Mailbag 27: What does the Fox say – With Dr. Nathan Fox

Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

Hey, everyone. Welcome to “Mailbag number 27: What Does the Fox Say?” Our first question is from Erica [SP]. “Hello. I have a 19-month old twin boys, and needed an urgent C-section at exactly 37 weeks due to a diagnosis of cholestasis. I did not present with the typical symptoms of intense itching, but was unexpectedly diagnosed after blood work showed elevated bile acids at 12. The day I gave birth was very chaotic. So, I did not realize until several weeks after that, 12 is only slightly higher than the normal range. Is it true that any level greater than the normal range is dangerous? Does the risk to pregnancy go up as the levels get higher? I would like another child one day. Am I at higher risk to get cholestasis again? Does advanced maternal age and/or multiples put one at greater risk of getting cholestasis? Thank you for taking the time to answer listener questions, and for such an amazing and informative podcast.”

All right. Erica, thank you for the question. Also, we did do a full podcast on cholestasis of pregnancy in December of 2021. My guest was Dr. Do. So, you can check that out for a fuller explanation. But in terms of your question and some background. So, cholestasis of pregnancy is a condition. It can happen when you’re not pregnant, but we’re going to talk about it in pregnancy, where basically, due to the hormones of pregnancy, there’s an effect on the mother’s liver, which slows down some of the processing of something called bile acids.

Now, it’s not dangerous for the mother. It’s not like a liver disease, where she’s in liver failure or anything like that. But the consequence of this is that you get a buildup in your bloodstream of these things called bile acids or bile salts, and then they end up embedding themselves sort of under the skin. And the thing that most women who have this have is intense itching. And it’s a particular kind of itching. Usually, it starts on the palms of the hands or the soles of the feet, which is an unusual place to get itching.

And so, when pregnant women complain of this, the first thing we think of is cholestasis. When this happens, it typically happens towards the end of pregnancy. It can happen early, but typically towards the end. And when we diagnose it, it’s either clinically because of that itching and/or with a combination of some blood tests. And what you were mentioning is this bile acids. We can measure the level of bile acids in the blood. And since there’s a buildup of cholestasis, if there’s a high level, that’s how we can make the diagnosis. You are correct. For most laboratories, the cutoff for normal versus abnormal is 10. So, 12 is just slightly above normal. It can go as high as 40 over 100, even rarely, like over 200. Twelve is slightly high.

Okay. So, what’s the problem with cholestasis? Problem number one is the symptoms. Right? The itching tends to be pretty intense, pretty annoying for women, and it does not go away with typical things like Benadryl or creams or this or that. And so, that’s problem number one. Problem number two is that for reasons we don’t understand that well, but there is an increased risk of stillbirth for women who have cholestasis. And that’s pretty scary, obviously. So, why does that happen? Again, there’s some theories of why the increased bile acids might do that, but it’s not entirely clear. And the other problem is that the stillbirth is not something that’s really predictable from testing, meaning usually everything’s just fine. And then rarely, but more common than in anybody else, there’s a stillbirth.

So, what do we do in that setting? Typically, the best treatment is just to deliver early. Exactly how early depends on a lot of factors, but essentially to deliver early before something happens. There is a medication we can give that lowers the bile acids. It’s called ursodiol or the brand name is Actigall. And it does lower the bile acids in the blood for most women, and it therefore usually reduces the itching significantly. Whether it does or does not decrease the risk of stillbirth is really unknown because we don’t typically give the medication and just wait indefinitely. We typically give the medication and still deliver early because, obviously, since stillbirth is such a horrible outcome, we don’t mess around. Right? So, typically, you give the medication. Hopefully, the symptoms get better. Hopefully, the blood levels get better, and then still deliver early.

Now, in terms of your specific questions, is it a lower risk at a level of 12 than a level of 20, 40, 80, 100? The answer seems to be yes. Right? The data out there is that the risk of stillbirth does seem to be higher as the bile acids go higher. Some people use a cutoff of 40 for differentiating sort of like a mild cholestasis versus a severe cholestasis. And also some people use a cutoff of 40 to determine exactly when to deliver. So, if it’s under 40, deliver at a certain gestational age, and if it’s over 40, deliver even a little bit earlier. But ultimately, it does seem to be that the higher the number, at least when you present, the higher the risk. So, yes, your number of 12 was just slightly above. I would still call it abnormal. I would still give you the diagnosis of cholestasis. I would still give you the medication. I would still deliver you early, but maybe we would tweak it a little bit as compared to if your numbers were higher.

