Midtrimester Loss: Preterm Labor vs. Cervical Incompetence
Saturday, March 01, 2008
Kenneth F. Trofatter, Jr., MD, PhD
Thanks to the many desperate patients I have had with advanced cervical change in midtrimester (generally, at 24 weeks or less), no evidence of overt infection, but some uterine contractions, who begged me to “do something because we have nothing to lose by trying at this point”, I quickly learned that many of these patients could have their pregnancies salvaged by using broad-spectrum antibiotics, a ‘rescue’ cervical cerclage, and suppressing the uterine contractions. In many (actually, most in my experience) of the cases, the pregnancies carried until there was a good outcome for both baby and mother. The only thing I asked these patients to agree with me on up front was that I would have to end the pregnancy, regardless of gestational age, if there was evidence of intrauterine infection. At that point, the mother’s life is at risk and there is no further benefit to the baby to remain in the uterus.
The series of comments below help you to understand the physician’s thought processes and, to some extent, the patient’s misconceptions, that occur around the always traumatic experience of losing babies in midtrimester. (I apologize to the reader because I have edited some of her comments).
• At Wed Feb 06, 06:57:00 AM 2008, Anonymous said…
Dear Dr T,
After my last miscarriage, my doctor evaluated me for the possibility of a thrombophilia problem but found nothing. Me and my partner have also had our chromosomes examined and both of us were normal. The upshot was that no causes for the miscarriages were found. This leaves me with a lot of questions. Why did I have twice very late miscarriages? Currently I am pregnant again, but I am very afraid that it will happen again. I fear that there is something wrong with me which have caused the miscarriages. How likely is this if I already have had a full term delivery? Could my second miscarriage have been caused by the progesterone injections I was given because of my first loss? Would you advise me to take progesterone injections in this pregnancy (my doctor does). Does progesterone have any adverse effects on pregnancies? I would be very grateful if you would like to answer these questions or advise me further on this.
Kind regards
• At Sun Feb 10, 07:02:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Feb 6: Answer several questions for me and then I will be in a better position to respond to yours:
1) Did you have the full-term pregnancy and then have the miscarriages?
2) Did you have any complications with the full-term pregnancy or with the delivery?
3) Did you have a vaginal delivery or a cesarean?
4) Have you had any cervical operations such as LEEP or cervical conization done?
5) How "late" were the miscarriages you had?
6) What were the circumstances surrounding those miscarriages, i.e., did the babies die in utero; did you have premature labor; did you break your bag of waters prematurely; did you have any evidence of 'infection'; did you labor or did your doctors put you into labor; did you receive progesterone with either of those losses; and, do you have any medical problems?
There are reasons for ALL of these questions and the answers will help me get a better idea as to what happened with your previous losses. Dr T
• At Wed Feb 13, 05:17:00 AM 2008, Anonymous said…
Here are my answers:
1) Yes, I had a full-term pregnancy first and had the two miscarriages thereafter.
2) The full-term delivery took very, very long (almost 40 hours from the first signs) and eventually I was given medicine to deliver my daughter. I could not have done it by myself probably. I had heavy bleeding afterwards (post-partum hemorrhage) and was very weak for more than two weeks following the delivery.
3) It was a vaginal delivery.
4) I don’t know what these (LEEP and cervical conization) are, but before having my daughter and the miscarriage, I had two abortions (I was too young then). And after the first late miscarriage the doctor cleaned up my uterus (did a D&C) as the pregnancy product did not leave my uterus completely (retained placenta).
5) The first time the baby was 20 weeks and a couple days old, he was born alive and I had premature labor. After this miscarriage the doctor thought (although I didn't have any infections) that the miscarriage might have been caused by a bacteria (slight increase of granulocytes in my blood) or cervical incompetence. However, he was not sure. I also then had a severe allergic reaction to the antibiotic I was given in the hospital in order to prevent any infections. My blood pressure was 80/40 and I was in very bad condition. So maybe this might also have caused the increase of the granulocytes or even the eventual delivery as I did not have a lot of dilation at first, but the situation got worse after I got the antibiotics.
The second time I delivered at 19 weeks; the baby probably had died at 15/16 weeks. I had no labor at all and was given medicine to deliver. Only in this pregnancy I was given progesterone (starting at week 16 because of the first miscarriage and in order to prevent any cervical incompetence. Again this time there were no signs of infections, and to my knowledge I am healthy and do not have medical problems. My age is 35.
