miscarriage
Mamas on Bedrest: Vaginal Progesterone Cuts Premature Births
December 23rd, 2011I’m tossing yet another tidbit of information for Mamas on Bedrest to share and discuss with their doctors.
In a study published online on December 14, 2011 in the American Journal of Obstetrics and Gynecology, a coalition of researchers from around the world (United States, Austria, Brazil, Denmark, India, South Africa, Turkey, and the United Kingdom) concluded that vaginal progesterone, administered in the mid-trimester of pregnancy to women with shortened cervix detected via ultrasound, can cut their risks of preterm labor by as much as half.
I found this information very interesting given the current brouhaha over Makena (the progesterone injections used for prevention of preterm labor) and how progesterone is often used early in pregnancy for women with repeated miscarriages (my situation!).
The researchers reviewed data from 5 highly respected studies and evaluated the efficacy and safety of using vaginal progesterone for the prevention of preterm labor in the presence of cervical shortening with rates of neonatal morbidity and mortality. Here are their findings:
- Vaginal progesterone reduced the rate of birth at less than 33 weeks’ gestation by 42% . It also reduced the risk for birth at less than 35 weeks’ gestation by 31% and less than 28 weeks’ gestation by 50% *.
- Vaginal progesterone also improved the following outcomes: respiratory distress syndrome, a composite measure of neonatal morbidity and mortality, birth weight less than 1500 g, admission to neonatal intensive care unit and need for mechanical ventilation.
Given these outcomes, one would think that physicians and researchers across the board would be recommending that women receive progesterone if they presented with shortened cevix. But such was not the case. Two commentators felt that the data was not conclusive enough. Sarah Bradley, MD, clinical assistant professor of obstetrics and gynecology from the University of Wisconsin–Madison felt that the data was “murky”. Her position stemmed from the fact that different studies used different definitions for shortened cervix. She also noted that many women had received a cervical cerclage (surgical stitch placed to keep the cervix closed) in addition to the progesterone and felt that it couldn’t be definitively stated that the progesterone was in fact the true reason that preterm labor was averted.
Aaron B. Caughey, MD, PhD, director of women’s health and chair of obstetrics and gynecology, Oregon Health Sciences University, Portland, had a similar comment on the definition of shortened cervix. He also felt that the meta-analysis really didn’t add any new information to what is already “standard of care”.
As a result, researchers recommend that women be advised of both treatments. While it is commonly recognized that either a cerclage or progesterone alone is often enough to prevent preterm birth, many women may elect to have both treatments and that is okay. Researchers also recommend that further research be undertaken to specify “shortened cervix” and to give specific measurements at which treatments are beneficial. They also recommend research to assess the effects of race, ethnicity, socioeconomic status, and maternal age on cervical shortening and preterm labor.
While I’m all in favor of evidenced based research, sometimes I think we analyze things to death. We know that adequate progesterone levels are essential to maintaining a healthy pregnancy. We see progesterone used in early pregnancy, especially in cases where women have undergone fertility treatments and/or have luteal phase defects resulting in repeated miscarriage. We know that progesterone injections (Makena and compounded variations) are effective in prolonging pregnancy in the instances of preterm birth later in pregnancy but before 37 weeks gestation. So I am not surprised that using vaginal progesterone is effective in helping prolong pregnancy and prevent preterm birth in cases of shortened cervix.
But I am surprised that commentators are pulling up short in making the recommendation that vaginal progesterone be used in the mid-trimester. Is it really necessary to determine that progesterone alone will prevent preterm birth in the presence of a cerclage? Is it really so awful if a woman has a cerclage and uses vaginal progesterone if she has a shortened cervix? And while it will be nice to know how efficacious progesterone is in various races, ethnicities, socioeconomic levels and in women of advanced maternal age, must we wait to have all this data before making recommendations? Can’t we do the work concurrently? It has been shown that use of progesterone produces more good than harm, so why not use it as currently stated and make the specific recommendations as the study data becomes available?
Many will judge my opinion and I am fine with that. But I was a woman who had repeat miscarriages until we figured out that my progesterone levels were not adequate to support pregnancy to term (beyond 1st trimester actually!). I know women who benefited from having progesterone injections in the second and third trimesters to prolong their pregnancies. I think that I can safely say, It didn’t matter if we were white or black, rich or poor, “old” or young, if it helped us to maintain our pregnancies and have healthy babies, we were all for it! If it helps specific subgroups, even better.
But on behalf of high risk pregnant women everywhere, please don’t wait to use a treatment that has been shown to be safe and efficacious in preventing preterm birth just so that you can get “exact” data. If you know that progesterone is efficacious in preventing preterm birth in a woman who has a cervix of 20mm and has a cerclage, why not try it in a woman whose cervix is 15mm or even 10mm? If she is at such risk, why not try? As a physician and scientist, you may think that it’s a waste. But for the mama desperately hoping and praying for her baby, it’s hanging on to all hope by a thread. Please don’t cut us off.
*This post is a summary and commentary of the MedScape report and the published article in The American Journal of Obstetrics and Gynecology online journal. Statistical information was attenuated for ease of reading. To read the full study results, please read the complete texts provided here.
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Mamas on Bedrest: Precious Soul Gone But Not Forgotten
October 19th, 2011Fall is my favorite time of year. But as the calendar approaches November 1st, I get a little wonky. On November 1, 2004, I learned that I had lost another precious soul, my second miscarriage, my third pregnancy.
