preterm labor and prematurity
Mamas on Bedrest: Vaginal Progesterone Cuts Premature Births
December 23rd, 2011I’m tossing yet another tidbit of information for Mamas on Bedrest to share and discuss with their doctors.
In a study published online on December 14, 2011 in the American Journal of Obstetrics and Gynecology, a coalition of researchers from around the world (United States, Austria, Brazil, Denmark, India, South Africa, Turkey, and the United Kingdom) concluded that vaginal progesterone, administered in the mid-trimester of pregnancy to women with shortened cervix detected via ultrasound, can cut their risks of preterm labor by as much as half.
I found this information very interesting given the current brouhaha over Makena (the progesterone injections used for prevention of preterm labor) and how progesterone is often used early in pregnancy for women with repeated miscarriages (my situation!).
The researchers reviewed data from 5 highly respected studies and evaluated the efficacy and safety of using vaginal progesterone for the prevention of preterm labor in the presence of cervical shortening with rates of neonatal morbidity and mortality. Here are their findings:
- Vaginal progesterone reduced the rate of birth at less than 33 weeks’ gestation by 42% . It also reduced the risk for birth at less than 35 weeks’ gestation by 31% and less than 28 weeks’ gestation by 50% *.
- Vaginal progesterone also improved the following outcomes: respiratory distress syndrome, a composite measure of neonatal morbidity and mortality, birth weight less than 1500 g, admission to neonatal intensive care unit and need for mechanical ventilation.
Given these outcomes, one would think that physicians and researchers across the board would be recommending that women receive progesterone if they presented with shortened cevix. But such was not the case. Two commentators felt that the data was not conclusive enough. Sarah Bradley, MD, clinical assistant professor of obstetrics and gynecology from the University of Wisconsin–Madison felt that the data was “murky”. Her position stemmed from the fact that different studies used different definitions for shortened cervix. She also noted that many women had received a cervical cerclage (surgical stitch placed to keep the cervix closed) in addition to the progesterone and felt that it couldn’t be definitively stated that the progesterone was in fact the true reason that preterm labor was averted.
Aaron B. Caughey, MD, PhD, director of women’s health and chair of obstetrics and gynecology, Oregon Health Sciences University, Portland, had a similar comment on the definition of shortened cervix. He also felt that the meta-analysis really didn’t add any new information to what is already “standard of care”.
As a result, researchers recommend that women be advised of both treatments. While it is commonly recognized that either a cerclage or progesterone alone is often enough to prevent preterm birth, many women may elect to have both treatments and that is okay. Researchers also recommend that further research be undertaken to specify “shortened cervix” and to give specific measurements at which treatments are beneficial. They also recommend research to assess the effects of race, ethnicity, socioeconomic status, and maternal age on cervical shortening and preterm labor.
While I’m all in favor of evidenced based research, sometimes I think we analyze things to death. We know that adequate progesterone levels are essential to maintaining a healthy pregnancy. We see progesterone used in early pregnancy, especially in cases where women have undergone fertility treatments and/or have luteal phase defects resulting in repeated miscarriage. We know that progesterone injections (Makena and compounded variations) are effective in prolonging pregnancy in the instances of preterm birth later in pregnancy but before 37 weeks gestation. So I am not surprised that using vaginal progesterone is effective in helping prolong pregnancy and prevent preterm birth in cases of shortened cervix.
But I am surprised that commentators are pulling up short in making the recommendation that vaginal progesterone be used in the mid-trimester. Is it really necessary to determine that progesterone alone will prevent preterm birth in the presence of a cerclage? Is it really so awful if a woman has a cerclage and uses vaginal progesterone if she has a shortened cervix? And while it will be nice to know how efficacious progesterone is in various races, ethnicities, socioeconomic levels and in women of advanced maternal age, must we wait to have all this data before making recommendations? Can’t we do the work concurrently? It has been shown that use of progesterone produces more good than harm, so why not use it as currently stated and make the specific recommendations as the study data becomes available?
Many will judge my opinion and I am fine with that. But I was a woman who had repeat miscarriages until we figured out that my progesterone levels were not adequate to support pregnancy to term (beyond 1st trimester actually!). I know women who benefited from having progesterone injections in the second and third trimesters to prolong their pregnancies. I think that I can safely say, It didn’t matter if we were white or black, rich or poor, “old” or young, if it helped us to maintain our pregnancies and have healthy babies, we were all for it! If it helps specific subgroups, even better.
