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Preterm Labor

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Resources




Preterm Labor  [Medscape, 12/5/11]

Premature Rupture of Membranes [Medscape, 6/13/11]


Risk Factors for 2 Types of Preterm Birth Vary Greatly [Medscape, 7/19/12] - Clinical characteristics are a poor predictor of spontaneous preterm birth (SPTB) in nulliparous women, according to the results of a new study. In addition, the trial suggests, the risk factors for SPTB with intact membranes (SPTB-IM) differ from the risk factors for SPTB after prelabor rupture of the membranes (SPTB-PPROM). This suggests that there are different pathophysiological pathways underlying these distinct phenotypes.


Vaginal Progesterone May Help Certain Patients [9/24/14] - By using progesterone, physicians may be able to reduce the risk of preterm birth for women who are pregnant with twins and have a short cervix, a review of past studies has found.


Labor Drug Assailed - Article Challenges Mag Sulfate Use By Sandra G. Boodman [10/10/06] - For the past 30 years or so, doctors have routinely given pregnant women intravenous infusions of magnesium sulfate to halt contractions that can lead to premature labor.  Now a prominent physician-researcher is calling on his colleagues to stop using the drug for this purpose, saying that the treatment is unproven, ineffective and potentially deadly

Magnesium sulfate tocolysis: time to quit.
Grimes DA, Nanda K.
Obstet Gynecol. 2006 Oct;108(4):986-9.

Intravenous magnesium sulfate tocolysis remains a North American anomaly. This therapy rose to prominence based on poor science and the recommendations of authorities. However, a Cochrane systematic review concluded that magnesium sulfate is ineffective as a tocolytic. The review found no benefit in preventing preterm or very preterm birth. Moreover, the risk of total pediatric mortality was significantly higher for infants exposed to magnesium sulfate (relative risk 2.8; 95% confidence interval 1.2-6.6). Given its lack of benefit, possible harms, and expense, magnesium sulfate should not be used for tocolysis. Any further use of magnesium sulfate for tocolysis should be restricted to formal clinical trials with approval by an institutional review board and signed informed consent for participants. Should tocolysis be desired, calcium channel blockers, such as nifedipine, seem preferable.


Obstetric issues in preterm birth. [Free full text article.]

Murphy DJ, Fowlie PW, McGuire W.
BMJ. 2004 Oct 2;329(7469):783-6.

"The most common clinical tests used to determine the risk of preterm labour are transvaginal sonography (to measure the length of the endocervix) and the cervicovaginal fetal fibronectin test. These tests have high negative predictive values—that is, if results are negative then the women probably will not progress to preterm delivery."


Predicting Risk for Preterm Birth: The Importance of Fetal Fibronectin Testing  CME
Are you doing all you can to identify and reduce the risk for preterm birth while preventing unnecessary interventions?

Biomarkers in Amniotic Fluid Predict Risk of Preterm Delivery [Medscape registration is free]


Frequency of Uterine Contractions and the Risk of Spontaneous Preterm Delivery
Jay D. Iams, M.D., Roger B. Newman, M.D., Elizabeth A. Thom, et al.
NEJM, Volume 346:250-255, January 24, 2002, Number 4


Atosiban as Effective as Beta-Agonists for Treatment of Preterm Labor [Medscape registration is free]


MEDLINE Abstracts - Prediction and Risk of Preterm Labor [Medscape registration is free]


A Perinatal Pathology View of Preterm Labor [Medscape registration is free]


Corticotropin-Releasing Hormone Predicts Premature Birth [Medscape registration is free]


This is just a wild guess about what might work to create a stronger cervix - try taking more vitamin D!

Higher Vitamin D Levels Linked to Lower Risk for Female Pelvic Floor Disorders



Analyzing Contractions




Limitation of external tocography has caused the development of another technique-electohysterography - that is based on the recording of electrical uterine activity. The comparison study between electrohysterography and tocography was carried out thanks to the possibility of simultaneous recording of mechanical and electrical uterine activities:

The humans electrohysterograms, waveforms and implications* [Full text]
S. D. Larks, Ph.D.
Proc Natl Acad Sci U S A. 1958 August 15; 44(8): 820–824.

Quantitative analysis of contraction patterns in electrical activity signal of pregnant uterus as an alternative to mechanical approach.
Jezewski J, Horoba K, Matonia A, Wrobel J.
Physiol Meas. 2005 Oct;26(5):753-67. Epub 2005 Jul 1.

Monitoring of uterine contraction activity is an important diagnostic tool used during both pregnancy and labour. The strain the pregnant uterus exerts on the maternal abdomen is measured via external tocography. However, limitation of this approach has caused the development of another technique-electrohysterography--which is based on the recording of electrical uterine activity. A computer-aided system is presented, which allows the recording of electrohysterographic signals from the maternal abdomen and their on-line analysis both in time and frequency domains. As a research material, we acquired 108 traces during a 24 h period before labour from a group of patients between 37 and 40 weeks of gestation. The comparison study between electrohysterography and tocography was carried out thanks to the possibility of simultaneous recording of mechanical and electrical uterine activities. The obtained results show that both methods demonstrate high agreement in relation to the number of contractions recognized as being consistent. However, their agreement in relation to the quantitative description of recognized patterns has appeared to be unacceptable to consider these methods as fully alternative. The appropriate way of further development of electrohysterography seems to be spectral analysis. Several spectral parameters describing electrophysiological properties of uterine muscle can be obtained by the use of electrohysterographic signals.



Noninvasive uterine electromyography for prediction of preterm delivery. [Full text]
Lucovnik M, Maner WL, Chambliss LR, Blumrick R, Balducci J, Novak-Antolic Z, Garfield RE.
Am J Obstet Gynecol. 2011 Mar;204(3):228.e1-10. Epub 2010 Dec 8.

CONCLUSION: Uterine EMG PV and PS peak frequency more accurately identify true preterm labor than clinical methods.



Use of uterine electromyography to diagnose term and preterm labor. [Full text]
Lucovnik M, Kuon RJ, Chambliss LR, Maner WL, Shi SQ, Shi L, Balducci J, Garfield RE.
Acta Obstet Gynecol Scand. 2011 Feb;90(2):150-7. doi: 10.1111/j.1600-0412.2010.01031.x. Epub 2010 Dec 7.

