.

28 Cost Savings (literature) Reduction in PTL admissions $486,000 saved (Joffe et al, AJOG 1999) Reduction in maternal transfers $30,297 saved (Giles et al, AJOG 2000)

29 Resource Utilization - Canada Royal Victoria Hospital Observational cohort design 20 week periods before and after ƒFN Singletons, 24-34 weeks, suspected PTL Abenhaim JOGC 2005; 27:689-94

30 _________________________________________________________ Baseline Period Study Period p value _________________________________________________________ Patients 116 116 Preterm Births9 (7.8%) 10 (8.6%)NS PTL Admissions 28 (24.1%) 14 (12.1%)0.02 Days Hospitalized145 28 Mean LOS5.2 0.60.01 Admission Costs$102,660 $26,169 Mean Cost$3,666 $5810.01 Abenhaim, JOGC 2005; 27:689-94 Effect of ƒFN on Resource Utilization

31 Considerations Cost:  Approximately $100+ per test  Patient demand – not experienced by other centres  Physician overuse  Estimate 20 -25 per years based on 2500 births/yr  Close adherence to guideline Savings  Cost of admission  Cost of transfer  Optimal use of tertiary beds  Maternal/family reassurance/satisfaction

32 Fetal Fibronectin Decision-Making Algorithm Network organizations will facilitate a supportive environment for adoption of CHN Practice Guidelines by incorporating the guidelines into their existing guideline process (order sets, intranet availability, etc). Network organizations will identify a “champion” to take the lead in ensuring implementation of the guideline at the organization. The CHN guideline will proceed through the organizational process for “approval” (MAC, Pharmacy, etc). Education sessions will be provided for staff. CHN will provide a Power Point Presentation for organizational use. CHN will monitor implementation through a variety of methods and report to members (surveys, chart audits, etc). Patient <34 wks Gestation with Symptoms of Preterm Labour Speculum exam before VE fFN swab from posterior fornix (see Appendix A) Cultures Management of PROM Discard fFN swab Evidence of Ruptured Membrane s Intact Membranes Vaginal Examination Cx ≥ 3 cm Dilation Regular uterine activity Diagnosis preterm labour Treat for preterm labour Discard fFN swab Send fFN swabReassure mother Discard fFN swab Cx < 3 cm dilated Ongoing uterine activity Clinical suspicion of preterm labour Cx Long + closed Contractions subsided No clinical evidence of preterm labour Positive Treat for preterm labour Tocolytics Corticosteroids Antibiotics Consider transfer to appropriate level of care Negative Reassure mother F/U endovaginal ultrasound of the cervix (if available) Treatment of BV Consider repeat test in 7-14 days, if symptomatic  Regular uterine contractions >6 per hour  Pelvic pressure  Low abdominal pain and/or cramps  Low backache Fetal Fibronectin Guideline for Use in the Management of Preterm Labour Practice Guideline June 2006 Background A guideline addressing the use of the Fetal Fibronectin (fFN) test for women in preterm labour was recommended by members of the Child Health Network for the Greater Toronto Area during the 2004-06 operating plan consultation process. Members of the Maternal Newborn Task Force believed that the test had the potential to avert maternal transfers from regional and community hospitals and optimize the use of tertiary antenatal and neonatal beds. It was also expected that admissions to both community and regional hospitals could be also be reduced as physicians could be assured that mothers with a negative fFNtest would not deliver their babies within 14 days.. The original draft was developed by an expert panel[1] and will be distributed for comment and input. The final guideline will be developed after discussion of the comments from the membership of the Network.[1] Implementation of the guideline will follow the approved process for guideline implementation as determined by the Board of Directors in December 2002. Briefly, the following steps will be followed during the implementation of the guideline throughout the Network: Introduction Fetal Fibronectin (fFN) is a glycoprotein produced by the chorionic membranes and is localized to the deciduas basalis adjacent to the intervillous space. Its primary purpose appears to be that of an adhesion molecule (tissue glue) which helps bind the chorionic membranes to the underlying maternal decidua. It is normally found in cervico-vaginal secretions until 22 weeks gestation but is virtually never found between 24 and 34 weeks gestation unless the cervix has undergone premature effacement and