In terms of getting cholestasis again, yes, if you get cholestasis in one pregnancy, you are more likely to get it in future pregnancies, though not definitively. And so, what do you do in the next pregnancy? There’s different strategies. Sometimes you just keep track of your symptoms. If you’re not itching, you know, you just leave it be. In your situation, since you didn’t have itching and you just had the blood test, sometimes people will do serial blood tests to see if you get it again. There isn’t, again, one particular strategy that people do, but just the knowledge that you’re at increased risk of happening it again, you’ll develop some strategy with your doctor about how to look for it, screen for it, and take care of it. And again, it doesn’t mean it will happen again. It might not happen again.

In terms of risk factors for cholestasis, advanced maternal age, I don’t believe, is a risk factor, or if it is, it’s a pretty minor one. Multiples definitely is a risk factor. You’re more likely to get it when you have twins. The thought process is that the hormones are higher. So, the chance of getting it is higher. All right. Great question.

Next question is from Jill. “Hi. First off, I’m a huge fan of your podcast, and cannot thank you enough for hosting such an informative, entertaining podcast.” Thank you, Jill. “I’m currently six weeks pregnant with my first baby.” All right. “And trying to decide if I should maintain care at my gynecology office or switch to a local practice that many of my friends go to and love. My current OB practice delivers at a large university medical center, which has a level four NICU. My husband and I both work in medicine, and our minds go to the worst, like ECMO and NICU capability, which we know seems extreme, but it’s easy to let your mind go there when you work in medicine. Neither of us work close to anything in women’s health. So, we feel very ignorant about the topics.”

“I’ve seen a lot of negative reviews delivering at the big hospital, and have friends who had difficult and impersonal experiences with prenatal care, delivery, and postpartum care. There’s a regional hospital nearby with an OB unit, and seems to be the place many women in the area go to deliver. And I’ve only heard mostly positive reviews. Working in the area, this is not somewhere my husband or I would choose to go to for general medical care and emergency. However, people seem to feel more supported and have more positive birth experiences there. How should I weigh the trade-offs between the reputation and resources of a big medical center versus the more personalized care people report getting at a smaller hospital?”

“If a large university medical center is better equipped for the worst case scenario, is it wrong to want to switch practices to deliver at the smaller hospital if my pregnancy goes uncomplicated and routine? At the same time, could it be true that the smaller hospital might actually be better to deliver at because they seem to do it more? I’m conflicted and obviously want what’s best for the baby and for me, but I do want it to be a positive experience we can all feel well taken care of.”

All right. Jill, that was a very thorough, long question, but a very good question, and this does come up a lot for people. And essentially, to boil it down, it’s, where should I get my care? Where should I deliver the baby if I have options? Right? Obviously, not everyone has options either based on where you live, or you have a particular doctor that you really like and they deliver at a certain place. But let’s say we’re thinking about options, and we’re trying to go into certain paradigms.

And so, you described two of the options. Right? One of them is sort of your big university hospital that has everything. Right? And this is sort of where you would go. You can go to deliver a baby. You can go to get heart surgery. You can go to get a knee replacement. You go to an emergency room. You go, you know, if you had a heart attack. I mean, everything, right, in one hospital. They probably have a medical school residents, fellows, the whole thing, the whole nine yards. Fine.

And then there’s sort of smaller community hospitals, which have…based on the hospital, based on the size, have maybe some of those things or maybe they have all of those things to a lesser degree. You’re trying to decide which of the two to go to and does it matter for the labor and delivery? And I would say, obviously, all of it depends. Right?

So, the first thing I would say, it depends on…in no particular order. One of the things it depends on is, how complex are you in your pregnancy? Right? So, someone who has a lot of, let’s say, medical issues, or they’re carrying twins or triplets, or they have a high risk for preterm birth, or there’s some issue where there’s a higher chance that you’re going to need all of those services, whether it’s a higher level NICU or whether it’s some sort of subspecialty care or intensive care unit or something like that. So, in those situations, typically, you’re going to lean towards a larger, busier, university type hospital, either yourself or if you’re being seen in a community by a community doctor who delivers at smaller hospital, they’ll say, you know what, this really isn’t the right place for you. We should transfer you, transfer your care to that higher level situation. So, that’s one factor.