Current methodologies to assess the process of labor, such as tocodynamometry or intrauterine pressure catheters, fetal fibronectin, cervical length measurement and digital cervical examination, have several major drawbacks. They only measure the onset of labor indirectly and do not detect cellular changes characteristic of true labor. Consequently, their predictive values for term or preterm delivery are poor. Uterine contractions are a result of the electrical activity within the myometrium. Measurement of uterine electromyography (EMG) has been shown to detect contractions as accurately as the currently used methods. In addition, changes in cell excitability and coupling required for effective contractions that lead to delivery are reflected in changes of several EMG parameters. Use of uterine EMG can help to identify patients in true labor better than any other method presently employed in the clinic.

Here's a pretty amazing collection of related articles


Test Can Cut Premature Births - This test monitors the electrical impulses that cause contractions.


Assessing Risk of Preterm Labor



Fetal Fibronectin Predicts Preterm Delivery but Raises Anxiety - 3/25/05 - [Medscape registration is free.]


Surprising New Research on the Risks for Preterm Birth [8/6/12] By Jamie Habib

FullTerm™, The Fetal Fibronectin Test results can help you determine if your patient should be on medications and/or bedrest to help prevent preterm delivery, or if she can continue working and normal activities.

How to order

Information for pregnant women


Elevated CRP Early in Pregnancy May Predict Preterm Delivery - Women who have very high levels of the inflammatory marker C-reactive
protein (CRP) early in pregnancy are at increased risk of delivering before term, based on the results of a study reported in American Journal of Epidemiology for December, 2005.


Maternal urine albumin excretion and pregnancy outcome.
Franceschini N, Savitz DA, Kaufman JS, Thorp JM.
Am J Kidney Dis. 2005 Jun;45(6):1010-8.

CONCLUSION: Low levels of albuminuria are associated with preterm birth. The mechanism underlying this association warrants additional exploration.


Elevated Uric Acid in Blood Linked To Preterm Births [Medscape registration is free]


Prior SIDS predicts birth complications - Women who have lost a child to sudden infant death syndrome (SIDS) are at increased risk of delivering a small or preterm baby in subsequent pregnancies, say UK researchers.


Sudden infant death syndrome and complications in other pregnancies.
Smith GC, Wood AM, Pell JP, Dobbie R.
Lancet. 2006 Dec 17;366(9503):2107-11.

FINDINGS: Women who had an infant who died from SIDS were at increased risk in their next pregnancy of delivering an infant small for gestational age (odds ratio 2.27, 95% CI 1.54-3.34, p<0.0001) and of preterm birth (2.53, 1.82-3.53, p<0.0001). The risk of SIDS was higher for the children of women whose previous infant had been small for gestational age (1.87, 1.19-2.94, p=0.007) or preterm (1.93, 1.24-3.00, p=0.004). Multivariate analysis showed that all associations were explained by common maternal risk factors for SIDS and obstetric complications and by the likelihood of recurrence of fetal growth restriction and preterm birth. INTERPRETATION: Women whose infants die from SIDS are more likely to have complications in their other pregnancies. Recurrence of pregnancy complications predisposing to SIDS could partly explain why some women have recurrent SIDS.


Predicting Preterm Birth CME


Protein Linked to Premature Births  [July 27, 2004] Protein tests for uterine infections.


The SalEst™ test is intended to detect and measure by enzyme-linked immunoabsorbant assay (ELISA) technology the level of salivary estriol in pregnant women.

The device is indicated for use as an aid in identifying risk of spontaneous preterm labor and delivery in singleton pregnancies. The device can be used every 1 to 2 weeks from gestational ages 22 to 36 weeks.


Three Factors Predict Risk of Preterm Birth Due to Premature Rupture of Membranes [Medscape registration is free]

The Preterm Prediction Study: prediction of preterm premature rupture of membranes through clinical findings and ancillary testing. The National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.
Mercer BM, Goldenberg RL, Meis PJ, Moawad AH, Shellhaas C, Das A, Menard MK, Caritis SN, Thurnau GR, Dombrowski MP,
Miodovnik M, Roberts JM, McNellis D
Am J Obstet Gynecol 2000 Sep;183(3):738-45


Fetal membrane healing after spontaneous and iatrogenic membrane rupture: a review of current evidence.
Devlieger R, Millar LK, Bryant-Greenwood G, Lewi L, Deprest JA.
Am J Obstet Gynecol. 2006 Dec;195(6):1512-20.

In view of the important protective role of the fetal membranes, wound sealing, tissue regeneration, or wound healing could be life saving in cases of preterm premature rupture of the membranes. Although many investigators are studying the causes of preterm premature rupture of membranes, the emphasis has not been on the wound healing capacity of the fetal membranes. In this review, the relevant literature on the pathophysiologic condition that leads to preterm premature rupture of membranes will be summarized to emphasize a continuum of events between rupture and repair. We will present the current knowledge on fetal membrane wound healing and discuss the clinical implications of these findings. We will critically discuss recent experimental interventions in women to seal or heal the fetal membranes after preterm premature rupture of membranes.


Computer Simulation Modeling and Birth Outcome by Lewis Mehl-Madrona, M.D., Ph.D


If she had a LEEP (they began doing that in the early 90's), or a cone biopsy (or cold knife cone), she may have some residual scarring.  These ladies are at slightly higher risk for cervical incompetence at one end of the spectrum, or rigidity at the other end.  I have had to manually break up adhesions when the cervix would not dilate despite strong contractions, but only once or twice in 26 years..  I would not risk a mom out of a home birth for this condition, but would want to monitor her carefully for preterm labor - maybe carefully check her cervix beginning at 20 weeks or so, and reinforce the precautions of PTL to her. Probably will not be an issue though.



Vaginal pH and Preterm Labor



Late abortions and premature births – general information
Erich Saling M.D. FRCOG, Jürgen Lüthje MD, Monika Schreiber M.D.
Institute of Perinatal Medicine, Berlin, Germany


I think this is a fascinating field of research, (although I think the doc has taken it a bit too far as so many docs often do).

