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Pregnancy After A Preemie

Once you've given birth to a preemie or have experienced a high-risk pregnancy, the decision to have another child can be a very difficult one. Three guest obstetricians have kindly answered some of the toughest questions about preterm labor, preterm birth, and pregnancy after a preemie. Talk with a doctor you trust about your specific circumstances, and discuss all your available options for prevention of preterm birth and treatment for preterm labor. We hope these questions and answers help you in your next pregnancy journey!

With my first pregnancy, I had several instances of preterm labor, starting at 29 weeks.  I want to ask my doctor about progesterone shots when we decide to have another baby. How successful are progesterone injections (17P) in women who have previously delivered a baby preterm or who experienced preterm labor in a prior pregnancy?

For women who have had a preterm birth (birth prior to 37 weeks’ gestation) in the past due to preterm labor, it is recommended that they be offered some form of progesterone to prevent recurrent preterm birth.  Progesterone can be given in one of two ways: either with weekly injections of 17-alpha hydroxyprogesterone caproate (17P) or with nightly vaginal progesterone suppositories. The medication should be started by 16 to 20 weeks of gestation and continued through 36 weeks. 

Studies have shown that either form of progesterone significantly reduces the risk of recurrent preterm birth by about 40 percent to 50 percent in women who have experienced preterm birth in a prior pregnancy due to preterm labor or preterm ruptured membranes.   —Dr. Ashley Roman

I'm getting the 17P injections, but I am having contractions more and more. They are irregular. They start and then go away. They don't seem to be getting more painful. Is this okay? I am 21 weeks and not on bed rest. Should I be?

To reassure you, it is common for all women to have some contractions throughout the pregnancy. These are rarely associated with preterm labor. The fact that yours are irregular is reassuring.  Beyond that, it is difficult to draw any conclusions without knowing more about your OB history and the indication for 17P injections. 
 
There are special tests that we commonly use to help us determine if preterm contractions represent merely 'false labor' versus if they are a risk for actual 'preterm labor'.  One test is fetal fibronectin. The other is transvaginal sonogram of the cervix. These are excellent tools to help doctors and pregnant women better understand the current risk for preterm birth. As a result, we all benefit by having either reassurance that that contractions are harmless or by having an opportunity to take actions to benefit the unborn child, such as using medications to halt labor and to mature the lungs and blood vessels. —Dr. Jim Byrne

I went into preterm labor with my first pregnancy in February. At the hospital, I was put on high doses of magnesium sulfate, terbutaline and endomethacin. After 48 hours, enough time to get the steroid shots the baby needed, attempts to keep him in were stopped and I delivered at 26 weeks. My discharge summary says, "With a future pregnancy, she would be a good candidate for weekly intramuscular 17-alpha-hydroxyprogesterone caproate beginning at 16 weeks gestation. Serial cervical lengths and/or a cerclage could also be considered, as her presentation falls into the gray area between preterm labor and cervical incompetence." Could you explain why the doctor says it is a gray area between cervical incompetence and preterm labor?

Cervical incompetence and preterm labor are two different problems, but each can lead to preterm birth.  Cervical incompetence is typically characterized by painless cervical dilation leading to pregnancy loss or early preterm birth.  In most case, it is detected when a woman comes in for a routine office visit or ultrasound and the cervix is found to be incidentally dilated on examination.  Preterm labor is characterized by uterine contractions that may be uncomfortable or painful and come at regular intervals (i.e., every 5 minutes) and lead to cervical dilation.  At times, it can be difficult to distinguish between cervical incompetence and preterm labor.  What starts out as painless dilation may turn into preterm labor once the cervix becomes very dilated.

