I am very pleased to present to you the interview that I had with Dr. Anthony Scisione, Maternal-Fetal Medicine Specialist.
Anthony Sciscione, D.O., serves as director of the Delaware Center for Maternal & Fetal Medicine and program director of the Christiana Care OB/GYN Residency Program. He is also Director of the Division of Maternal Fetal Medicine and the OB-Gyn Residency Program at Christiana Care Health System, the Director of the Delaware Center for Maternal & Fetal Medicine and Professor of Obstetrics and Gynecology at the Sidney Kimmel Medical College at Thomas Jefferson University. Dr. Sciscione is widely published and is a principle and co-investigator on a number of national clinical studies in Maternal-Fetal medicine as well as a reviewer for articles in maternal-fetal medicine/health and obstetrics and gynecology.
Dr. Sciscione graciously agreed review the role of progesterone in the treatment of preterm labor as well as in the treatment of incompetent cervix. He gives a great overview, shares what is currently going on in the research arena and answers questions submitted by Mamas on Bedrest.
Please enjoy this very informative podcast and share your comments, suggestions and questions about progesterone therapy in the comments section below.
Mamas on Bedrest: Can routine cervical measuring and treatment with progesterone as indicated reduce and/or eventually eliminate bed rest?January 6th, 2015
Hello Mamas and Happy New Year!!!
Right before we all took a much anticipated holiday break, The Society for Maternal-Fetal Medicine (SMFM) added their voice to those of The American Congress of Obstetricians and Gynecologists (ACOG), The American College of Nurse Midwives (ACNM), The March of Dimes, Medicaid and The Perinatal Research Branch of the Eunice Kennedy Shriver Institute to recommend that preterm birth risk screening include cervical length measurements and for those women at increased risk, treatment with progesterone injections.
Why is this important? Well, if you visit our Facebook page, you will notice that a large number of the mamas in our community are on bed rest for cervical insufficiency or incompetent cervix. Cervical insufficiency is one of the leading causes of preterm labor in the US and one of the leading causes of infant mortality (infant death). The United States ranks 55th globally in infant mortality, with 26,000 infants dying annually before their first birthdays. This is a horrendous and utterly embarrassing statistic given that the US is one of the richest countries in the world with some of the most advanced health care, yet we can’t seem to save our babies. What is worse, infant mortality in the United States for African American babies is twice that of Caucasian babies, so deaths among little black infants is disproportionately high in the US.
But despite all this doom and gloom, the upside is that all of these medical societies have looked at the data as well as at available treatments and they have all come to the same conclusion: If there is more screening for preterm labor in pregnant women-measurement of the cervix and in those women at risk, the initiation of progesterone injections-the rates of preterm labor can be reduced 40-50% in mamas having just one baby and no prior history of preterm birth. And if every pregnant woman is screened for shortened cervix and those at risk identified and started on progesterone shots, medical costs associated with preterm labor, premature birth and subsequent medical and developmental support could be reduced by $750 million annually. Given that preterm labor and prematurity currently costs the US in excess of $26.2 billion annually, this is substantial savings. All of the medical societies are also in agreement that if a woman is noted to have a shortened cervix and is less than 24 weeks gestation, she should have a cerclage (a surgical stitich placed to hold the cervix closed) placed.
Preterm labor and prematurity are major issues in Maternal and Infant health and the leading cause of infant death before one year in the United States. If by simply screening and measuring cervical length early on with ultrasound and providing treatment with progesterone and cerclage can reduce preterm labor and prematurity and save the lives of babies, then we should be adopting these recommendations.
The elephant in the room for us here is will these practices negate the need for prescribed bed rest? That subject was not addressed in these recommendations, however, many of these same professional medical societies are recommending that bed rest not be routinely prescribed due to the negative effects that is has on Mamas’ bodies. So it will be very interesting to see how these recommendations are implemented and their effect on the overall preterm labor and prematurity rates. My guess is that if rates start dropping, we my in fact see a reduction in the bed rest prescription. Now wouldn’t that be exciting???
Mamas, share this information with your health care providers and see what they have to say. If you’ve been screened for a shortened cervix and started on progesterone, let us know in the comments section below. We would love to share the journey with you (join our Facebook Community!!)! And if you are prescribed the progesterone and/or cerclage without bedrest, do let us know how you fare and when you deliver your baby.
Society for Maternal-Fetal Medicine Joins with Other Organizations to Brief Congress on Need for Medical Protocols that will Save the Lives of Infants in the US by Reducing Preterm Birth. (Press Release December 17, 2014, Washington, D.C. Society for Maternal-Fetal Medicine. www.smfm.org
Mama on Bedrest Addison asked this question of the community:
“Previous Bedrest Mama Here… I am currently 26 weeks, 3 days, due Sept. 6. I delivered my first little one at 35 weeks, after 5 weeks of bedrest. This pregnancy, I am getting Makena injections weekly and was wondering if they’ve worked for any mamas with previous preterm labor. Thank you in advance.”
