Preterm Labor or Cervical Incompetence?: Unclear Diagnoses Complicate Choices for Therapy
Thursday, February 14, 2008
Kenneth F. Trofatter, Jr., MD, PhD
Thu Feb 07, 02:36:00 PM 2008 Anonymous said...
I have previously been pregnant 3 times and have delivered prematurely with all of them, 17 wks, 22 1/2 wks, and 7 1/2 wks. I am currently pregnant for the fourth time, and will be 16 wks this saturday. My doctors suggest that I have weekly injections of 17-hydroxyprogesterone to prevent preterm labor of this pregnancy, however, they are uncertain as to whether the cause is preterm labor or incompetent cervix. I am very skeptical when it comes to relying on drugs of any sort, and am not sure as to whether I should go through with this treatment or not, only to regret it later I have researched this and have not found enough inormation assuring its safety. I am currently on bed rest. Can strict bed rest keep me from delivering prematurely again, or will I need to have the injections administered? Are there any alternatives to this?
Thu Feb 14, 07:24:00 PM 2008 Kenneth F. Trofatter, Jr., MD, PhD said...
To Anonymous Feb 7: Personally, with your history, I would have placed the cerclage at 13-14 weeks, still followed your cervix with serial ultrasound examinations, starting at about 16 weeks, and considered the 17P if you had any evidence of uterine activity or cervical shortening. I think you would "regret" delivering early again much more than you will ever have cause for regretting the use of 17P. As an alternative, however, we have done a study with a vaginal progesterone compound (Prochieve) that seemed to be most effective in preventing early delivery in women with a short cervix (De Franco, et al., Ultrasound Obstet Gynecol 2007;30:697-705). Since this is a compound with the same 'natural' progesterone that your body and the placenta make, it should be completely safe for the baby. I do NOT trust bedrest alone under these circumstances for various reasons, especially if you have an incompetent cervix (and there are risks such as deep venous thrombosis and pulmonary emboli from prolonged bedrest). And I certainly do not trust progesterone alone in any form for a true incompetent cervix! Good luck and let us know how things turn out. Dr T
Thu Feb 07, 02:51:00 PM 2008 Anonymous said...
Dear Dr. T:
In your opinion, which is more beneficial, a cerclage or 17-hydroxyprogesterone injections? I was recently told What factors make me a candidate for either of these and determine their effectiveness? What are the risks and side-effects, long-term and short-term?
Thu Feb 14, 06:58:00 PM 2008 Kenneth F. Trofatter, Jr., MD, PhD said...
To Anonymous Feb 7: Your questions are straightforward and excellent and the answer is not so simple. At some point I will have to devote another whole post to cerclage. The answer depends on what your doctors think they might be treating and quite frankly, that depends, somehwat, on a detailed review of the previous pregnancy complications that have led you to this point. If you truly have an 'incompetent cervix', personally, I am a cerclage person. Placed early in pregnancy (13-14 weeks), a cerclage carries very low risks and is highly effective if the person who has placed it really does it right. Unfortunately, many cerclages are NOT well-placed and their efficacy has come into question more for this reason than anything else.
Your doctors probably have not been able to determine (based presumably on your past OB history) whether you had problems related to premature labor or whether you have an incompetent cervix. (It can be extremely difficult once the cervix has begun to change to decide which came first, the cervical change or the contractions). Under those circumstances, we will often follow you with cervical ultrasounds, consider using 17P if the history is strong enough, and then place a 'rescue cerclage' if and when the cervix starts to shorten (particularly if there is "funneling" of the membranes into the cervical canal), although this might not happen until 18-22 weeks (and sometimes even later). Of course, placing a cerclage at this point always carries more risk (primarily related to infection) than if placed earlier in the pregnancy, but again, in experienced hands, it is often successful in prolonging pregnancy, especially if very early preterm birth appears imminent if something isn't done (and there is no evidence of intrauterine infection already). The 17P appears to be relatively safe from midtrimester on, but I would suggest you read the blogs I have already posted on this subject. I wish you luck! Please let us know how things turn out.
Dr T
Fri Feb 08, 05:46:00 PM 2008 Anonymous said...
Dear Dr. Trofatter:
If I take 17P for one pregnancy, would I be required to take it for all future pregnancies, or will I be given the option?
Thu Feb 14, 07:29:00 PM 2008 Kenneth F. Trofatter, Jr., MD, PhD said...
To Anonymous Feb 8: If the 17P has a beneficial effect in your case, that will not carry over to another pregnancy. It has no long-term benefits. If you take it for one pregnancy, didn't really need it, and did well, you'll probably do well the next time whether or not you take it! The question is, do you want to take the chance of not taking it if you really do benefit it! Wish the answers were simple, but they are not! Thanks for reading!
Dr T
Labels: 17-hydroxyprogesterone caproate, 17P, cervical incompetence, preterm labor
12 Comments:
At Fri Feb 15, 01:21:00 AM 2008,
Anonymous said…
I am currently 19wks pregnant with my first child and have a huge growing concern. I started growing right away at 3 months but since at least the start of the fourth have not seen any changes whatsoever. Im tiny, you cant tell im pregnant at all, have no symptoms and have not yet felt any movement. Im terrified something may be wrong and cant see a doc until next week. Is this normal?
At Fri Feb 15, 10:00:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Feb 15: I think you should call your doctor's office and tell them exactly what you have told me. Everything may be just fine, and I hope it is, but it would be very easy for them to find out for sure at this point. Best of luck to you and please let us know! Dr T
At Wed Apr 23, 02:06:00 PM 2008,
answers said…
im currently 16wk with my 4th child and my 1st was born at 24 1/2 wk and my 2nd was a termination my 3rd was full with a cerclage and now at 16wk my doc is trying bedrest and 17p injections. He tried to place a cerclage at 15wk and was not successful while operating he discovered that my cervix was too short and thin to place the cerclage without rupturing membranes. Do you think i can survive this pregnancy or do you recommend something else?
