incompetent cervix
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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Bedrest: What’s the Point?
May 5th, 2011This is podcast discusses the rationale for the bed rest prescription, indications for bed rest and new advances in the treatment of high risk pregnancy. Available as a download only.
“Abortions cause mamas to go on bed rest”
September 22nd, 2010I recently read a blog post in response to a blog post on RH Reality Check entitled, “Breaking the Bank for Bed Rest” which insinuates that the reason women are prescribed bed rest is because they have had previous abortions and now are having high risk pregnancies as a result. Because of this association pregnant women, and high risk pregnant women in particular, should not be entitled to paid maternity leave and the U.S. Government should do nothing to financially assist women and their families during maternity leave. Instead, we should be doing more to prevent abortion and then many of these problems would be avoided.
The author, Jill Stanek, RN, is a conservative pro-life blogger who wrote the blog post, “Liberal feminists want paid leave for pregnant moms on bed rest but not prevention of need.” While I completely respect Ms. Stanek’s pro-choice position and appreciate that there is a link between previous abortion and pregnancy complications as demonstrated by the literature, the literature in no way states that women who go on bed rest are on bed rest as a result of a prior abortion or pelvic infection.
Women who have had prior abortions are at increased risk of pregnancy complications. But women go on bed rest for a variety of reasons and most certainly not all women who go on bed rest have had abortions or pelvic infections. Currently there is no study documenting that all women who go on prescribed bed rest have had prior abortions or previous pelvic infections. Until such definitive data exists, I think it is not only accusatory but irresponsible to make it a woman’s fault that she is on bed rest.
Women who go on prescribed bed rest already feel a tremendous amount of anxiety and guilt. “Is it something that I have done?” “Is there anything that I can do to make this situation better?” “How can I help my baby?” Additionally, in the United States women have the additional stress of worrying about what prolonged absence from their jobs will do to their family’s finances as well as to their jobs. Stress of this nature has been linked to preterm labor, yet Ms. Stanek seems to disregard this association.
In my literature search I found that Brent Rooney, MD and Byron Calhoun, MD, have extensively researched the association between induced or elective abortion and preterm births. They have found that induced abortion does increase the risk of preterm birth and the risk increases with each induced abortion a woman has. In addition to their own research, they have extensively reviewed the work of several large studies done in Germany, Denmark and Australia. I found additional studies performed in India which substantiate the claims that induced or elective abortions, especially those performed after 8 weeks, do increase the risk of preterm birth in subsequent pregnancies. However, an Oxford study showed that induced abortion is not a cause of preterm delivery in subsequent pregnancies in teenagers. Dhaliwal, Gupta and Gopolan also noted their study cohort consisted mostly of married women 21-30 years of age. These women were having complications but noted that this contrasted with younger, unmarried, low income teens in the West who had abortions and didn’t seem to have complications with subsequent pregnancies.
What I didn’t find is a definitive study which shows that all or even the majority high risk pregnancies can be traced back to a prior abortion. Ms. Stanek and others also point out that promiscuity and Sexually transmitted diseases are also a major cause of pregnancy complications and preterm birth. There is the association, but again, this has not been substantiated as “the leading causes” of pregnancy complications. As Ms. Stanek herself pointed out in her blog post, there are a number of reasons that women are prescribed bed rest during their pregnancies. The link between an incompetent cervix and an abortion can’t be ignored. But that is only one reason that women are placed on bed rest. What about Pre-eclampsia? What about multiple gestations? What about uterine and placental issues? Is Ms. Stanek trying to say that all these complications are a result of abortion or pelvic inflammatory disease?