Another factor is, straight up, who is your doctor? Right? If you have a relationship with your doctor and you really like and trust him or her, I would say that’s probably a bigger factor in your experience for prenatal care, and delivery, and postpartum care than the building in which you deliver. Right now, that itself is a complicated question. Some people go to large groups of doctors where they don’t feel like they have a relationship with a particular doctor or those groups of doctors. And so, it doesn’t really matter to them are they in place A or place B because the experience in terms of them vis-a-vis the doctor or midwife is going to be the same. Whereas if you do have a practice or a person or a group of people that you really like and you really trust and you’re going to, my personal advice would be to stick with them because I do think, again, the people who care for you is probably more important than the building in which you deliver.

A third factor is, what is the reality of these reviews that we’re talking about? It’s reviews and things you see online and talking to friends. There’s obviously value to it. I’m not completely dismissing it or pooh-poohing it, but you have to be cautious because there are so much gaming of the system. Sometimes certain hospitals are just better at getting people to leave positive reviews than others. And sometimes the people who go to a certain hospital are more likely to give reviews than others are. And it’s a little bit tough.

And so, if you’re going by reviews, I would probably focus on people that you know and that you could speak to, who have delivered at both places, and ask them very specific questions like why was it a good experience? Why was it a bad experience? What exactly is it? And you might find, for example, let’s say they said it was a really good experience because I really loved the doctor who delivered me. Well, okay. Then like I said before, it really doesn’t matter where you deliver. It’s who the doctor is. If they said, I really like the experience because at hospital A, you always get a private room after you deliver, in hospital B, you always get a shared room after you deliver. All right. That is tangible. That is objective. That is something you can weigh. How important is that to me in the decision?

If they say, you know, I like my nurse, I didn’t like my nurse, I mean, okay. Each place probably has 50 nurses that rotate through labor and delivery. And if every single person you speak to says the exact same thing, all right, then that’s probably a trend. But if one or two people say I like my nurse and one or two people say I didn’t like my nurse, I don’t know how much weight I would put into that.

Some of it is also convenience, obviously. Right? Is it worth it based on which is convenient or not convenient? Another might be, do you care in one way or another? Are there medical students in residence who might see you in the hospital? For some people, they really don’t want that. For other people, they really do want that. Why would you want that? Sometimes you feel like, all right, there’s more people watching me. I feel like I’m getting more attention. Nothing’s going to get missed. People who might not want it, they’re like, I don’t want so many people, you know, looking at me being part of my care, whatever it is. You guys are in medicine. Some people in medicine specifically feel one way. Some people in medicine specifically feel the other way. I’ve seen both. And so, that’s another thing that might go into it.

I think, at the end of the day, it probably doesn’t make a big difference as long as the smaller community hospital is busy enough, right, that they’re doing deliveries, that they have a labor and delivery unit. They have some level of a NICU. And there is an option if something went totally sideways. Right? Everything’s going well and suddenly didn’t. You did have an option to switch the university or transfer to the university, or the baby could transfer from one place to the other. As long as that option exists for 99% plus of people, it probably does not make a big difference.

This is sort of parallel to the conversation of a home birth. We’re not talking about a home birth here, but sort of the conversation is very similar that if you say, okay, for people who are looking for a totally different experience than delivering at a hospital and they want to deliver at home or in a birthing center or something that’s not a hospital. Right? It’s sort of the same discussion, but just to the next degree.

And so, the same thing is true. If everything is fine, and you’re healthy and well, for most people, it probably isn’t going to make a difference. And that, it’s a little bit…obviously, it’s slightly more pronounced. Right? Because if something goes sideways and you’re at home, it’s much different than if something goes sideways and you’re in a hospital, but it’s a smaller hospital. So, again, I was just saying the conversations are parallel. But these are the things you should probably be considering when going from one to the other.

Again, I would probably first focus on who the doctor or group of doctors are. Second, do you yourself have any real risk factors for needing a higher level of care? Third, sort of what is your comfort level in general if there’s the possibility that you could switch care for it, that you’re going to use sort of anecdotes, really try to dig into it, like speak to the people, get exactly specifically what are the things and whether it’s going to matter for you? Either way, good luck. I hope it goes well for you.

All right. Next question is from Minnie [SP]. All right. “What factors impact a woman’s natural ability to go into labor and deliver a baby vaginally versus needing a C-section? Are there some women who are just able to labor naturally more easily versus just don’t go into or progress well in labor? I recognize it’s probably not a simple question, given all the factors involved, but just curious what is known about this topic. Thank you. Really like the useful and clearly presented information in the podcast.” All right. Thank you, Minnie. You’re correct. That is not a simple question, given all the factors involved. So, your gut is right.