I’ve been recommending to check vaginal pH for a while because a low pH is pretty predictive of risk for PPROM and PTL, and there are simple things which often work to help bring the vaginal flora into a more healthy ballance.


 This topic is discussed – with references -- in Research Updates for Midwives 2005, available on the Midwifery Today website.
Here's A Timely Birth


In midwifery school I learned that:
-- amniotic fluid is deep blue/alkaline(but so is semen and soap – so don’t get confused!)
---- and a healthy vagina shouldn’t ever show  green on the paper


Here's an article about pH.



Genetic Factors in Preterm Labor



Heritability of preterm delivery confirmed from orgyn.com

The heritability of preterm delivery.
Ward K, Argyle V, Meade M, Nelson L.
Obstet Gynecol. 2005 Dec;106(6):1235-9.

CONCLUSION: This study confirms the familial nature of preterm delivery. On average, gravidae randomly selected from our population are 23rd degree relatives, while these preterm delivery probands are eighth-degree relatives. A genome-wide scan using these affected families is underway. LEVEL OF EVIDENCE: II-3.


The study above is more honest in discussing this issue as "the familial nature" rather than the "genetic influences" below.  Preterm labor is known to be related to infection, and infections (or simply normal bacterial flora) are sensibly familial in nature rather than genetic.


Genetic influences on premature parturition in an Australian twin sample.
Treloar SA, Macones GA, Mitchell LE, Martin NG.
Twin Res. 2000 Jun;3(2):80-2.

"We investigated possible genetic influences on women's liability to preterm birth, using data from a large sample of Australian female twin pairs. In a 1988-90 questionnaire survey, both members of 905 parous twin pairs (579 monozygotic and 326 dizygotic) reported on whether deliveries had been more than two weeks preterm. Tetrachoric twin pair correlations for first birth were rMZ = 0.20+/-0.11 and rDZ = -0.03+/-0.14, and for any birth were rMZ = 0.30+/-0.08 and rDZ = 0.03+/-0.11. Best-fitting models to data contained only additive genetic influences and individual environmental effects. Heritability was 17% for preterm delivery in first pregnancy, and 27% for preterm delivery in any pregnancy. In the former case, however, we could not reject a model without genetic influences. Although our data did not allow for differentiation of the varying aetiologies of premature parturition, results from this exploratory analysis suggest that further investigation of genetic influences on specific reasons for preterm birth is warranted."



Causes Of Preterm Labor



A Perinatal Pathology View of Preterm Labor [Mescape registration is free.]


Some of our local chiropractors have found that chiropractic adjustments can help ease or stop preterm labor.  They've found that many women complaining of preterm labor had an anterior subluxation to the pelvis. Unfortunately, adjustments often don't hold well during pregnancy because of the increased joint mobility, so the women may need to have the adjustments repeated from time to time.  The chiropractors also felt that other types of subluxations could contribute to PTL.


Premature Birth Bibliography from An annotated bibliography on Development, Behavior, and Psychic Experience in the Prenatal Period and the Consequences for Life History compiled by M. Maiwald - The bibliography contains > 1200 assorted literature references covering prenatal matters including biological, medical and psychological topics which eventually influence later life. An Amazing Site!  [Ed. This title is translated from the German, and I strongly suspect that "Psychic" is meant to be Psychological.]


Gum Disease and Preterm Labor


Preterm birth and licorice consumption during pregnancy.
 Strandberg TE, Andersson S, Jarvenpaa AL, McKeigue PM.
Am J Epidemiol. 2002 Nov 1;156(9):803-5.

In conclusion, heavy glycyrrhizin [licorice] exposure was associated with preterm delivery and may be a novel marker of this condition.



Incompetent Cervix



About Terminology

Many people find the term, "incompetent cervix", offensive, as it sounds judgmental. Anne Frye suggests the term, "loose cervix", which is perhaps more accurate but has some judgmental potential of its own.  In some ways, the term, "incontinent cervix" is perhaps more accurate, reflecting the fact that the cervix is not containing the fetus.  This is one of those areas where you may want to ask your client what terminology she would like you to use in referring to her body.


One midwife suggests an alternative term - Undecided Cervix or Cervical Expansion

Latest Research - Premature silent labor (often called incompetent cervix syndrome) is possibly caused by thrombophilia - an unusual tendency for the blood to clot.  I haven't found any studies about this, but it's worth looking into, especially for women who've had one premature baby.  I would expect that insurance companies would gladly pay for this treatment rather than risk another very premature baby.  Dr. Beer of the Reproductive Medicine Program at the Chicago Medical School does seem to attribute many disorders of pregnancy to immune system disorders, so I would take this with a grain of salt, but it's worth reading.


Saliva Test Helps Predict Preterm Delivery - although used primarily for symptomatic women, this test also predicted asymptomatic labors, such as occur with a yielding cervix.


Stitches don't stop preterm birth - Kings College Hospital London, June, 2004


INCOMPETANT CERVIX AND CERCLAGE PROCEDURES - a nice explanation with some good links at the bottom


Cervical cerclage from surgeryencyclopedia.com


The Incompetent Cervix referenced from Uterine, Placental and Cervical Complications at childbirth.org


Information On the Incompetent Cervix - a personal Web page with some good links

Another good meta page with links


Incompetent Cervix - Medical Protocols


Recent Review Articles

Cerclage and cervical insufficiency: an evidence-based analysis. [full-text article]
Harger JH.
Obstet Gynecol. 2002 Dec;100(6):1313-27

The incompetent cervix--a review.
Edozien LC
Br J Clin Pract 1992 Winter;46(4):264-7
Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria.

Repeated midtrimester pregnancy loss due to incompetence of the cervical os has long been recognised as a treatable condition, but the aetiology, diagnosis and management of this condition remain controversial.
Incompetent cervix: pathogenesis, diagnosis and treatment.
Jewelewicz R
Semin Perinatol 1991 Apr;15(2):156-61
The incompetent cervix is a diagnostic dilemma.