In both cases I did not have break of bags/water.
So this leaves me with questions: Why does this happen so late and do I have to live with the knowledge that this kind of thing happens without reasons? And, could the second miscarriage have been caused by the progesterone as the period the baby died was more or less the period I started with the injections? Would you advise me to take these injections also in this pregnancy?
Would you advise me to take extra vitamins, other than folic acid (as I have been pregnant many times in a relatively short period)? Could this circumstance have played a role (short period in between pregnancies) in my losses? I would be grateful for your answers.
• At Fri Feb 22, 07:06:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Feb 13: I do not think the abortions you had when you were younger contributed in any way to your more recent losses. However, I am worried that the first full-term delivery might have. You could have had damage to your cervix from the difficult labor and delivery or from the D&C procedure that had to be done to stop your hemorrhage.
I believe your first loss at 20 weeks, was the result of cervical incompetence and probably a secondary ascending infection. Once the cervix started to change, the contents (baby, membranes, and placenta) are more readily exposed to the bacteria within the vagina. I am not sure you really had an 'allergic reaction’ to the antibiotics. The low blood pressure and being in “very bad condition” is more consistent with 'septic shock’ resulting from a bacterial infection that had gotten into your blood stream from your uterus. I also do not think either the antibiotics or your 'bad reaction' caused you to lose that baby, it may well have just seemed that way because everything was getting worse after the antibiotics were given, but it was probably too late for them to be of any benefit. Significant infections in the womb will usually cause delivery within 48-72 hours regardless of any antibiotics that could be given to you.
Your loss at 15-16 weeks might also be the result of infection, or perhaps the baby had a chromosomal abnormality and that’s why he/she died. It is VERY unlikely the progesterone alone caused you to lose that baby. Indeed, the baby could have died even before you got the first shot based on the timing you have given to us. However, some people believe that progesterone can possibly reduce your body's ability to fight off some infections (although that has NOT yet been proven), so I will not rule out that possibility completely.
Before you get pregnant again, I would recommend that you have a sonohysterogram and perhaps a hysteroscopy done to evaluate the uterine cavity for any abnormalities that could be present (e.g., fibroids, polyps, scar tissue, and endometriosis). Your doctor might also consider treating both you and your husband with a 10-14 day course of an antibiotic such as doxycycline. I would suggest starting a prenatal vitamin and extra folic acid a month or two before you decide to try again and then, when you do get pregnant, personally, I would recommend placement of a cerclage at 13-14 weeks. I also recommend that before that is done (at 11-12 weeks), you have first trimester screening for aneuploidy (fetal chromosomal abnormality) performed. This involves only a simple ultrasound of the baby and some blood work on you. Your doctors can explain all of these procedures and the reasons for having them done. Incidentally, I would probably also offer you the progesterone injections again, serially follow your cervix by ultrasound starting at 15-16 weeks,and periodically evaluate you for evidence of asymptomatic urinary tract and vaginal infections until you got past 28 weeks.
Best of luck to you and please let us know what is found, what you do, and how things turn out!
Dr T
Labels: 17-hydroxyprogesterone caproate, cerclage, cervical incompetence, midtrimester pregnancy loss, preterm labor
6 Comments:
At Tue Apr 29, 12:56:00 PM 2008,
Mamma-to-be said…
Dear Dr T,
I have a question related to the suggested empirical treatment you described above. I had two second trimester losses, and was advised on an empirical treatment very similar to yours. I am currently 19 weeks pregnant with a cerclage placed at 12w and getting weekly 17p shots. I'm taking prenatal vitamins, and 4mg of folic acid daily.
My question is how should the periodical evaluation for evidence of asymptomatic urinary tract and vaginal infections be conducted, specifically the vaginal infections? Visually and by smell done by an OB or with vaginal cultures? Which bacteria could be found to be harmful to the pregnancy if found in the vagina? (MY OB is against vaginal cultures unless he notices smell and discharge. His opinion is that different type of normal bacteria will be found in the vagina and so the culture wouldn't lead to any complication or alert us of any upcoming problem.) I was just wondering what your suggestion was when you recommended those tests...
The treatment I'm following includes Macrodantin 100mg from week 14 through 36. Taking this antibiotic prophylacticly hasn't been well received by a different MFM specialist I consulted. Your thoughts?