dilatation, usually in association with symptomatic uterine contractions. It can also be released in response to inflammation or separation of amniotic membranes from the deciduas. There is a strong association between the presence of Fetal Fibronectin in cervico-vaginal secretions and preterm labour after 24 weeks gestation. Expert Panel Discussion/Literature Review The expert panel reviewed the literature[2] provided in the package provided by the CHN. Trials have shown an association between the presence of fFN and preterm birth as well as a decrease in the risk of preterm birth when tests are negative for the presence of fFN. The literature was judged to be conclusive for the negative predictive value of the fFN test. A negative test confers a more than 95% likelihood of the woman remaining undelivered for the 14 days following a negative test result.[2] The Expert Panel heard a presentation from Dr. Ford Luk, chief of obstetrics from York Central Hospital, who presented results on 35 women who had received the test at York Central and showed similar negative predictability reported in the literature as well as cost savings from the reduced admissions to the antenatal and birthing unit. This small sample of experience from the GTA was helpful for the Expert Panel to consider. Additional literature reflecting Canadian experience with the Fetal Fibronectin Test confirmed the utility and predictive value of the test. Agreement to proceed with the recommendation for use of fFN in Network Hospitals was reached. The following are the recommendations of the Panel: Purpose of the Fetal Fibronectin Test: The purpose of testing for Fetal Fibronectin in women with symptoms of premature labour is to: 1.Prevent unnecessary admissions to community, regional and tertiary hospitals 2.Prevent unnecessary transfers of mothers with symptoms of preterm labour to tertiary or regional centres 3.Decrease the numbers of out-of-region transfers 4.Decrease costs associated with an admission to a tertiary (or community and regional hospital) especially those related to a stay in the birthing unit 5.Provide reassurance to mothers and their families that birth of their baby prematurely is highly unlikely within fourteen days of the onset of symptoms when the test is negative. General Recommendations:[3][3] 1.All women presenting in the Emergency Department or Birthing Unit with one or more signs/symptoms of threatened preterm labour ( Figure 1) should have a mandatory consult with a obstetrician who will perform an assessment of the patient and may order the test. Figure 1 Signs of Threatened Preterm Labour NOTE: PRIOR TO ANY VAGINAL EXAMINATION, A SPECULUM EXAM SHOULD BE DONE AND THE SWAB FOR FETAL FIBRONECTIN OBTAINED. THE DECISION TO SEND THE SWAB FOR TESTING CAN BE MADE ONCE THE PATIENT PHYSICAL ASSESSMENT IS COMPLETE. 1.Indications for Testing  Intended transfer of women between 24 and 34 completed weeks to a tertiary unit or regional unit, for example, i.Threatened preterm labour (Figure 1) ii.Intact amniotic membranes iii.Cervix <3 cm dilatation iv.Established fetal well-being  Intended admission of women between 32 and 34 completed weeks to a community or regional hospital with the above symptoms of preterm labour  Intended administration of antenatal corticosteroids 1.Contraindications for Testing  Estimated gestational age (EGA) 34 completed weeks  Preterm rupture of membranes (PROM)  Cervix ≥3 cm dilatation  Cervical cerclage  Active vaginal bleeding  Vaginal exam or sexual intercourse in the past 24 hours 2.Specimen Collection  Use only the ADEZA Fetal Fibronectin Kit i.Equipment required includes the swab, collection tube, tube cap, test cartridge and instrument based system to perform the fFN test.  Collect specimen during a speculum exam with special fFN swab using an unlubricated speculum  Speculum exam must occur before vaginal ultrasound, before digital examination and without the use of lubricants (all can alter predictability of the test)  If any of the above exams have taken place, wait 24 hours and then obtain the test  If test cannot be performed within 8 hours of collection, refrigerate specimen until test is performed  Perform test within 3 days of specimen collection NOTE:Once the swab has been obtained, if subsequent physical exam does not indicate that there are sufficient signs of preterm labour (or if other contraindications are present i.e., ruptured membranes, cervical dilatation > 3 cm, etc.), the swab should be discarded and the test NOT performed 1.Test