Effects on Labor of Cerclage

The effect of cervical cerclage on the course of labor.
Weissman A, Jakobi P, Zhi S, Zimmer EZ
Obstet Gynecol 1990 Aug;76(2):168-71

Cervical cerclage does not appear to cause any problems with the normal course of labor.


Ultrasound Evaluation

Women with a personal history of "incompetent cervix" or a family history of preterm labor without known cause or asymptomatic labor might consider an ultrasound evaluation of cervical thickness and/or response to transfundal pressure:

A new method using vaginal ultrasound and transfundal pressure to evaluate the asymptomatic incompetent cervix.
Guzman ER, Rosenberg JC, Houlihan C, Ivan J, Waldron R, Knuppel R
Obstet Gynecol 1994 Feb;83(2):248-52


Success Rates for Cervical Cerclage

Cervical Cerclage in Pregnancy: To Treat or Not to Treat? [Medscape registration is free.]

Cervical cerclage for the incompetent cervical Os. Improving the fetal salvage rate.
Golan A, Wolman I, Arieli S, Barnan R, Sagi J, David MP
J Reprod Med 1995 May;40(5):367-70

They report a term delivery rate of 78%.

[Cervix cerclage. A 20-year case load].
D'Addato F, Malagnino F, Repinto A, Mocchia M, Andreoli C
Minerva Ginecol 1992 Jun;44(6):313-6

Healthy term infants were born in 73% of cases.


Role of Dehydration in Preterm Labor



Hot, Humid Day May Bring on Early Labor

BY JODY A. CHARNOW 

c.1997 Medical Tribune News Service
In hot and humid weather, pregnant women may want to make a special effort to stay cool.

Researchers at the State University of New York Health Science Center at Brooklyn have found that as the heat-humidity index rises, so does the rate of premature labor.

The researchers, led by Dr. Howard L. Minkoff, examined preterm labor and delivery rates during two summer and two winter weeks with the highest and lowest heat-humidity indexes for each season. The study was conducted from March 21, 1993, to March 20, 1994.

Writing in the July issue of the American Journal of Public Health, the investigators reported that the rate of preterm labor increased from slightly over 1.23 percent to 3 percent as the heat-humidity index rose from 25 to 79.5.

The findings suggest that ``pregnant women would be well advised not to get in `heat-stress' situations,'' said Joseph Feldman, a professor of preventive medicine and a member of the research team.

The investigators said they believe that their study is the first to look at the relationship between real weather conditions and preterm labor.

They cited a previous study in which researchers found that pregnant women exposed experimentally to moderate heat stress experienced contractions.

Another study in pregnant sheep found that heat stress stimulated release of antidiuretic hormone - which reduces urine production by the kidneys to conserve water - and oxytocin, a hormone that stimulates the uterus to contract. Both hormones are released from the pituitary gland at the base of the brain.

Minkoff and colleagues said it is possible that increased heat-humidity indexes cause dehydration that results in release of antidiuretic hormone. This could stimulate release of oxytocin, they speculated.

Despite a rise in the rate of preterm labors, the researchers did not observe an increase in the rate of preterm births. One explanation, according to the report, may be that women hospitalized for preterm labor receive intravenous therapy, ``which might suffice to interrupt labor in women whose contractions are linked to dehydration.''

American Journal of Public Health (1997;87:1205-7)


I went to a preterm birth prevention workshop at a birth type conference in the early 1980s. Dr. Paul Meier spoke both on VBAC and PTBP. He stated that the literature showed that you could knock out preterm uterine contractions with simple hydration in 40 % of cases. I like oral hydration better than IVs because you don't run the risk of pulmonary edema.


I thought the decreased fluid intake led to decreased fluid volume, which led to increased concentration of oxytocin in the blood. If this increased oxytocin concentration met the increased uterine receptivity, then contractions resulted.

You can reverse the effect by increased fluid intake, bolstered by deep water immersion to push the fluids into the bloodstream. This is why baths can stall out early labor or ease the intensity of active labor.


This might belong in the half-baked theory category but someone (can't remember who) once told me that the reason dehydration causes contractions is that the other hormone produced by the posterior pituitary is anti-diuretic hormone (ADH). Dehydration causes the release of ADH and the stimulation of the posterior pituitary causes some oxytocin to be released as well. Seems to make sense but I don't know whether it's accurate.



Periodontitis and Preterm Labor



Mouth Rinse Effective in Reducing Risk for Preterm Birth - An over-the-counter mouthwash reduced the risk for preterm birth by more than two thirds in women with periodontal disease


A study published in the Journal of Periodontology showed treating severe gum disease with scaling and root care cut premature births by 84%.



Connection Between Vaginal Infection and Preterm Labor




Chlamydia, Gonorrhea Linked to Stillbirth or Preterm Birth [9/6/13] from Medscape



Prevalence of the Bacterial Vaginosis and Group B Streptococcus in Term and Pre-term Pregnancies
Theoretically, pathogenic organisms ascend via lower genital organs to uterine and may cause fetal membrane inflammation which leads to preterm rupture of membranes and labor (3).

Infection, antibiotics, and preterm delivery.
Locksmith G, Duff P.
Semin Perinatol. 2001 Oct;25(5):295-309.