Ms. Stanek then makes a startling leap stating, “Abortion and promiscuous sex are also implicated in the rising number of mothers pregnant with multiples, another reason for bed rest.” While multiple gestation is a risk factor for preterm birth, I can’t see how she made the leap from promiscuity to multiple pregnancy. One thing that we do know is that women who undergo fertility treatments are at increased risk of having a multiple pregnancy. But according to Ms. Stanek, women undergo fertility treatments because they were promiscuous as younger women and had abortions so that they could delay pregnancy. Young (promiscuous) women also contract STD’s that lead to pelvic infections damaging their reproductive organs. When these same women later decide to get pregnant over age 35-after pursuing careers- they need help conceiving and undergo fertility treatments which lead to the multiple gestation and high risk pregnancy. In one fell swoop Ms. Stanek has labeled young women promiscuous, states that all women with fertility issues have them because they had abortions or pelvic infections as a result of being promiscuous, she criticizes women for pursuing careers instead of marriage and family and finally implies that if you have a high risk pregnancy, It’s your own damned fault! (my words not hers.) Ms. Stanek goes on to report that African American Women have a disproportionately higher number of preterm births because they have a disproportionately higher number of abortions.
As an African American woman who had 2 high risk pregnancies and 2 miscarriages, yet never had an abortion or pelvic infection (i.e. STD due to being promiscuous) to say that I was offended is clearly an understatement. Yes, I married later, not because I was pursuing a career but because my husband and I dated in college, broke up and reconnected 10 years later. It happens. But I am going to put my own feelings aside and deal with the issues in Ms. Stanek’s post specifically.
Rooney, Calhoun and other researchers showed that women who have elective induced abortions need to be strongly counseled about the increased risk of pregnancy complications in subsequent pregnancies. They found that instrumentation for Dilation and Curettage significantly increased the risk of cervical damage leading to the increased risk of incompetent cervix in subsequent pregnancies and recommend suction evacuation be used. All researchers found that induced or elective abortions performed after 8 weeks lead to increased risk of preterm labor and pregnancy complications. So Ms. Stanek is correct. Having an abortion does increase a women’s risk of having pregnancy complications. But again, Pregnancy complications are not only the result of a prior abortion or pelvic infection. It is not due to solely to promiscuity.
What concerns me the most about Ms. Stanek’s post is not just the inflammatory nature of her comments but also her blatant disregard for working women of the United States in general. Some of the current employment rules and regulations were put into place as much as 50 years ago. At that time few if any women worked outside the home once they got married. Husbands worked and women stayed home so the issue of maternity benefits was not an issue at all. This is not the case today where nearly 50% of our nation’s workforce is women. Despite progress in the working world, women still bear the brunt of the responsibility for taking care of the family and the full responsibility for bearing children. Even in the best of circumstances, and that being a stable married relationship according to Ms. Stanek’s and others stated standards, many women make more money than their husbands and are the principle wage earners for the family. So how is the family to fare when the principle wage earner is earning no wages? Even if women are not the principle wage earners, many families simply cannot survive on one salary. Is Ms. Stanek and her like-minded supporters willing to deny all working women paid maternity leave benefits because they believe that high risk pregnant women seeking benefits need them because they caused their own situations?
This is a very slippery slope. If Ms. Stanek and others get their way, not only will women never receive any sort of paid medical leave when they have children, women will be forced to leave the workforce entirely when they start their families. All that women have fought for over the years; the right to vote, equal opportunity to participate in team sports in schools and universities, equal pay for equal work…it will all be for naught. What’s more, some of the brightest minds and innovations in this country will be silenced. At a time when the United States of America is lagging woefully behind other countries in maternal and infant mortality, education, science and technology I have to ask Ms. Stanek and her associates, can the United States really afford not to support working women with paid maternity leave?
References:
“Breaking the Bank for Bedrest” by Amie Newman, RH Reality Check.
“Liberal feminists want paid leave for pregnant moms on bed rest but not prevention of need” Jill Stanek
“Induced Abortion and Risk of Later Preterm Birth” Brent Rooney, Byron Calhoun, MD. Journal of American Physicians and Surgeons Volume 8 Number 2 Summer 2003
“Induced Abortion and Subsequent Pregnancy Outcome” L.K. Dhaliwal, K.R. Gupta, S. Gopalan. The Journal of Family Welfare, Vol 49, No. 1. June 2003
“Induced Abortions is not a cause of subsequent preterm delivery in teenage pregnancy” T.T Lao and L.F Ho. Oxford Journals, Medicine, Human Reproduction, Issue 3 Volume 13 Pgs 758-761