At Thu Apr 24, 06:28:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To answers: I suggest you see a specialist in Maternal-Fetal Medicinc. If you really have cervical incompetence, the 17P alone may not be adequate. You might be a candidate for a Shirodkar cerclage or even an abdominal cerclage. Eiether one would be better placed SOONER than much later in the pregnancy. Good luck! Dr T
At Mon Jul 28, 03:14:00 PM 2008,
Nicole said…
I am on pregnancy #2. 1st pregnancy had zero complications. This pregnancy I began bleeding due to placenta previa at 11.5weeks and continued for 6 weeks. There is no longer any sign of a previa but about a week after the bleeding stopped (19wks)I began to have a lot of pressure. My ultra sound showed that I had a shortening cervix 2.2cm. I am now at 29.5 weeks and my cervix has been measured weekly and bounced around between 2.1 - 2.9cm. I am currently at a 2.1cm and have been on bed rest since 19 weeks along with 600mg of ibuprofen & 30mg of Nifedical XL 3 times a day. I am very worried about taking all these drugs. My Dr. assures me that it will not harm the baby and that it is better than having the baby premature. Can you please tell me your opinion on this???
At Mon Jul 28, 05:21:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Ncloe: Those drugs are relatively "safe" and in difficult patients I have used a similar regimen. But, you are getting far enough along that some thought should be given to stopping the ibuprofen soon. NSAIDs can have some constricting effects on the fetal ductus arteriosus (the blood vessel by which most blood bypasses the lungs and goes directly into the aorta. It's nt suposed to close until after the baby is born. Have the baby's growth and fluid been good luck. Dr T
At Mon Aug 25, 06:21:00 PM 2008,
gloryrevealed said…
I am currently almost 20wks pregnant with our third child. I had preterm labor with both of my earlier pregnancies and my 2nd was born at 35 weeks. I began to have contractions at 12 weeks and have had bi-weekly or weekly tvs ultrasounds to watch my cervix. I had an early complete placenta previa and now have a partial. We've seen some evidence of blood clots near the cervix, although I have not had any bleeding. Between 15 and 19 weeks, my cervix shortened from 3 cm to 2.6 cm, despite bed/pelvic rest. This week, my doctor put me on cephalexin/metronidazol to treat any possible infection prior to a cerclage, should I need one, as well as 600 mg ibuprofin/4 x per day to try to stop contractions that are getting stronger. We've done lots of "lifestyle" modifications, including hydration, protein, folic acid, and calcium-magnesium suppliments. We've decided not to use 17-P based on questions about it's long-term safety. I have two questions - first, if the primary issue is uterine irritability, can a cerclage make this worse? Second, what is the difference between indomethacin and ibuprofen? Thanks!
At Mon Sep 15, 06:49:00 AM 2008,
Anonymous said…
I am 15 weeks pregnant and have the normal ligament pain and cramping, but the other day I felt contractions, my belly was hard as a rock and it came and went very frequently. I did have a leep procedure done about 6 months before I became pregnant and they have me scheduled anyway for a cervical length u/s in 10 days. I informed the midwife of this new symptom, and she said it is okay, just come in in 10 days for the u/s...and drink lots of fluids. Should I be worried that they won't do the u/s now - in case I need a cerclage?
Shannon
At Tue Sep 23, 06:22:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To glory: In my experience, a cerclage by itself rarely makes the uterine irritability worse except in the immediate post-operative period (3-7 days). And, I do believe a cerclage will decrease your risk for earlier delivery if you have uterine irritability that can slowly wear down the cervical integrity - although this point has yet to be proven in our literature. In cerclages placed later in pregnancy, as will be the case with you if it is done, I agggressively treat contractions and watch carefully for infection. I usually start off with a 72 hour course of indomethacin. Both indomethacin and ibuprofen are nonsteroidal antiinflammatory drugs (like aspirin) but indomethacin is more potent for control of contractions. Unfortunately, prolonged use of indomethacin can cause a reduction in amniotic fluid by affecting (reversibly) urine production by the fetal kidneys. I will frequently switch to ibuprofen if indomethacin has been effective in decreasing uterine irritability or to a drug such as nifedipine. Good luck and let us know how things turn out! Dr T
At Tue Sep 23, 06:25:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Shannon: It would be unusual to have significant cervical change with an incomptenet cervix this early in pregnancy, but it can occur. I think it would be a good idea to look for evidence of a urinary tract infection and have the cervical ultrasound done sooner if the symptoms persist. Good luck and let us know how things turn out. Dr T
At Tue Oct 14, 11:43:00 AM 2008,
Anonymous said…
I am 27wks, and for the last month of me going to the doctor my cervix has been shortening. It went from being 4 centimeters to 2.9 centimeters all within 3 weeks!! I've been having weekly ultrasounds because of this and my doctor says that if when I go back to the doctor if my cervix is 2.5 or less I would have to get stitches. What does this mean?
At Fri Oct 17, 03:55:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 14: It could mean you have some degree of cervical insufficiency or it could mean absolutely nothing. You did not tell me if this is your first baby, or if you are having contractions, or if you have carried other pregnancies to term, or if you have delivered prematurely before. All of these factors (and several others) play into the significance of the cervical change or lack thereof. It is unusual in this day and age to place a cerclage at 28-30 weeks, so if that's what your doctor thinks should be done, you might just ask for a second opinion from a specialist in Maternal-Fetal Medicine. Regards and best wishes for the rest of the pregnancy! Let us know what happens. Dr T
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