The relationship between genital tract infection and preterm delivery has been established on the basis of biochemical, microbiological, and clinical evidence. In theory, pathogenic bacteria may ascend from the lower reproductive tract into the uterus, and the resulting inflammation leads to preterm labor, rupture of the membranes, and birth. A growing body of evidence suggests that preterm labor and/rupture of the membranes are triggered by micro-organisms in the genital tract and by the host response to these organisms, ie, elaboration of cytokines and proteolytic enzymes. Epidemiologic and in vitro studies do not prove a cause-and-effect relationship between infection and preterm birth. However, the preponderance of evidence indicates that treatment of asymptomatic bacteriuria and symptomatic lower genital tract infections such as bacterial vaginosis (BV), trichomoniasis, gonorrhea, and chlamydia will lower the risk of preterm delivery. Based on current evidence, pregnant women who note an abnormal vaginal discharge should be tested for BV, trichomonas, gonorrhea, and chlamydia. Those who test positive should be treated appropriately. A 3- to 7-day course of antibiotic treatment for asymptomatic bacteriuria during pregnancy is clinically indicated to reduce the risk of pyelonephritis and preterm delivery. Routine screening for chlamydia and gonorrhea should be performed for women at high risk of acquiring sexually transmitted diseases. The practice of routine screening for BV in asymptomatic women who are at low risk for preterm delivery cannot be supported based on evidence from the literature. Routine screening for asymptomatic bacteriuria during pregnancy is cost-effective, particularly in high-prevalence populations. The results of antibiotic trials for the treatment of preterm labor have been inconsistent. In the absence of reasonable evidence that antimicrobial therapy leads to significant prolongation of pregnancy in the setting of preterm labor, antibiotics should be used only for protecting the neonate from group B streptococci sepsis. They should not be used for the purpose of prolonging pregnancy. Multiple investigations have shown that, in patients with preterm premature rupture of the membranes, prophylactic antibiotics are of value in prolonging the latent period between rupture of the membranes and onset of labor and in reducing the incidence of maternal and neonatal infection. The most extensively tested effective antibiotic regimen for prophylaxis involves erythromycin alone or in combination with ampicilln. Controversy still exists regarding the appropriate length and route of antibiotic prophylaxis.


Drug Used to Prevent Preterm Labor Might Cause It, Study Finds [Jan 17, 2006]

A randomised controlled trial of metronidazole for the prevention of preterm birth in women positive for cervicovaginal fetal fibronectin: the PREMET Study.
Shennan A, Crawshaw S, Briley A, Hawken J, Seed P, Jones G, Poston L.
BJOG. 2006 Jan;113(1):65-74.

Conclusion Metronidazole does not reduce early preterm birth in high risk pregnant women selected by history and a positive vaginal fFN test. Preterm delivery may be increased by metronidazole therapy.


Metronidazole to Prevent Preterm Delivery in Pregnant Women with Asymptomatic Bacterial Vaginosis. [Medline entry]
Carey JC, Klebanoff MA, Hauth JC, et al.
N Engl J Med 2000 Feb 24;342(8):534-540

Conclusions: The treatment of asymptomatic bacterial vaginosis in pregnant women does not reduce the occurrence of preterm delivery or other adverse perinatal outcomes.

Prevention of Prematurity - a review of our activities during the last 25 years from the Institute of Perinatal Medicine in Berlin.  This includes very useful information about a simple screening of vaginal pH and possible treatment with lactobacillus acidophilus (by vaginal suppository?)


Vaginal pH as a marker for bacterial pathogens and menopausal status.
Caillouette JC, Sharp CF Jr, Zimmerman GJ, Roy S
Am J Obstet Gynecol 1997 Jun;176(6):1270-5; discussion 1275-7


[from ob-gyn-l]


Is anyone (or everyone) culturing for and treating gardnerella in pregnancy in an attempt to prevent premature labor? If so, when, how treated and do you reculture later in gestation? My partners and I are trying to come up with a rational approach to this problem.


I suspect what you really want to know is, are we screening people for bacterial vaginosis?

A popular misconception is that Gardnerella=BV, whereas in fact, Gardnerella is more likely to be a marker for BV (more appropriately termed anaerobic vaginosis?)

It is BV which has been shown to be primarily related to PTL and chorioamnionitis, as far as I know.


I don't routinely culture ( no interventional RCTs yet ) but if I happen to see a BV+ve report I treat it !


Last I knew, there was still no evidence that treating gardnerella will reduce preterm labor. Unless this has changed, the only rational approach, IMHO, is to ignore it (unless symptomatic, of course).


There is evidence ( largely UK based literature ) of an association between BV/gardnerella and increased risk of preterm labour or PROM.

I am unaware though of any evidence of benefit from interventionism aimed at eradicating BV.


Gardnerella, more commonly referred to now as bacterial vaginosis, should be easily diagnosed by wet prep (clues, pH, positive amine and lack of lactobacilli). I treat BV with oral clindamycin 300mg bid for 7 days with a test of cure in 2 weeks. The latest research cites systemic treatment as the only treatment that had correlated with a decrease in PTL, as opposed to topical treatment (either metronidazole or clindamycin) (Am J of OB/GYN, v173 1995, pp157-67). Our practice is fairly aggressive with the treatment of BV, we have a growing respect for the evidence linking it to PTL.


Is there a randomized controlled trial? If not, then there is not enough evidence to treat (or even look for) asymptomatic BV. Correlation does not equal cause.


I referred to the Joesoef et al. article. It refers to the majority of the recent BV research, particularly the Hillier and Hauth.

A good discussion of the cost-effectiveness is found in The New England J, v334(20) pp1337-1339. As Dr. Bloom points out, seldom do we find such improved outcomes at such a low cost. By the way, the cultures are useless not to mention more expensive than a pair of eyeballs and a nose at the microscope...a dying art as evidenced by the myriad of students that can't tell an epithelial cell from trich!


I treat gardnerella or bacterial vaginosis in pregnancy with Flagyl in the second trimester to prevent preterm labor. Diagnosis may be made on the basis of a Pap smear finding or symptomatic patient and wet smear confirms clue cells.


I don't culture, I do a wet prep ($15 vs. $30ish for the culture). If a woman has a discharge on her initial prenatal visit when I'm doing a pap anyway, I'll take a look under the scope and do a "whiff" test. If she complains of an unusual discharge or has any signs or symptoms of PTL, I'll look for BV. I treat with metronidizole 500mg BID x 7 days, after 13/14 weeks.


I don't believe that Pap smear diagnosis of BV is very accurate. The old wet prep and KOH are still the best way to make the diagnosis.


I seem to recall a paper from Hauth at Alabama showing a decrease in PTL after treating with metronidazole for BV. But then my memory is going as I get older. Anybody else remember this paper??


You're right. They used metronidazole plus erythromycin, though in the discussion section they hinted that, in retrospect, they thought the erythromycin was probably unnecessary. Interestingly, both this and one other treatment study (not placebo-controlled) studied only patients already deemed at high risk for PTL, so screening and treatment of the general obstetric population remain unproven, as far as I can tell.