But on behalf of high risk pregnant women everywhere, please don’t wait to use a treatment that has been shown to be safe and efficacious in preventing preterm birth just so that you can get “exact” data. If you know that progesterone is efficacious in preventing preterm birth in a woman who has a cervix of 20mm and has a cerclage, why not try it in a woman whose cervix is 15mm or even 10mm? If she is at such risk, why not try? As a physician and scientist, you may think that it’s a waste. But for the mama desperately hoping and praying for her baby, it’s hanging on to all hope by a thread. Please don’t cut us off.
*This post is a summary and commentary of the MedScape report and the published article in The American Journal of Obstetrics and Gynecology online journal. Statistical information was attenuated for ease of reading. To read the full study results, please read the complete texts provided here.
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Mamas on Bedrest: For Prematurity Awareness Day, A Talk with “Sweetie’s Mama”
November 18th, 2011On Twitter she’s known as @Sweetiesmama, but Charisse Mora Medina is so much more! Mama, wife and preemie activist, Mora Medina has gained a wealth of knowledge in learning to care for “Sweetie”. From her intuitive knowing that “Sweetie” was coming, to his early birth and subsequent NICU stay, Mora Medina has traveled and maneuvered a multitude of conundrums in an effort to secure the best care for her child-including her own battle with Post Traumatic Stress Disorder, PTSD. Now that “Sweetie” is almost 2 years old, Mora Medina has shifted her focus (at least some of it) to helping other preemie parents. So her is Mora Medina in her own words as she shared the wisdom she has gained in raising “Sweetie”.
Mamas on Bedrest: Are You Aware of Prematurity?
November 4th, 2011November is Prematurity Awareness Month.
Throughout the month various organizations will be presenting programs to raise awareness about prematurity.
What’s most interesting to me is that prematurity and preterm birth are not discussed during pregnancy-at least they weren’t discussed during my first pregnancy. When I was pregnant with my daughter, I had complication after complication. It was with her that we contemplated bed rest, but she and I would always rally, we’d both settle down and we managed to keep going. I went into labor at 36 weeks, 6 days. She was coming fast and furious and there was no stopping her! Still, I was unaware that she would be considered premature (she missed 37 weeks by a mere 4 hours!!) and that she would land in the NICU. I’m not going to rehash that story as I have already told it here. But I often wonder, given my complications and mishaps why no one ever mentioned,
“If this baby comes before 37 weeks, she will be considered premature. One out of every 8 babies is born premature in the United States. Worldwide, 13 million babies are born premature each year. These are the potential complications that could arise and if she is born early, she will likely be cared for in the NICU (neonatal intensive care unit). “
I realize that most OB’s prefer to be positive and to avoid “planting seeds of doubt” in minds that may already be “overactive”. But I was really taken aback the first time that I saw my daughter with a myriad of wires and leads attached to her and was scared out of my wits when I picked her up and an alarm went off. (It merely indicated that a lead had come off of her little foot, but the bells, whistles and lights that began wailing were frightening to say the least!). There should be at least some mention of preterm labor and preterm birth and what that means at some point in the prenatal period. Perhaps as each trimester begins, OB’s and midwives could review what is going on developmentally and what would happen if the baby were to be born at that point in time and how the baby would be cared for. That would have helped me greatly.
So Mamas on Bedrest, I am sharing a few resources here that I highly suggest you review. You don’t have to delve deep into prematurity, but be aware that if you are not at or beyond 37 weeks and your baby were to be born now, your baby is premature and will need special care-perhaps for years to come. Here are some resources to “keep handy”.
March of Dimes
The March of Dimes is quite frankly the most widely known organization dedicated to the health and well-being of babies. They have (in the United States) nationwide offices and resources on all things baby. They have supported extensive research and programs to promote full term pregnancies and to help prevent preterm birth. They run awareness campaigns for Prematurity Awareness Month and in January 2012 will host the Prematurity Prevention Symposium in Washington, DC.
The Preemie Primer
The Preemie Primer by Dr. Jennifer Gunter should be “required reading” for parents of preemies. Dr. Gunter is a mama to very premature triplets, 2 here and one in heaven, and shares how she combined her extensive knowledge as an OB/GYN and Rehabilitation physician to help with the care and development of her boys (now approximately age 8).
Fragile Beginnings Preemie Parent Alliance
A Massachusetts Based Coalition of Organizations, Fragile Beginnings is committed to improving the lives of parents of premature infants through direct support services, providing educational materials, as well as connecting them to community resources and to each other. They are hosting Prematurity Awareness, an event on November 16, 2011, to raise awareness about Prematurity in Massachusetts.
We are constantly adding to our resource page for Preemie Parents as we learn of organizations and resources.
Do you have a preemie parent resource or other information on prematurity? Please share such information at info@mamasonbedrest.com so that we can make it widely available.
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