By Camille D. Walker, MD, FACOG
This is something that goes through every woman’s mind when she has had a premature baby. You wonder why did this happen to me, will this happen again, and what can I do to prevent this from recurring.
Unfortunately, the majority of cases of preterm delivery occur in women with no risk factors and/or risk factors that cannot be changed. In addition, science has shown there are biochemical, hormonal, anatomical and other causes for preterm delivery but there is continuing debate as to the final pathway(s) for preterm delivery. Approximately 80% of deliveries are spontaneous (unexpected) but the other 20% are due to medical or pregnancy situations that require a preterm delivery. Some risk factors for spontaneous preterm deliveries include previous preterm delivery, twins and greater, problems with the uterus (holds the baby) and/or cervix (mouth of uterus that opens for baby to come out) and African-American heritage.
In the United States, 1 in 9 babies are born premature. About 1 preterm baby is born every minute! The subsequent risk for another preterm delivery is two fold (15 – 30%) but most women deliver at term. Some factors that increase risk for another preterm delivery include African-American heritage, short interval between pregnancies (6 – 18 months) and gestational age of preterm delivery (the earlier the delivery, the higher the risk for another preterm delivery).
What can you do prior to another pregnancy to the decrease the risk of another preemie?
- WAIT an appropriate time interval to get pregnant again ( > 12 – 18 months)
- STOP smoking or using illicit drugs such as cocaine, and decrease drinking
- Extremes of weight have been associated with preterm delivery. Weight loss or weight gain maybe recommended prior to pregnancy.
- EAT healthily—start prenatal vitamins before next pregnancy. Some studies suggest that folic acid and omega – 3 fatty acids may improve outcome (controversial).
- SPEAK with high risk pregnancy specialist (maternal fetal medicine specialist or perinatologist) prior to next pregnancy
- To review if other risks factors, such as history of surgery on the cervix—cone biopsy or multiple abortions ( > 2)
- To perhaps have special testing of the uterus to determine if there is a defect that increases risk for preterm delivery
- If it was an indicated preterm delivery, the doctor may order blood work or other testing to see if there are risk factors for another preterm delivery.
- To discuss potential management with the next pregnancy
- If your next pregnancy is going to be the result of in-vitro fertilization, ask for the transfer of one embryo to decrease risk of twins and higher.
What can be done during pregnancy to decrease risk the risk of another preemie?
- Start prenatal care very early to initiate preventative therapy
- Request to be seen by a high risk pregnancy specialist, if not seen prior to pregnancy
- If in your previous pregnancy you delivered spontaneously between 20 0/7 – 36 6/7 weeks, you are a candidate for 17- hydroxyprogesterone (17-OHP) injection (hormone injected on a weekly basis between 16 – 20 weeks until 37 weeks). Please note that some doctors may start therapy if your prior pregnancy outcome occurred between 16 – 19 6/7 weeks. Even if you have a spontaneous delivery at 36 weeks, it is still a preterm delivery and you are a candidate for the 17-OHP injections.
- Ask the doctor to start monitoring your cervix every 1 – 2 weeks between 14 – 16 weeks. If the doctor sees that the cervix is shortening and/or opening up from the inside, he/she may recommend a cerclage (stitch around the cervix to hold the baby) and/or vaginal progesterone (hormone placed in the vagina to decrease preterm delivery). Vaginal progesterone is more likely to be used if the cervix is short and there is NO history of preterm delivery.
- Some doctors may also perform fetal fibronectin testing (swab of the vagina which can predict risk for preterm delivery) between 22- 34 weeks.
- Screening for certain infections has not been shown to decrease risk of preterm delivery. However, some studies suggest that treatment of urinary tract infections (bladder infections) can decrease risk of preterm delivery.
- Be aware of signs and symptoms associated with preterm labor/delivery such as menstrual cramps with or without diarrhea, contractions, pelvic pressure, vaginal bleeding or leakage of fluid, change or increase in vaginal discharge, or lower backache or pain. If present, contact your doctor for further instructions.
- Reduce moderate/severe stress level
What happens if you go into preterm labor again?
- The doctors will use tocolytic drugs (special medications stop labor) long enough for your baby to receive steroid shots (drugs to help strengthen the baby’s lungs).
- The doctor may use fetal fibronectin testing (see above) to predict risk of early delivery
- You may be transferred to a regionalized perinatal center—centers that have high risk pregnancy specialists and neonatal intensive care units ( units that take care of premature and high risk babies).
- Antibiotics may be used for a short period of time to decrease risk of infection in the baby or prolong pregnancy, if your water bag broke.
- One of the tocolytic drugs is called magnesium sulfate and has been shown in some studies to protect the baby’s brain. Some of the studies suggest that this drug be used if preterm delivery is likely. Please note there is no consensus on timing and dosing.
- If you are at high risk for delivery, speak with neonatologist (high risk baby doctor) to review issues and management after the baby is born.
- If your labor is stopped, please note that long term tocolytic drugs (usually taken by mouth) have not been shown to prolong pregnancy and are usually not used after the acute treatment of preterm delivery.
- Please note that bed rest, limited work and reduced sexual activity has not been shown to reduce preterm delivery in women at risk. However, we as healthcare providers, including myself sometimes, continue to recommend this. Some studies have shown bed rest to increase risk of gestational diabetes, excessive weight gain and thrombosis (blood clots). In addition, this can cause social and psychological disruption such as income loss.
So if you question if you should have another baby, in most cases, the answer is YES. The majority of times the next pregnancy will be a full-term delivery. Don’t wait until the next pregnancy to start evaluation. Be PROACTIVE and start before your next pregnancy. There are now certain precautions and treatments that can be used to decrease the risk of preterm delivery. As with all medical information seen on any website, please discuss and review with your healthcare provider.
Good luck with next pregnancy!