Results  Positive ≥ 50 ng/ml  Negative ≤ 50 ng/ml 2.Factors Affecting Accuracy of the Test  False positive tests may be caused by: i.Digital exam prior to the speculum collection of the sample ii.More than a minimal amount of blood in the specimen (fFN is present in plasma) iii.The presence of amniotic fluid in the specimen(amniotic fluid contains high levels of fFN) iv.Intercourse within the previous 24 hours (fFN is present in seminal fluid)  False negative tests may be caused by: i.Presence of a lubricant on the speculum 3.Positive Test Result  Indicates a higher risk of preterm delivery  Consider: i.Admission or transfer of the woman to an appropriate facility for treatment of preterm labour and possible delivery of a preterm baby 1.<32 weeks – Tertiary centre 2.≥32 weeks – Level 2 or Level 2+ centre ii.Administration of tocolytics and/or corticosteroids as indicated 4.Negative Test Result  Indicates that delivery will not take place within 7-14 days (>95% accuracy)  Discharge home with instructions to return if symptoms worsen and limit activities that aggravate her symptoms if geographical, weather and other medical circumstances permit  Close follow up care may include a vaginal ultrasound to assess cervical length (If cervical length is >2.5 cm it provides further reassurance that delivery will not occur preterm) +/- a swab for bacterial vaginosis.  Re-evaluate in 7-14 days 5.Patient Education  The purpose and function of the test should be explained to each patient in order to decrease ‘patient demand” for the test in subsequent weeks Evaluation/Audit An audit tool monitoring the following parameters will be submitted to the Maternal/Newborn Task Force of the CHN for a quarterly report on the use and reliability of the test as well as the impacts on the CHN perinatal system. The following indicators will be monitored: 1.The number of fFN tests performed by organization, level of care and as a whole 2.The number of negative/positive tests recorded 3.The number of transfers of others to network hospitals for the diagnosis of premature labour 4.The number of transfers avoided through negative test results 5.Estimated cost of the test to the system (# of tests performed multiplied by the cost of the test) 6.Estimated savings to the system days avoided by use of test) 7.Patient days for admission for preterm labour and compare to retrospective patient days in previous year prior to implementation of the fFN test Flowchart Fetal Fibronectin Testing for Suspected Preterm Labour References: 1.Abenhaim HA, Morin L, Benjamin A. Does Availability of Fetal Fibronectin Testing in the Management of threatened Preterm Labour Affect the Utilization of Hospital Resources? J Obstet Gynaecol Can 2005;27(7):689-694. 2.ACOG Practice Bulletin. Assessment of Risk Factors for Preterm Birth. October 2001 3.Anderson HF. Use of Fetal fibronectin in Women at Risk For Preterm labor. Clinical obstetrics and Gynecology;43(4):746-58. 4.Armson BA, Dodds L, Dooley K, Howlett A, McPhee A, Scott H. Fetal Fibronectin Testing for Suspected Preterm labour in Nova Scotia. Am J Obstet Gynecol 2004;191:S115 5.British Columbia Reproductive Care Program. Obstetric Guideline – Preterm Labour. February 2005 6.Colombo DF. Predicting spontaneous preterm birth. BMJ 2002;325:289-90. 7.Farquharson, D, Skoll A. Fetal Fibronectin. BCRCP Perspectives, Winter 2004 8.Garite TJ, Casal D, Garcia-Alonso A, Kreadon US, Jimenez G, Ayala JA, Reimbold T. Fetal fibronectin: A new tool for the prediction of successful induction of labor. Am J Obstet Gynecol 1996;175:1516-21. 9.Giles W, Bisits A, Knox M, Madsen G, Smith R. The effect of fetal fibronectin testing on admissions to a tertiary maternal-fetal medicine unit and cost savings. Am J Obstet Gynecol 2000;182:439-42. 10.Goldenberg RL, Iams JD, Das A, Mercer BM, Meis PJ, Moawad Ah, Miodovnik M, VanDorsten JP, Caritis SN, Thurnau, Dombrowski MP, Roberts JM, McNellis D. The Preterm Predeiction Study: Sequential cervical length and fetal fibronectin testing for the prediction of spontaneous preterm birth. Am J Obstet Gynecol 2000;182:636-43. 11.Goldenberg RL, Mercer BM, Iams JD, Moawad AH, Meis PJ, Das A, McNellis D, Miodovnik M, Menard MK, Caritis SN, Thurnau GR, Bottoms SF. The preterm prediction study: Patterns of cervicalvaginal fetal fibronectin as predictors of spontaneous preterm delivery. Am J Obstet Gynecol 1997; 177:8-12. 12.Honest H, Bachmann LM, Gupta JK, Kleijen J, Khan KS. Accuracy of cervicvaginal fetal fibronectin test in predicting risk of spontaneous preterm birth: systematic review. BMJ 2002;325:301-11. 