Something about that miscarriage has stuck with me. For some reason or other that soul had, and still has, a hold on me. While I was sad when I had my first miscarriage (June 25, 2001), I was devastated with this one and I am not exactly sure of the reason for the depth of my feelings. Perhaps it was because I learned that I was pregnant on my daughter’s birthday, my 4th anniversary. Perhaps it occurred almost one year to the day that my father in law passed away. I have yet to make the connection, but November 1st is always a day upon which I stop and reflect on that little soul that I still miss and for whom I sometimes still shed a little tear.
I am a firm believer that things happen for a reason and I believe that to be the case for both of my miscarriages, my difficult pregnancy with my daughter, her traumatic birth and then the virtually complication free pregnancy and birth of my son. Even though I grieved deeply for this particular little soul that I lost, I have to say, had that soul survived, I would not have my son today. Had that soul survived, I very likely would have not started Mamas on Bedrest & Beyond. Had that soul survived, I would not be so determined to smooth the path for other high risk pregnant women.
They say that success comes out of struggle. I believe that there is an element of truth to that statement. When things go well, we seldom stop to reflect on the goodness of life. More importantly, we seldom push ourselves to present our gifts and talents to the world. But when there is a crisis, when the normal responses and actions just won’t do, that is when we dig deep and pull from a pool of strength seldom tapped yet rich with possibilities. It’s where we make the decision to push forward or give up in defeat. It’s a dark and difficult place, yet when we emerge, we are one step closer to “diamonds”.
My ruminations have come early this year. I suppose it’s due to the weather change here in Austin and the fact that it finally feels like fall-cool and breezy. And as I once again give pause for my precious little soul I say,
“You are gone yet not forgotten. Your tenure on this earth was mere weeks, yet the impact has continued for years. You’ve inspired me, caused me to move and to act. I love you!”
How has your high risk pregnancy experience changed you? If you have a soul (or souls) in heaven, how have they inspired you? Share your comments below.
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Mamas on Bedrest: Coping with Pregnancy Loss
March 14th, 2011
I got yet another heartbreaking e-mail last week. A grandmother-to-be was writing on behalf of her daughter. Her daughter is pregnant with her first child and at the 20 week office visit some anomalies were noted on ultrasound. Further evaluation showed that the fetus has malformation of blood vessels and some other anomalies consistent with a chromosomal defect. Physicians have recommended terminating the pregnancy. This mother/grandmother to be was calling to see if there are any resources that I could share to help her daughter deal with this devastating blow.
There is no easy way to help a mother who is losing or who has lost a child. I know this first hand because I suffered such loss myself-twice. There are no words to describe the grief of losing a child. You cry. You ache. You keep thinking, hoping, that’s it’s a bad dream and you’ll wake up soon. You hope that the OB missed something, that the baby was turned in some funny way and that’s why the heartbeat couldn’t be detected. Your mind does all these tricks in an attempt to shield you from the pain. But in the end, you have to feel the pain and endure its excruciating sting.
In the meantime, it’s a very powerless feeling to watch someone you love deal with this burden, so I can only imagine this mother/grandmother’s pain. On the one hand, she is grieving the loss of her grandchild. At the same time, she has to watch her daughter, her own baby, endure such unspeakable pain and not be able to take that pain away. I think that this pain is sometimes harder to endure. Ask any mother and they will quickly tell you that they would rather suffer themselves than to see their children suffer in any way.
The loss of a pregnancy or child is never easy. Even after time, there can still be considerable pain and sadness – especially surrounding the date of birth or death of the child. One thing is certain, the little life that is too soon over is never forgotten.
There are many wonderful resources and supports available to grieving families and below are just a few. They will also be posted in our Resources Section.
Comeunity – This website provides information and resources to families of premature infants and children and children with special needs. I particularly like the listing of helpful books and resources.
SHARE: Pregnancy and Infant Loss Support – A national organization providing resources and support following the loss of a pregnancy or child. I especially like their page telling family and friends what not to say.
Mommies Enduring Neonatal Death (MEND) – A Christian, non-profit organization that reaches out to families who have suffered the loss of a baby through miscarriage, stillbirth, or early infant death.
Mothers in Sympathy & Support (MISS) - The MISS Foundation is a non-profit, volunteer based organization committed to providing crisis support and long term aid to families after the death of a child from any cause.
Now I Lay Me Down To Sleep (NILMDTS) – This national non-profit organization assists families suffering an early infant loss with the gift of free professional portraiture. I know of a few families who have used this service and while they were initially opposed to photographing their infant are pleased to have this tangible memory of their child.
SHARE: Pregnancy and Infant Loss Support – A national organization providing resources and support following the loss of a pregnancy or child. I especially like their page telling family and friends what not to say.
The March of Dimes – A Comprehensive resource for families experiencing difficult pregnancies, preterm labor and prematurity and pregnancy loss.
The Missing Grace Foundation – A non-profit foundation started by Steve and Candy McVicar following the stillbirth of their baby daughter Grace.
I am concerned for this mother/grandmother. There will be few people who will ask her how she is faring. She may not even take time to grieve the loss being so focused on her daughter. But certainly, this mother/grandmother is as much in need of comfort as her daughter and son in law. Loss is loss. We have been corresponding and I will certainly do all that I can to support her. Hopefully she and her daughter will make use of some of the resources listed.
Pregnancy loss or the loss of a child is devastating. I am so glad that there are so many wonderful organizations and resources available to support families following the loss of a child. Please use these resources and please share this information with families in need.