Whether a woman is diagnosed with cervical incompetence or preterm labor leading to preterm birth, each problem is associated with a high risk of recurrent preterm birth.  This means that they should be watched more closely in the next pregnancy.  There are a couple of ways to predict a woman’s risk of recurrent preterm birth.  Cervical length measurements by transvaginal ultrasound during the second and early third trimesters have been shown to predict a woman’s risk of preterm birth.  The shorter the cervix is, the greater the risk of preterm birth.  This is primarily useful in women who do not have a cerclage in place.  Additionally, the fetal fibronectin test can predict a woman’s risk of preterm birth.  The fetal fibronectin test uses a swab to test for the presence of fetal fibronectin in the vagina.  If the test is negative, that means a very low risk of preterm birth in the subsequent 2 to 3 weeks (approximately 2 percent risk) and both the patient and the physician can be reassured; if the test is positive, that means that there is a 15 to 20 percent risk of preterm birth in the subsequent 2 to 3 weeks, in which case closer surveillance of the patient might be advised and consideration should be given to giving steroids to accelerate fetal lung maturity. —Dr. Ashley Roman

I had a premature rupture of membranes (PROM) with my first pregnancy at 28 weeks with my son. The doctors said that I didn't have an infection, and they didn't know the cause of the rupture. I was only 1 cm dilated and wasn't contracting and had good prenatal care.  If I were to become pregnant again, do you have any recommendations of medications to take or what I could do so I wouldn’t have a PROM again? Also, I have heard that if you have a PROM, then you are at increased risk of it happening again with future pregnancies. Is this true?

You have lived through one of the most difficult challenges that any parent can face and I applaud you for being proactive in seeking information to help improve your next pregnancy. As a maternal-fetal medicine specialist, your story is one that I am very familiar with and I know that the concern about the risk to your future children can be very intimidating.
 
Lacking the specific medical information about your initial pregnancy, I can only draw some general impressions and advice. Yes, women with a history of spontaneous preterm birth and PPROM are at risk for recurrent preterm birth and PPROM. Fortunately, we now have medical tools to help provide healthier outcomes.  And most future pregnancies result in healthy children. This is the goal of all parents as well as their OB/GYN doctors and Maternal-Fetal Medicine doctors.
 
One main tool is progesterone supplementation. In the United States, the data most strongly supports weekly injections of 17-alpha hydroxyprogesterone (17P) but data from other countries has shown benefit from vaginal progesterone as well. Ideally, this is started prior to 20 weeks gestation in women who’ve had a prior spontaneous preterm birth. Women who delivered early due to twins or preeclampsia do not appear to benefit from this treatment.
 
A second set of tools are the fetal fibronectin test (fFN) and transvaginal sonogram of the cervix.  While I prefer fFN, these two tests used together can identify women at risk for preterm birth within the next two weeks. Testing which is normal ("negative") provides great value for reassuring both the woman and her doctor. Testing which is positive provides great value by allowing us to consider interventions that can improve the health of the child. These include medications known as antenatal steroids that mature the lungs and blood vessels. It also includes medications to help decrease contractions. —Dr. Jim Byrne

What does a cerclage do, and what are the different types of cerclage?

Cerclage are sutures placed around the cervix to prevent it from dilating and result in miscarriage or premature birth. There are abdominal and vaginal cerclages. Two types of vaginal cerclages are McDonald and Shirdkar. Both of these can be performed using various different sutures. Abdominal cerclages have been performed during and prior to pregnancy and generally are done after failed vaginal procedures. —Dr. Andrei Rebarber

I lost twin girls at 22 weeks, and I recently I delivered a baby girl at 29 weeks. Is it likely that I have an incompetent cervix? Would I be a good candidate for cerclage in a future pregnancy? How does a cerclage work?

Cervical incompetence is typically characterized by painless cervical dilation leading to pregnancy loss or early preterm birth.  In most case, it is detected when a woman comes in for a routine office visit or ultrasound and the cervix is found to be incidentally dilated on examination.  What starts out as painless dilation may turn into preterm labor once the cervix becomes very dilated.

For women diagnosed with cervical incompetence for the first time, the doctor may try to put in a cerclage if the woman is in the second trimester. This procedure can be technically challenging if the cervix is significantly dilated.  For women with a history of cervical incompetence in a prior pregnancy, treatment might involve placement of a cerclage at the end of the first trimester.  A cerclage is a reinforcing stitch, like a purse-string that is placed around the cervix to keep it closed.