13.Iams JD. Prediction and Early Detection of Preterm Labor. Obstet Gynecol 2003;101:402-12. 14.Iams JD, Casal D, McGregor JA, Goodwin TM, Kreadon US, Lowensohn R, Lockitch G. Fetal fibronectin improves the accuracy of diagnosis of preterm labor. Am J Obstet Gynecol 1995;173:141-5. 15.Joffe GM, Jacques D, Bemis-Heys R, Burton R, Skram B, Shelburne P. Impact of the fetal fibronectin assay on admissions for preterm labour. Am J Obstet Gynecol 1999;180:581-6. 16.Lopez RL, Francis JA, Garite TJ, Dubyak JM. Fetal fibronectin detection as a predictor of preterm birth in actual clinical practice. Am J Obstet Gynecol 2000;182:1103-6. 17.Lowe MP, Zimmerman B, Hansen W. Prospective randomized controlled trial of fetal fibronectin on preterm labor management in a tertiary care center. Am J Obstet Gynecol 2004;190:358-62. 18.Macones GA, Segal SY, Stamilio DM, Morgan MA. Prediction of delivery among women with early preterm labor by means of clinical characteristics alone. Am J Obstet Gynecol 1999;181:1414-8. 19.Meis PJ, Goldenberg RL, Mercer BM, Iams JD, Moawad AH, Miodovnik M, Menard K, Caritis SN, Thurneau GR, Bottoms SF, Das A, Roberts JM, McNellis D. The preterm prediction study: Risk factors fro indicated preterm births. Am J Obstet Gynecol 1998;178:562-7. 20.Mozurkewich EL, Naglie G, Krahn MD, Hayashi RH. Predicting preterm birth: A cost-effective analysis. Am J Obstet Gynecol 2000;182:1589-98. 21.Peaseman AM, Andrews WW, Thorp JM, Cliver SP, Lukes A, Iams JD, Coultrip L, Erikson N, Holbrook H, Elliot J, Ingardia C, Pietrantoni M. Fetal fibronectin as a predictor of preterm birth in patients with symptoms: A multicenter trial. Am J Obstet Gyncol 1997;177:13-18. 22.Plaut MM, Smith W, Kennedy K. Fetal fibronectin: The impact of a rapid test on the treatment of women with preterm labor symptoms. Am J Obstet Gynecol 2003;188:1588-95 23.Reis FM, Gervasi MT, Florio P, Bracalente G, Fadalti M, Severi FM, Petragalia F. Prediction of successful induction of labor at term: Role of clinical history, digital examination, ultrasound assessment of the cervix and fetal fibronectin assay. AmJ Obstet Gynecol 2003;189:1361-7 24.Rozenberg P, Goffinet F, Hessabi M. Comparison of the Bishop score, ultrasonographically measured cervical length and fetal fibronectin assay in predicting time until delivery and type of delivery at term. Am J Obstet Gynecol 2000;182:108-13. APPENDIX 1 Expert Panel on Fetal Fibronectin Members Dr. Tony AddisonObstetricianWilliam Osler Health Centre Dr. Jon BarrettObstetricianSunnybrook & Women’s Dr. Tatiana Friere-LizamatObstetrician St. Michael’s Hospital Dr. Mathias GyslerChief of ObstetricsCredit Valley Hospital Ms. Kathryn Hayward MurrayNursing DirectorCredit Valley Hospital Ms. Nazira JafferDirectorNorth York General Hospital Ms. Moya JohnsonClinical AdvisorChild Health Network Dr. Terry LogaridisChief of ObstetricsRouge Valley Health System Dr. Fork LukChief of ObstetricsYork Central Hospital Dr. Nan OkunObstetricianMount Sinai Hospital Dr. Andrew ShennanVP Perinatal ServicesSunnybrook & Women’s Dr. Nick ShilettoObstetricianNorth York General Hospital Dr. Jonathan TolkinMedical AdvisorChild Health Network Dr. Rory WindrimObstetricianMount Sinai Hospital Dr. Suzanne WongDeputy Chief of ObstetricsSt. Joseph’s Health Centre Tony WongLaboratoryYork Central Hospital [1][1] Appendix 1 – Members of CHN Expert Panel Fetal Fibronectin Test Guideline [2][2] See References for a complete list of literature used by the Expert Panel. [3][3] Based on BC Reproductive Care Guideline on Management of Preterm Labour see Reference # 5 Patient <34 wks Gestation with Symptoms of Preterm Labour Speculum exam before VE fFN swab from posterior fornix (see Appendix A) Cultures Management of PROM Discard fFN swab Evidence of Ruptured Membranes Intact Membranes Cx ≥ 3 cm Dilation Regular uterine activity Diagnosis preterm labour Treat for preterm labour Discard fFN swab Send fFN swabReassure mother Discard fFN swab Cx < 3 cm Dilated Ongoing uterine activity Clinical suspicion of preterm labour Cx Long + Closed Contractions subsided No clinical evidence of preterm labour Positive Treat for preterm labour -Tocolytics -Corticosteroids -Antibiotics Consider transfer to appropriate level of care Negative Reassure mother F/U endovaginal ultrasound of the cervix (if available) Treatment of BV Consider repeat test in 7-14 days, if symptomatic Vaginal Examination BCRCP (2005) Obstetric Guideline 2A – Preterm Labour, p. 11

