Fetal Health and Development

Mamas on Bedrest: How Progesterone Helps Prevent Preterm Labor

June 9th, 2014

Greetings Mamas!!

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.

 

Resources:

March of DimesA

Agency for Healthcare Research and Quality: Progesterone to Prevent Preterm Birth.  A Review of the Research About Progestogens for Women at Risk.

Mamas on Bedrest: Genetics and Stress add to Racial and Ethnic Disparities in Preterm Births

March 31st, 2014

Wow.

More and more research is indicating that not only genetics, but stress and racial and ethnic health care disparities are responsible for not only the rise in many chronic diseases, but also for the high rate of preterm births-especially in African Americans and Latinas.

Research in a relatively new field of genetics called epigenetics is finding that our environment-chemicals and other toxins-as well as increased stress are responsible in part (if not entirely) for the high rates of preterm labor in the United States. The United States has the highest rates of preterm labor and prematurity in the industrialized world, and rates are highest amongst African Americans and Latinas. While genetics and cultural evolution are often blamed for the increases, researchers have come to the conclusion that the rise in various chronic diseases, the rise in preterm births and the health care disparities that exist between the races simply cannot be explained by genetics alone.

Michael K. Skinner, a professor at Washington State University and the founding director of the Center for Reproductive Biology in the School of Biological Sciences is a researcher in epigenetics.

“Genetics is part of the story, an important part of the human story,” says Skinner. “But epigenetics, that is the other half of the equation.”

Epigenetics is the study of molecular changes including DNA methylation, the technical term for the way that our environments and experiences can subtly alter our gene activity. The genes turned “on” and turned “off” when we are exposed to certain chemicals, man-made poisons, or—perhaps most surprisingly—emotional experiences, can make us more or less susceptible to particular health problems.

Elizabeth Corwin, dean of research at Emory University’s Woodruff School of Nursing, and her team of researchers closely tracked more than 100 women during the last three months of their pregnancies. They found that women of all races and ethnicities who were poor during their pregnancies were more likely to suffer from chronic stress, a biologically detectable and quantifiable condition. But what was more alarming was that middle-class black women and all Latinas except for those who were immigrants were also more likely to suffer from chronic stress and they had higher rates of chronic stress and more pronounced negative side effects. According to Corwin and her colleagues,

Black women and Latinas across socioeconomic categories—those with and without insurance, college degrees, and access to the best food and information—were significantly more likely to test positive for elevated levels of stress hormones and conditions than those hormones can set in motion. This made the women more likely to deliver their children early. Chronic stress, the team determined, is the reason approximately 30,000 more African-American babies are born prematurely each year than any other group.

Corwin and her team also found that chronic stress is entirely different from day to day “annoyances”. ‘Chronis stress is created by some combination of financial stress, relationships stress, community pressures, and experiences like racism—actual and perceived.’ (paraphrased from original statement to add clarity)

What is even more alarming is the fact that stress experienced by one generation is actually perceived and affecting offspring 2, 3 and 4 generations out. Skinner and his colleagues have proven exposure to certain chemicals can affect the genes likely to activate in the sperm and egg cells of mice four generations down the line. His findings have been repeated in other large animals, been published in peer-reviewed scientific journals, and have significant implications for humans.

Both Corwin and Skinner know that their research will fall on many a “deaf ear” and opponents will balk at the implication that racism, classism and other forms of subtle and not so subtle discrimination are affecting the health of people and up to 4 generations removed. However, their research is clearly making the case.  Four to five generations ago, the ancestors of today’s middle-class African-Americans were likely to have been enslaved in brutal physical and emotional conditions. Large numbers of Mexican nationals came to the U.S. beginning in the 1940s to work in the agricultural industry were regularly exposed to chemicals used in farming. Some workers were even sprayed with pesticides upon arrival. Descendants of both ethnic groups suffer some of the worst health outcomes across the board. On top of that history, informal social codes, land prices, and land-use laws often leave poor communities closest to local waste facilities, mines where workers rake coal from the earth, or coastlines dotted with refineries and those residents who live in proximity to those areas at increased risk for disease.

Ana Penman-Aguilar is the associate director for science in the Office of Minority Health and Health Equity at the Centers for Disease Control and Prevention. She states that the CDC is very interested in this work as it has far reaching implications for our nation as a whole. “The Health of the Nation as a whole cannot be improved without making significant gains in Minority Health”, she says. And adds that the CDC is also a focusing on the social determinants of disease, “the way income, diet, neighborhood—basically how and where we all live, learn, work, and play—can drive health disparities.”

The study of epigenetics is a relatively new field, but its results are nothing short of astounding! While opponents may want to ignore the cultural and societal implications of this research, we can no longer claim ignorance of the role discrimination is playing in our society, especially as it pertains to the health of certain ethnic groups of people. If our interpersonal behavior is effecting people 2, 3 and 4 generations down the line, we as a society have no choice-if we wish to survive-but to address our societal and cultural biases and meet the needs of ALL our citizens.

 Reference:

Epigenetics: The Controversial Science Behind Racial and Ethnic Health Disparities.  The National Journal

 

Mamas on Bedrest: ACOG Issues New Guidelines for Gestational Diabetes Management

July 26th, 2013

Green_JournalHi Mamas,
While Gestational Diabetes Mellitus (GDM) is a less frequent reason for being prescribed Bedrest, GDM can significantly complicate pregnancy as well as maternal and fetal health. Close management of GDM and tight control of blood sugars is essential for best pregnancy outcomes.

In the August issue of Obstetrics and Gynecology, researchers report that new studies comparing single step and 2 step GDM screening indicate that 2 step screening, which is the current course of screening in the US, is still the preferred method of care. Many other countries use the single step method, but ACOG researchers feel more researcher needs to be done before recommending changing screening protocols.

The two step screening process requires pregnant women between 24 and 28 wks gestation drink a 50gm glucose solution followed by blood glucose levels taken one hour later. If a woman’s blood sugar levels are elevated, the test is repeated using a 100gm solution and blood levels drawn 3 hours later. If the second test comes back elevated, the woman is diagnosed with GDM and started on dietary management first, than oral medications and/or insulin injections are added if necessary to reach and maintain proper blood sugar levels.

According to ACOG’s report, 4 million American women give birth annually and 7% will develop GDM. GDM complicates pregnancy by putting mamas at increased risk of pregnancy induced hypertension, pre-eclampsia, c-section delivery and developing Type II Diabetes later in life. Infants born to mothers with GDM are at risk of macrosomia (being large for gestational age), hypoglycemia, birth trauma and c-section delivery.

GDM is a relatively common occurrence during pregnancy and is on the rise with the national rise in obesity and mamas delaying pregnancy until later in life. ACOG reaffirming it’s recommendation for the 2 step GDM screening procedure goes far in detecting GDM early and starting treatments as soon as possible when needed.