For women who have had a preterm birth (birth prior to 37 weeks’ gestation) in the past due to preterm labor, it is recommended that they be offered some form of progesterone to prevent recurrent preterm birth.  Progesterone can be given in one of two ways: either with weekly injections of 17-alpha hydroxyprogesterone caproate (17P) or with nightly vaginal progesterone suppositories.  The medication should be started by 16 to 20 weeks of gestation and continued through 36 weeks.  Studies have shown that either form of progesterone significantly reduces the risk of recurrent preterm birth by about 40 percent to 50 percent in women who have experienced preterm birth in a prior pregnancy due to preterm labor or preterm ruptured membranes.

Whether a woman is diagnosed with cervical incompetence or preterm labor, there are a couple of ways to predict a woman’s risk of recurrent preterm birth.  Cervical length measurements by transvaginal ultrasound during the second and early third trimesters have been shown to predict a woman’s risk of preterm birth. The shorter the cervix is, the greater the risk of preterm birth.  This is primarily useful in women who do not have a cerclage in place.  Additionally, the fetal fibronectin test can predict a woman’s risk of preterm birth.  The fetal fibronectin test uses a swab to test for the presence of fetal fibronectin in the vagina.  If the test is negative, that means a very low risk of preterm birth in the subsequent 2 to 3 weeks (approximately 2 percent risk) and both the patient and the physician can be reassured; if the test is positive, that means that there is a 15 to 20 percent risk of preterm birth in the subsequent 2 to 3 weeks, in which case closer surveillance of the patient might be advised and consideration should be given to giving steroids to accelerate fetal lung maturity.—Dr. Ashley Roman

At just over 25 weeks, I gave birth 15 minutes after my first contraction and water breaking and with only two pushes. How likely is this to happen again during my next pregnancy? Will it be more harmful if I have a cerclage? The birth was so quick I worry that a cerclage would have torn my cervix.

What you describe is concerning for cervical incompetence:  painless cervical dilation leading to preterm birth. Often, women with cervical incompetence experience no symptoms until the cervix is very dilated, at which point the water may break and the uterus may begin contracting. The reason why contractions start and one’s water breaks at that point
seems to have to do with infection.  The cervix protects the pregnancy from being exposed to bacteria that are normally present in the vagina. Once the cervix is dilated, the pregnancy comes in contact with these bacteria, which then leads to contractions and ruptured membranes.  A cerclage can help keep the cervix long and closed in women with cervical incompetence, thus preventing this cycle from starting in the first place.  One of the risks of having a cerclage is that it could tear your cervix if you go into labor or if your cervix dilates despite the cerclage, but the risk of this happening is low.  And the cerclage is generally removed as you get close to term or if you experience preterm labor to minimize the chance that it could tear your cervix.—Dr. Ashley Roman

I have a bicornuate uterus and a septate as well, causing my daughter to be born at 29 weeks. Now I'm considering another pregnancy.  Can you recommend any resources to help me decide whether or not to correct my septate? I've met with three doctors and none of them can give me a definitive diagnosis and recommendation.  It's very frustrating. Thanks!

The conditions of bicornuate uterus and septate uterus are something that many lay-people are not familiar with and these terms can lead to confusion. There are variations of the uterus shape and structure that are present from the time of birth. Instead of one single uterine cavity that is 'normal size' there is either two smaller cavities that can be conjoined to varied degrees (bicornuate) or a single cavity with a partial wall dividing it into two sections (septate). Both conditions can be associated with pr-term birth and malpresentation (which is to say, the baby remains breech rather than converting to a heads down position). They are actually two different things, so it would be highly unusual for you to have both. It is often difficult to make an accurate assessment at the time of delivery since the uterus is so distorted and enlarged from the pregnancy. To determine which condition is present, doctors often require either a special uterus x-ray with a dye (known as an HSG) or to perform a special exam with a micro-camera into the uterus (hysteroscopy). Those special tests can help provide the definitive diagnosis you are seeking. With that information about which one condition you have, it will be easier for your physicians to discuss options that may increase your chance for your next child to deliver closer to term. —Dr. Jim Byrne

I'm 30 weeks pregnant and have contractions mostly at night when I'm lying down to go to sleep. I thought lying on my side should stop the contractions! What's up? Why am I having contractions then?