Hillier et al. published their study re:BV and PTL in the New Eng J (v333(26), 1995, pp1737-1742) found an association between BV and PTL independent of other risk factors. I can e-mail the full text article to anyone who may want it.


But that is not the same (in fact, far from it) as demonstrating that a universal screening/treatment program is effective in reducing pre-term birth. That has only been demonstrated patients already judged high-risk.


BV is so easily diagnosed and treated there is far more good in treating than leaving it to descend onward and upwards. PTL incurs a greater cost than a wet prep and 7 days of antibiotics. I understand your position, but I am not inclined to hold out for further evidence on this one. I do about 5-6 pelvics a day, BV is by far the most prevalent vaginitis I see, often, concomitant with trich, GC and chlamydia. I also have a high risk population for PTL. Thus, the zealousness I suppose.


In view of the recent studies (e.g.. NEJM 1995;333:1732-6 & 1737-42) we're treating any incidental discovery of BV in pregnancy only when there's a risk factor for preterm delivery (e.g.. previous preterm delivery, booking weight <50kg). Not screening.


1. Treating BF (metronidazole 250 mg tid for seven days) in women with idiopathic preterm labor in a previous pregnancy who were screened for it at 13-20 weeks gestation led to lower rates of ptl, prom, premature delivery and low birth weight. Morales et al. Oral metronidazole for bacterial vaginosis during pregnancy. American Journal of obstetrics and gynecology 1994; 171;345

I see a high-risk population for prenatal care - I screen all women with previous preterm labor or prom for BV using simple wet prep - and ask pathology to look for it on the pap smear. (I also look at a wet prep/KOH on anyone with a discharge or itching) CDC recommends clindamycin 300 mg bid for seven days as treatment for BF in pregnancy, and I offer that and the metronidazole treatment to women with information about side effects and the above article. Most who have taken metronidazole in the past choose clindamycin. Perhaps a trial of intravaginal metronidazole and clindamycin as well as oral clindamycin in the future will show these effective in reducing preterm labor as well.

2. My objections to capitation are based on the premise that I am happy to accept financial risk for my own behavior, but not for someone else's behavior. I would be glad to be paid according to my adherence to guidelines or accepted, published standards; but if I'm to be paid according to my patients' health outcomes, I want some control over their behaviors that affect these outcomes. During early "health system reform" efforts, much discussion was held on the structure, process, and outcome methods of evaluating quality of care. Because structure and outcome are easier to measure than process, they were chose (hence HEDIS, JCAHO outcomes project, etc.). But process is really all that matters. It's the part of the quality equation that physicians can actually impact.



Prevention of Preterm Labor




Progestogens Curb Preterm Singleton Births - [9/21/12] - Pooled data indicate that progestogens may help prevent preterm birth among women who've delivered early in the past.


Effective Ways to Prevent Preterm Birth in High-Risk Women - Clinical update [2/4/13] from obgyn.net.


Synthetic Steroid Doesn't Hold off Preterm Birth in Primiparas With Short Cervix [10/3/12] - The synthetic steroid 17 alpha-hydroxyprogesterone caproate (17-OHP) does not reduce preterm birth rates in women with a mid-trimester cervical length of less than 30 mm during their first pregnancy, according to a new study.

Can Vitamin D Treat Pain? by Pauline Anderson [Medscape, 2/27/12] - Vitamin D may have anti-inflammatory properties and interfere with prostaglandins.  This can be helpful to a lot of processes during pregnancy and might even help to prevent preterm labor, but it could also delay the onset of labor.  Once you get to term, you might want to scale back a little bit.  Your body stores vitamin D anyway, so you're not going to get into a deficiency state if you stop taking vitamin D a couple of weeks before your due date and then start up again after baby comes.

Improvement of Primary Dysmenorrhea Caused by a Single Oral Dose of Vitamin D: Results of a Randomized, Double-blind, Placebo-Controlled Study.
Lasco A, Catalano A, Benvenga S.
Arch Intern Med. 2012 Feb 27;172(4):366-7.
[No abstract available.]


FDA Panel Votes Down 8% Progesterone Gel for Preterm Births [Medscape, 1/20/12]


Advances in Prevention of Preterm Birth: The Role of Transvaginal Ultrasonography and Progesterone CME/CE
Slide/Lecture Presentation 2012


How Women Can Carry their Unborn Babies to Term - The Prevention of Premature Birth through Psychosomatic Methods
Rupert Linder MD
APPPAH Journal : 20 (4). Summer Issue

ABSTRACT: This article presents a method that has been developed in Germany, during practical work in an office for gynecology, obstetrics, and psychotherapy, which has resulted in an astoundingly low rate of premature births among the pregnant women cared for. The actual rate of premature births in the last 15 years stands at something over 1 per cent instead of about 7 per cent usual in Germany. It has been found that a threatened premature birth should be regarded within the entirety of physical and emotional processes. In contrast to the traditional approach, symptoms are not to be regarded as problems that have to be got rid of, but are rather to be interpreted as important signals and signposts that point towards more appropriate modes of behavior. Suggestions for primary prevention are the encouragement of the expectant mother to heed her inner emotional and physical state and to get into contact to her unborn child. Four case histories are included.



Gel Did Not Reduce Premature Births in US: FDA Review By Anna Yukhananov

(Reuters) Jan 17, 2012 - Columbia Laboratories' gel for reducing the risk of premature birth did not work for U.S. women, U.S. health reviewers said on Tuesday.

The Food and Drug Administration reviewers said the gel's efficacy was "a major concern" and asked an advisory panel to consider whether the company should conduct more U.S. clinical trials.

The vaginal gel Prochieve, which contains 8% progesterone, is meant for women with a short cervix, who have a higher risk of premature birth.


Vaginal Progesterone Cuts Premature Births [Medscape, 12/20/2011] - Women with a sonographically detected short cervix cut their risk for preterm birth in half with vaginal progesterone.

Diet influences preterm delivery? - Adopting a cholesterol-lowering diet could reduce the risk of preterm delivery in low-risk pregnancies, according to the findings of a new study.