33 Obtain specimen prior to procedures that may disrupt cervix: Digital examination Vaginal ultrasound Microbiologic culture Pap smear Specimen should not be obtained in presence of: Cervical dilatation >3 cm PROM Soaps, gels, lubricants, or disinfectants Cervical cerclage Moderate or gross vaginal bleeding Sexual intercourse within 24 hours Source: Honest BMJ, Aug 2002 Guidelines for Use of fFN test

34 Specimen Collection for ƒFN Testing Lightly rotate swab across either the posterior fornix of the vagina or the ectocervical region of the external cerical os for 10 seconds.

35 Specimen Collection for ƒFN Testing Remove swab and immerse Dacron ® tip in buffer Break the shaft even with the top of the tube (at the score)

36 Specimen Collection for ƒFN Testing Align the shaft with the hole inside the tube cap and push down tightly over the shaft to seal the tube.

37 Fetal Fibronectin (ƒFN) Test Results Rapid fFN for the TLi™ System Analyzer produces results in 23 minutes Around-the-clock availability Rapid fFN is run like a pregnancy test Several sites in Canada run the assay in L&D

38 Implementation of fFN in insert province/territory or region

39 Conclusion Fetal Fibronectin is a useful adjunct to diagnosis and manage preterm labour Reduced hospital admission and transfers of women with symptoms of preterm labour. Decreased costs associated with hospital admissions, transfers Improved identification of women who need corticosteroid and tocolytic therapy Provide reassurance to women and families


41 Thank you!

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