To reassure you, it is common for all women to have some contractions throughout the pregnancy. As you get past 30 weeks, these often increase in frequency and intensity. It is very common for the contractions to occur in a circadian pattern, that is to say they occur more commonly in the evening hours and then they resolve on their own. If only there was a trick! Sleeping on your side in the third trimester can benefit fetal blood flow but tends to do little to alter uterine contractions. Instead, consider increased fluid intake in afternoons and evenings. Water is best. These evening contractions rarely result in changes to your cervix or preterm labor. But it can be helpful to be evaluated by your doctor or nurse to confirm the status. There are tools that we use to help determine the risk of preterm birth. These include fetal fibronectin and transvaginal sonogram of the cervix. These excellent tools are used either by themselves or in combination to help determine the risk for preterm birth. The results can bring benefit through reassurance or from allowing the opportunity to use medications to halt labor and to mature the lungs/blood vessels. —Dr. Jim Byrne

I felt like such a weirdo every time I went to the hospital having contractions. It seemed like they didn’t believe me when I told them I thought I was having preterm labor. Why was it hard to believe?

Many women experience preterm contractions during their pregnancy.  When they come at regular intervals, this can be a sign of preterm labor. The difference between preterm labor and simple preterm contractions (or “Braxton Hicks”) is that the contractions with preterm labor are actually shortening and dilating your cervix.  It is impossible to differentiate preterm labor from Braxton Hicks contractions without doing a cervical examination by your physician or nurse. Therefore, it is very important to call your doctor when you experience frequent preterm contractions (more than 4 per hour). 

What can make the early diagnosis of preterm labor even more difficult for the patient and the healthcare provider is that some signs of preterm labor can be very vague and non-specific.  For some women who go into preterm labor, all they feel is mild menstrual cramping.  Other women may only feel a low backache.  The bottom line is, when you feel anything unusual and it concerns you, it is important to inform your healthcare provider.   

If you are found to be dilated, then the diagnosis of preterm labor is made in most cases and attempts may be made to stop it.  If it is unclear based on cervical examination if you are in preterm labor, your healthcare provider may decide to do a fetal fibronectin (fFN) test.  The fFN test involves putting a swab into the vagina and sending it to the lab.  If the test returns with a “negative” result, this means there is a 98 to 99 percent chance you will NOT deliver the baby in the next two weeks.  If the test is “positive,” however, that means there is about a 20 percent risk of giving birth in next two weeks.  Based on the results of the fFN test, your doctor may decide to keep you in the hospital for treatment and monitoring or send you home.—Dr. Ashley Roman

Meet Our Guest Obstetricians

Dr. Andrei Rebarber is a Board-Certified OB/GYN and Maternal Fetal Medicine Specialist in private practice at Mount Sinai Hospital in New York City.  He can be reached at Maternal Fetal Medicine Associates, PLLC 212-722-7409 or at Carnegie Hill Imaging for Women, PLLC 212-722-7426
 
Dr. Jim Byrne is Chief of Obstetrics and Maternal-Fetal-Medicine at Santa Clara Valley Medical Center and is affiliated Clinical Associate Professor at Stanford University School of Medicine. He received his medical degree from Loyola University and completed his fellowship and residency at the University of Southern California.
 
Dr. Ashley Roman is a Board-Certified OB/GYN and serves as an assistant director of perinatology at the Yale-New Haven Health System/Greenwich Hospital in Greenwich, Connecticut, as well as in the Maternal-Fetal Medicine Specialist Department of Obstetrics and Gynecology Yale University School of Medicine New Haven, Connecticut.

The opinions expressed here are those of the physicians listed. These questions and answers are for informational purposes only and do not constitute medical advice.