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
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.
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
in Amniotic Fluid Predict Risk of Preterm Delivery [Medscape
registration is free]
Uterine Contractions and the Risk of Spontaneous Preterm
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
Effective as Beta-Agonists for Treatment of Preterm Labor
[Medscape registration is free]
- Prediction and Risk of Preterm Labor [Medscape
registration is free]
Perinatal Pathology View of Preterm Labor [Medscape
registration is free]
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!
D Levels Linked to Lower Risk for Female Pelvic Floor Disorders
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
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.
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
Acid in Blood Linked To Preterm Births [Medscape
registration is free]
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
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.
Preterm Birth CME
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]
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
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
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.
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
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
Genetic Associations with Gestational Duration and Spontaneous Preterm Birth. [full text]
Zhang G1, Feenstra B1, Bacelis J1, Liu X1, Muglia LM1, Juodakis J1, Miller DE1, Litterman N1, Jiang PP1, Russell L1, Hinds DA1, Hu Y1, Weirauch MT1, Chen X1, Chavan AR1, Wagner GP1, Pavličev M1, Nnamani MC1, Maziarz J1, Karjalainen MK1, Rämet M1, Sengpiel V1, Geller F1, Boyd HA1, Palotie A1, Momany A1, Bedell B1, Ryckman KK1, Huusko JM1, Forney CR1, Kottyan LC1, Hallman M1, Teramo K1, Nohr EA1, Davey Smith G1, Melbye M1, Jacobsson B1, Muglia LJ1.
N Engl J Med. 2017 Sep 6. doi: 10.1056/NEJMoa1612665. [Epub ahead of print]
Conclusions In this genomewide association study, we found
that variants at the EBF1, EEFSEC, AGTR2, WNT4, ADCY5, and RAP2C
loci were associated with gestational duration and variants at the
EBF1, EEFSEC, and AGTR2 loci with preterm birth. Previously
established roles of these genes in uterine development, maternal
nutrition, and vascular control support their mechanistic
involvement. (Funded by the March of Dimes and others.).
Six Genes Linked With Preterm Births - Researchers have found mutations in six genes that affect whether a woman is likely to have a preterm baby. . . . “Not only did the study reveal several genes linked to preterm birth, it also identified a simple, low-cost solution — selenium supplements for expectant mothers — that, if confirmed, could save thousands of lives,” . . . Mutations in genes called EBF1, EEFSEC, AGTR2, ADCY5, RAP2C and WNT4 could often point to gestational time. Variations of three genes especially – EBF1, EEFSEC and AGTR2 – were associated with preterm birth, they found.
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.
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."
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.
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
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
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.
Helps Predict Preterm Delivery - although used primarily for
symptomatic women, this test also predicted asymptomatic labors,
such as occur with a yielding cervix.
don't stop preterm birth - Kings College Hospital London,
AND CERCLAGE PROCEDURES - a nice explanation with some good
links at the bottom
cerclage from surgeryencyclopedia.com
Cervix referenced from Uterine,
and Cervical Complications at childbirth.org
Information On the Incompetent Cervix - a personal Web page with some good links
meta page with links
Cervix - Medical Protocols
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.
The incompetent cervix is a diagnostic dilemma.
Cervical cerclage does not appear to cause any problems with the normal course of labor.
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
for the incompetent cervical Os. Improving the fetal salvage
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%.
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.
BY JODY A. CHARNOW c.1997 Medical Tribune News ServiceIn 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.
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
study published in the Journal of Periodontology showed
treating severe gum disease with scaling and root care cut
premature births by 84%.
Chlamydia, Gonorrhea Linked to Stillbirth or Preterm Birth [9/6/13] from Medscape
Microbiome May Predict Preterm Birth [8/18/15] - The
presence of a Lactobacillus-poor vaginal microbiome appeared to
exhibit "both dose–response and temporal relationships with
the Bacterial Vaginosis and Group B Streptococcus in Term and
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).
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
Drug Used to Prevent Preterm Labor Might Cause It, Study Finds [Jan 17, 2006]
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
Prevent Preterm Delivery in Pregnant Women with Asymptomatic
Bacterial Vaginosis. [Medline
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.
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?)
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
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
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
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
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.
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
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
weight in relation to plasma lipid concentrations in early
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."
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.
for probiotics to prevent bacterial vaginosis and preterm labor.
Reid G, Bocking A.
Am J Obstet Gynecol. 2003 Oct; 189(4): 1202-8.
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."
randomised controlled trial of vitamin E in the treatment of
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".)
Vitamin E on Prostacyclin (PGI2) and Prostaglandin (PG) E2
Production by Human Aorta Endothelial Cells: Mechanism of
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. :-(
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.
Most pregnancy belly support products are focused on back support
or comfort. As a way of helping to prevent preterm labor, it
can be helpful to get the baby's weight off the cervix, to reduce
cervical ripening, i.e. softening, funneling, early dilation.
A few products looked like they might be helpful in transferring some of the belly/baby weight onto the mom's shoulders and thus the spine, rather than onto the cervix and pelvis.
The Best Cradle from It's You Babe - Their Products page gives a brief overview of the different types of support available. The Best Cradle claims to support some of the weight of the pregnancy.
The Best Cradle from Perinatal Cares - Perinatal Cares also claims to be the manufacturer of the Prenatal Cradle brands, and they look exactly the same. I'm confused.
Babybellyband Shoulder Straps from Cabea - add-on shoulder straps
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
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.
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.
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!]
(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
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
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
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 . . .
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. )
A nightly epsom salts bath can work wonders to reduce
contractions. After all . . . it's mag sulfate!
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
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 !
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.