Issue 23: 14 Nov 2005
Source: American Journal of Obstetrics & Gynecology 2005; 193: 1292-301

Maternal birth weight in relation to plasma lipid concentrations in early pregnancy.
Dempsey JC, Williams MA, Leisenring WM, Shy K, Luthy DA.
Am J Obstet Gynecol. 2004 May;190(5):1359-68.

CONCLUSION: Our findings suggest that factors that are related to growth in utero may help to predict the subsequent risk of altered lipid metabolism during pregnancy, which may, in turn, be causally related to the occurrence of preeclampsia.


Noting that PROM is thought to trigger 40 percent or more of all preterm labors, Casanueva et al say: "supplementation could be a valuable tool in sustaining pregnancy to term."

Vitamin C supplementation to prevent premature rupture of the chorioamniotic membranes: a randomized trial.
Casanueva E, Ripoll C, Tolentino M, Morales RM, Pfeffer F, Vilchis P, Vadillo-Ortega F.
Am J Clin Nutr. 2005 Apr;81(4):859-63.

CONCLUSION: Daily supplementation with 100 mg vitamin C after 20 wk of gestation effectively lessens the incidence of PROM.


The potential for probiotics to prevent bacterial vaginosis and preterm labor.
Reid G, Bocking A.
Am J Obstet Gynecol. 2003 Oct; 189(4): 1202-8.


How to Avoid Having a Premature Delivery by Dr. Joseph Mercola


Report From the 23rd Annual Meeting of the Society for Maternal-Fetal Medicine [Medscape registration is free]
17-Alpha Hydroxyprogesterone Resurrected for the Prevention of Recurrent Preterm Delivery, Part 1
February 3-8, 2003; San Francisco, California


Michel Odent says you do not have prematurity in women living on islands. He says the fish oil keeps them from going into labor to such a degree that they have to go off it to have their babies. Also lots of calcium is supposed to help stop preterm labor.

This could be because of the vitamin E in fish oils . . . this Reuter's article about a study on painful menstrual cramping says, "Common menstrual cramps, or primary dysmenorrhea, are thought to result from the release of hormone-like substances called prostaglandins. Prostaglandins cause the uterus to contract in order to expel the uterine lining, resulting in menstrual blood flow. Vitamin E, by acting on two enzymes in the body, can inhibit the formation of prostaglandins -- and, potentially, menstrual cramps, according to Ziaei and her colleagues."

A randomised controlled trial of vitamin E in the treatment of primary dysmenorrhoea.
Ziaei S, Zakeri M, Kazemnejad A.
BJOG. 2005 Apr;112(4):466-9.

Then again, looking into the general relationship between vitamin E and prostaglandins, one finds that it increases the production of PGE(2) in the heart.  (And the uterus and the heart have a lot in common from an anatomical view, which is why the uterus is sometimes called "the lower heart".)

Effect of Vitamin E on Prostacyclin (PGI2) and Prostaglandin (PG) E2 Production by Human Aorta Endothelial Cells: Mechanism of Action.
Wu D, Liu L, Meydani M, Meydani SN.
Ann N Y Acad Sci. 2004 Dec;1031:425-7.

"Results showed that vitamin E increased production of both prostanoids by HAECs."

Maybe it's one of those really complicated biological interdependencies that is going to take us many more years to figure out.  :-(



Forestalling Preterm Labor



Electrical therapy may prevent early births

Electrical inhibition of preterm birth: inhibition of uterine contractility in the rabbit and pup births in the rat.
Karsdon J, Garfield RE, Shi SQ, Maner W, Saade G.
Am J Obstet Gynecol. 2005 Dec;193(6):1986-93.

CONCLUSION: Electrical inhibition of the uterus is possible. Electrical inhibition is rapid and localized; the duration can be prolonged, and the reversibility is spontaneous. Electrical inhibition may be a new method of tocolysis in the human.


If she's not too far into it, try some Cramp Bark & Black Haw.  It might help settle things down a bit and prevent her from going into full blown labor.


Around 28-32 weeks, the baby moves from a transverse position (lying sideways across the belly, as if in a cradle) to a vertical position, which is called "a vertical lie".  (Typically the baby is head up for a while, until 32-34 weeks, and then the baby starts running out of room and turns head down, so the head fits nicely in the bottom of the pear-shaped uterus, and then the baby has more room to stretch out the legs in the upper part of the uterus.)

Especially when the baby first moves into a vertical position, the baby is small relative to the pelvis, and the baby's presenting part fits very easily into the pelvis, especially the head.  With a first baby, the uterine structure is usually enough to hold the baby up out of the pelvis, but with a second baby, the uterus is much more elastic, and the baby's head can easily sag down into the pelvis, putting pressure on the cervix.  Some women will start to experience a lot of pelvic pressure or may start to have regular contractions.  Even if these are just toning contractions and not causing any cervical change, they often raise concern about preterm labor.

Something that has worked for some women is to wear a baby support system - there are some like suspenders, but anything that physically holds the baby up off the cervix  would be a likely candidate.


One that I have seen great success with is drinking a GALLON of fluid a day, 1/2 water (so 2 qts) and 1/2 other liquid.

Just recently I have had two students/clients who were put on bedrest and meds due to preterm labor. Drinking the recommended (by the OB's) 8 glasses of water a day did nothing. Drinking a gallon a day, recommended by me (and I got it from a CNM), they quit having breakthrough ctx, were even able to go off the meds and bedrest.


Black haw may be helpful; have her check with her care provider or local herbalist.


I have only run into this one time. Most on the list know the story. A woman with a confirmed rupture at 22 weeks. Initially we referred her out.

The neonatologist wanted to "evacuate her uterus". Our official back up was willing to let her go home and wait for "the inevitable". She went home despite the horror stories of the neonatologist. We agreed to a "house arrest" for the duration of the pregnancy. I agreed to see her at her home once a week and she agreed to monitor her own vitals. She worked very hard on her diet and nutrition issues. She did extra C and a variety of herbs to strengthen and tone. There were no vag exams. She had a bout of rhythmic contractions at 28 weeks. She drank a dose of Jagermeister and took a valerian/skullcap/hops combo tincture and meditated ..eventually the contractions stopped. It was an uphill battle from that point with a body pretty determined to end the pregnancy and a mother determined not to. She continued to leak clear fluid daily which she checked with nitrazine at home and got repeatedly positive results. She had 3 more bouts of strong contractions stopped the same way. At 34 weeks she was confirmed to be dilating with her contractions (used Dr. Greg White's antiseptic vag exam technique).. so she doubled the doses and tried really hard to keep them at bay. She carried to 35 weeks and 6 days...with no s/s of infection. She gave birth to a 5 lb 8oz boy at that time who is fine and healthy today.