First, I’m really grateful to Addison for asking her question and feeling comfortable enough with our community to share her story. The quick answer to Addison’s question is, “Yes, Makena injections do work.” Now let’s look at why Makena or 17 Alpha hydroxyprogesterone caproate (17OHP) shots work.
It really comes down to simple physiology. We all know that estrogen and progesterone cause the cyclic changes that are our menstrual cycles. In the first 2 weeks of our menstrual cycles, estrogen levels rise as a follicle in the ovary matures an egg in preparation for ovulation and subsequent fertilization. Estrogen also prepares or “plumps up” the uterus to receive the fertilized egg for implantation and subsequent development into the baby. At Ovulation, estrogen levels dramatically drop (and the egg is released from the ovary) and progesterone levels begin to rise during the last 2 weeks of the menstrual cycle. Progesterone maintains the plumped up uterine tissue so that the fertilized egg can implant in the uterine wall. If there is no implantation, progesterone levels drop and the outer uterine layer “sloughs off” and this sloughing is the resulting menstrul period.
If there is fertilization, the progesterone levels continue to rise so that the uterine wall continues to be a plump and fertile “ground” into which the growing and developing fertilized egg can embed. Progesterone levels will remain high thoughout much of the pregnancy, but especially during the first trimester so that the uterine wall stays rich and nutrient dense to “feed” the fertilized egg. By the end of the first trimester, the placenta has developed and it assumes the primary role of feeding the growing infant and progesterone levels will decrease, but still remain high in comparison to non-pregnancy levels.
So one can see that progesterone plays a vital role in the development of an infant. When progesterone levels are not high enough, the uterus doesn’t “plump” enough to be able to host a fertilized egg. When this occurs, a woman may miscarry early on in the pregnancy. This is what I had, and why I lost 2 of my pregnancies in the first trimester. Upon further evaluation, my OB discovered that I had a luteal phase defect; I didn’t make enough progesterone during the second part of my menstrual cycle, so my uterine lining would plump up, but not be sustained in an early pregnancy. Luteal Phase defect has also been named as the reason that I developed Uterine Fibroids. Without adequate progesterone in the second half of my menstrual cycles, my uterine linings didn’t fully “slough off” and my estrogen levels weren’t offset. So I had too much estrogen, not enough progesterone and fibroids-which love and live off of estrogen-and were able to grow.
But why do some women need to take progesterone in their pregnancies? If the placenta takes over the role of feeding and nourishing the infant, why do women need progesterone? The simple answer is because the uterine walls still need to be plump to maintain the pregnancy. This is the major role of progesterone during pregnancy. Yes, in early pregnancy it helps provide nourishment to the developing fetus, but progesterone’s major role is to sustain a rich, plump uterine wall in which the fertilized egg embeds, from which the placental tissue can draw nutrients and develop and so that the uterus remains a safe, protective environment for the growing baby.
Prescription progesterone helps prevent preterm labor in 2 particular situations: Incompetent Cervix and Preterm Labor.
Incompetent Cervix. A woman who has an incompetent cervix has a cervix that is shortening and thinning too early in the pregnancy. If this shortening and thinning occurs before 37 weeks of gestation, a woman is at risk of going into preterm labor. If a woman has a cervix that is shortening and thinning and is only carrying one baby, inserting progesterone gel into her vagina daily (Beginning between 20-23 weeks and continuing until 37 weeks or just before) will help keep her progesterone levels up, keep her uterus and cervix nourished and in functional form and prevent preterm labor. To date, there are no side effects to mama or baby from progesterone gel.
Preterm labor. Preterm labor is labor that occurs spontaneously before 37 weeks of pregnancy. The exact causes of preterm labor are unknown, but the bottom line is that the uterus begins to contract and be “inhospitable” to the growing baby, forcing it out. Progesterone shots have proven to be very effective at preventing preterm labor and preterm birth in women with a history of previous spontaneous preterm birth and who are carrying only one baby. Progesterone shots are either compounded (individually made solutions of) progesterone or Makena, pharmaceutically manufactured progesterone. Progesterone shots are typically started between 16-20 weeks and given weekly until 37 weeks of gestation. There have been no reported side effects of progesterone shots to mamas or babies.
So this is the long and short on progesterone. If you have been prescribed progesterone to prevent preterm labor, know that it has a long track record of efficacy and an equally long track record of no negative effects (except for some mild vaginal irritation with the gel and some mild irritation at injection sites) on mamas and babies. While it’s no fun to have to use progesterone gel or to take progesterone shots, know that this course of treatment is highly effective and will give you and your baby a great chance of going to full term pregnancy.