Master Class

For preterm birth, we must avoid being too quick to prescribe therapeutic measures


 

As ob.gyns., our decisions not only deeply affect the health and well-being of our patients, but can also dramatically impact their children and families. Perhaps nowhere else is the gravity of our medical choices more felt than in the management of premature labor. Premature birth is one of the major drivers of infant mortality, which remains a significant public health problem in the United States where the rate of infant mortality is nearly 6 of every 1,000 live births.

Dr. E. Albert Reece, vice president for medical affairs at the University of Maryland, Baltimore, and the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine.

Dr. E. Albert Reece

Historically, ob.gyns. have used an approach whereby therapeutic interventions are applied based on the patient’s symptoms and disease manifestations, and not necessarily on the underlying biological mechanisms. The widespread use of tocolytic agents to delay preterm labor exemplifies this approach. Many of these agents relax the smooth muscle, thereby halting uterine contractions – the major symptom of preterm labor. However, these drugs can have severe side effects not conducive to a healthy pregnancy and birth, including hypertension for the mother and hypoglycemia, hypotension, and hyperbilirubinemia for the baby. Several different classes of drugs have been applied to prevent preterm labor, the beta-2 agonist terbutaline, the NSAID indomethacin, the calcium channel blocker nifedipine, and magnesium sulfate, all with varying results and none with broad success.

Therefore, when the two seminal studies were published that showed using injectable or vaginal progesterone successfully delayed labor with fewer neonatal complications, the findings were quickly embraced and applied clinically. However, subsequent studies indicated that progesterone is only beneficial to a certain subset of patients – those with singleton pregnancies and a short cervix. The variance in the results of this research highlights an important point: We must treat each patient as an individual, based on her unique medical history, circumstances, and, yes, symptoms. One size does not fit all.

Equally important is a greater need across our practice to avoid being too quick to prescribe therapeutic measures that do not treat the root of the problem. We must instead provide guidance based on rigorously conducted research and analysis. However, even very promising results should not necessarily be used to guide all of clinical practice, and certainly not without scrutiny and considerable analysis.

To dissect the available data and present the most current findings regarding progesterone use to prevent preterm labor, we have invited Steve Caritis, MD, professor of obstetrics, gynecology, and reproductive sciences at Magee-Womens Hospital, University of Pittsburgh, to be the guest author for this month’s Master Class.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

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