The choice to stay home was hers. It was very outside the norm for us. I believe the herbs helped her. I also think staying home and avoiding exams increased her odds. But the most powerful thing to me was her own sheer determination and belief that she could do it. . This is not a choice for just anyone. But I would do it again for someone similarly motivated and dedicated to it.



Diagnosis of Preterm Labor



Cervical Length Equivalent to Fetal Fibronectin for Predicting Preterm Birth [5/28/10] — A new disposable measuring probe called CerviLenz, designed to measure vaginal cervical length, is as effective as fetal fibronectin in assessing risk for preterm delivery, according to researchers here at the American Congress of Obstetricians and Gynecologists 58th Annual Clinical Meeting. But whether the tool has any advantages over physical examination by an experienced clinician and/or screening by ultrasound remains unclear.
[Ed.: I cannot imagine that it is better care to stick something into the cervix than to do an ultrasound, especially when the concern is about the possibility of preterm labor!]


Fetal Fibronectin (fFN): A Test for Preterm Delivery - To help predict  preterm delivery, some doctors now suggest that women with symptoms of preterm labor be screened for the presence of fetal fibronectin (fFN).


The SalEst™ test is intended to detect and measure by enzyme-linked immunoabsorbant assay (ELISA) technology the level of salivary estriol in pregnant women.

The device is indicated for use as an aid in identifying risk of spontaneous preterm labor and delivery in singleton pregnancies. The device can be used every 1 to 2 weeks from gestational ages 22 to 36 weeks.


Blood Test Confirms Preterm Labor



About Bed Rest



Complete bed rest often results in a release of calcium from the bones, and this can also release any lead accumulated in the bones.  It's wise to ask your care provider how to counteract this - perhaps by a customized exercise regimen or dietary supplements.


Don't Take This Lying Down By SARAH BILSTON [3/24/06]

" . . . there is substantial doubt within the medical profession about the efficacy of bed rest . . .


Coping With Bedrest

As regards the colleague who has been given a bedrest 'sentence'... The absolute best form of support for women in bed during pregnancy comes from a group called SIDELINES. I am a volunteer with this wonderful organization made up of women who have had problem pregnancies and who now offer support to others on bedrest. We have a national magazine and will pair this woman up with someone in her region who has had a similar experience for emotional support. There is no charge for our services.

The idea of a doula lending support is a good one too. However, no one understands what it is like to be remanded to bed during pregnancy unless they have been there before. The emotional ramifications are so HUGE...especially at 5 months of pregnancy. ( I went into preterm labor at 22 weeks and spent the rest of my pregnancy in bed. )



Treatment of Preterm Labor



A nightly epsom salts bath can work wonders to reduce contractions.  After all . . . it's mag sulfate!


Benefit of Bed Rest Is Largely a Wives' Tale


I use alcohol for premature labor, usually in conjunction with a warm bath. I also have her push fluids (non alcoholic). If that doesn't provide an immediate relief, we start herbs such as wild yam and lobelia.

OK. I'm curious about whether anyone knows if nitroglycerin i.v. is used on a routine basis anywhere else in the world for immediate uterine relaxation? On which indications? They are/were making a study at the university hospital in Uppsala, and I have not been able to detect if they have obtained the necessary permission.


I know that the anesthesiologists where I work will use IV nitroglycerin if we have someone who needs uterine relaxation. It seems to work well but gives the woman one raging headache.


Yes, the nitro is the same stuff, just the method it is delivered in is different.

I would not recommend it's use without a lot of thought. One of the most prominent features is that it WILL lower the blood pressure. How much it lowers it is individual. I would hate to see someone crash with hypotension and no means to get it back up.


Yes! I have heard of nitroglycerin for uterine relaxation. No papers or studies, but from an anesthesiologist.

I had a client with where I missed her breech. She had SROM and called us. When we arrived she was 8cm and a butt was presenting. We called around and found that one of the local docs used as backup would do a vaginal breech as long as it was Frank or complete.

When we brought her in they did a double set up and the OB and Gas passer were excited as kids! It seems that the anesthesiologist was waiting to try his latest Gizmo. He explained that he was standing by with aerosol nitroglycerin, and if the aftercoming head was trapped by the cervix, he would spray the nitro under the mom's tongue and the nitro would relax the cervix to allow the head to be delivered.


Ok, now not saying I would ever do such a thing, but am thinking of the footling I did last year. Would the nitro be the same as the stuff for angina? It goes under the tongue. My deceased ex-husband had a bunch of those little bottles. Relaxing a cervix could save a baby's life, especially out-of-hospital birth.


There were a series of case reports a few years ago about nitroglycerin spray sublingual used to relax the uterus to allow internal version of second twins. For ages I kept some spray in my locker and never got to use it !


Do Not Use Ibuprofen

What I have heard about ibuprofen and other prostaglandin inhibitors is that while they may work there is the risk of premature closure of the ductus arteriosus. I think this was with indomethacin.

Coping With Bedrest

As regards the colleague who has been given a bedrest 'sentence'... The absolute best form of support for women in bed during pregnancy comes from a group called SIDELINES. I am a volunteer with this wonderful organization made up of women who have had problem pregnancies and who now offer support to others on bedrest. We have a national magazine and will pair this woman up with someone in her region who has had a similar experience for emotional support. There is no charge for our services.

The idea of a doula lending support is a good one too. However, no one understands what it is like to be remanded to bed during pregnancy unless they have been there before. The emotional ramifications are so HUGE...especially at 5 months of pregnancy. ( I went into preterm labor at 22 weeks and spent the rest of my pregnancy in bed. )


Resources about prematurity - a collection of Web resources put together by parents of a beautiful preemie.

 




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