Lastly, a few weeks ago I wrote you about my Modified Sequential test results. I just want to mentioned I had an amnio done 10 days ago and I'm still waiting for the results. I will update you once the results come in.
Thanks again for such a fantastic blog!
Mamma-to-be
At Thu May 01, 07:33:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Mamma Apr 29: I usually will not put you on suppressive urinary tract infection prophylaxis unless you have a history of recurrent asymptomatic urinary tract infections or a history of pyelonephritis (kidney infection) during pregnancy. Women can be screened for asymptomatic infections at each regular office visit by a simple dipstick that includes nitrites and leukocytes. If these are positive, then a culture can be sent.
With regard to the vaginal infections, I also usually don't use prophylaxis in patients who have an uncomplicated first trimester cerclage, simply screen by asking if you have any change in discharge, and then look if you do. Some women will develop a chronic 'bacterial vaginosis' discharge related to the fact that the cerclage is a 'foreign body' in the vagina that may make it easier for the unfavorable bacteria to grow. When this occurs, or if a patient has an emergency cerclage placed later in midtrimester, I will place her on metronidazole to treat the acute infection and then a lower dose on an ongoing basis (2-3 times per day) for sometimes the duration of the pregnancy. An alternative is to treat acutely and simply retreat each time the discharge comes back. There is no "right way" to do this, but it is an approach I have used very successfully over the years. Good luck to you and please let us know about the amnio results! Dr T
At Thu May 01, 12:55:00 PM 2008,
Mamma-to-be said…
Thank you again Dr T for your response.
I actually saw my OB this morning and he decided to discontinue the Macrodantin.
And the Amnio results are back! We have a healthy baby on our way! We decided to not find out his/her gender yet...
Best, Mamma-to-be
At Thu May 01, 06:13:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
Congratulations Mamma! Best of luck for the rest of the pregnancy and thanks for letting me know. Dr T
At Wed May 07, 08:48:00 AM 2008,
Anonymous said…
Dear Dr T.
I had a question regarding Hydroxyprogesterone injections given weekly between weeks 20-36.
I suffered the loss of my first pregnancy at 22 1/2 weeks. At 17.5 weeks I had a sudden bleed due to a low-lying placenta which never healed. I bled continuosly till 22 weeks and then my water broke. The doctors were concerned that I may develop an intrauterine infection and the baby had no chance of survival at that stage so I was induced and delivered. The baby was immobile on birth and it was a very traumatic loss.The reason given to us was that there was a placental abruption and that the constant bleeding led to the amniotic membrane rupture.
I am now in my second trimester about 18.5 weeks and have been followed closely by the ob and specialists. I have been on folic acid from the start but I have also been recommended weekly hydroxyprogesterone injections. I have a few questions as I am trying to research more about these injections.
1. Do you think I need these based on my previous history? i.e. am I an ideal candidate for these. My cervical length is so far normal around 5cm today.
2. What are the side effects of these injections for both me and baby? I read something about the urinary tract formation in boys can be misdirected. Is this something I need to worry about at this stage? We know we are expecting a boy.
3. What about after birth, are there any known side effects in childhood or am I putting my child at greater risk for any type of diseases/conditions?
4. Is this form of progesterone used commonly in women both in the US and Europe?
I guess I am concerned about the risks versus benefit. I really want a full-term healthy and normal pregnancy but I am confused as I need to make a decision soon. Any information would be much appreciated. Thanks very much
Mum to be
At Fri May 09, 07:11:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
Dear Mum to be: You lost your last baby as the result of the persistent bleeding and ascending infection. That commonly happens. Was there any evidence of premature cervical change when you first had the bleeding with that pregnancy - doesn't sound like it. In view of your concerns (and the past history and the current cervical length) regarding 17P, it is probably safe to simply follow your cervical length by ultrasound and then consider 17P and/or cervical cerclage if the c ervix begins to develop 'funneling' (loss of integrity at the internal cervical os with protrusion of membranes into the cervical canal). However, at this point, it is very unlikely that 17P would cause any fetal abnormalities and as far as we know, there have not been any long-term developmental problems with 17P-exposed babies, although there is always a chance that something 'subtle' has been missed or will be found along the way. Yes, 17P is being used in many countries around the world and is a drug that was used for many years before the studies were published supporting its use in women who have previously had preterm deliveries. Good luck and I hope this answers some of your questions. Let us know how things turn out! Dr T
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