The short answer is we do not know. There are definitely women who go into labor easier. You know, if they have multiple pregnancies, meaning they have several pregnancies, they go into labor each time. Some women who have very quick and easier labors. I don’t think anyone has an easy labor. Right? But you know, easier compared to somebody else that someone, you know, have easier labors. They don’t have to push a long time. The babies come out. They don’t tear much. They recover easily versus others who have very long, difficult, hard labors that either end with a vaginal delivery after pushing for a long time or end in a C-section. And sort of why? Why A versus B?

So, some of it is geometry. Right? There’s this sort of shape of the woman’s pelvis. There’s the size of the baby. I think that that is a factor, but not a huge factor for most people. It probably was thought to be a much bigger factor in the past, but as we’ve learned more and more, that whatever the shape of the pelvis, usually it’s going to accommodate a baby. There are exceptions, but usually it’s going to accommodate a baby. And again, people deliver babies of all sizes, but okay, some of it’s geometry. Some of it is physiology we don’t quite understand. As women get older, labors tend to get more difficult. Why that is, is complicated. Some of it may just be like strength of muscles and strength of tissue. And as we get older, those things are…you know, they’re less strong than as we’re younger. All right. That maybe there’s something to do with our vasculature again, but there…we don’t really know all of the reasons why, but as women get older, that might be one thing.

There is some evidence that women who are more physically fit, like women who exercise regularly, or maybe women are able to exercise regularly, sometimes go into labor better and have better labors. It’s one of the many, many, many reasons we do recommend regular exercise in pregnancy, if it’s possible. Some of it seems to be familial, meaning sometimes in families, there are families where all of the women in the family tend to have, you know, easier labors or other families where sort of all of them end up with C-sections. Why that is, we don’t exactly know.

And then what’s also interesting is that even within the same woman, she could have one pregnancy that’s more difficult or one labor that’s more difficult and one labor that’s easier. Now, typically, the first labor is going to be more difficult than the subsequent labors, but not always. Sometimes we have women who have a relatively easy first labor and delivery, and then the second one is not. And it’s really hard to tease that all out and to know why. And we guess and we have our theories and we try to figure it out. But as you said in your question, it’s really not a simple question. And we don’t really know that much about it.

And it’s sometimes hard to predict it as well. I mean, someone who’s at the end of pregnancy and we’re just trying to figure out, are they going to go into labor, or when are they going to go into labor? Yeah. So, we try and we examine the cervix, and we feel where the baby is, is it high, is it low, is the cervix open or not or soft? And there’s some predictive ability to that, but not reliably. Right? You could see someone who everything seems perfect and you’re like, oh, I think you’re going to go into labor the next three days, and then she doesn’t for two weeks. And others who everything seems, oh, there’s nothing happening. It’s not going to happen. And then she goes into labor that night. And so, we’re always humbled by this, and we really don’t understand it that well. Sorry I couldn’t give you a better answer, but that’s all we got.

All right. The next question is from an anonymous listener. “Hi, Dr. Fox. I love your podcast. Thank you for providing insightful and digestible information on all things women’s health. I listened throughout my first pregnancy and found it incredibly helpful.” Thank you very much. “I’d like more information on interpregnancy intervals after C-section. Long story short, with my first baby, my water broke in the middle of the night, and I was fully dilated and pushing about five hours later in the hospital.” Ouch. “Despite my best efforts, baby did not progress. So, an epidural was placed — let me tell you, sitting for an epidural while in active labor was an experience — to maneuver the baby out of the OP position to help with delivery.”

“Sadly, they were only able to turn her about 45 degrees after multiple attempts. And after letting me push for another two and a half hours to make five, she barely progressed, had sustained deceleration. So, I had a C-section. The OB did not note anything abnormal to my uterus at the time of surgery. And I’m so grateful for their patience and amazing care. As I look ahead for my next pregnancy, at which time I will be advanced maternal age, can you share some insight on the data around optimal interpregnancy intervals to reduce the risk of uterine rupture? As I’d ideally like to have an unmedicated vaginal birth. I know not wanting the epidural may be a challenge, but would an OB be open to having it placed but not using it to give me the best chance at my goals for delivery? Thank you so much for everything you do.”

All right. Now, you threw in a second question at the end related to the epidural, which is cool. That’s fine. There are definitely OBs who would be comfortable with you either not having an epidural or having an epidural placed, but not using it. That’s something you may want to ask early just so you don’t have a surprise when you’re in labor, but that is a possibility. Fine.

In terms of your main question about the interpregnancy interval. So, there’s two factors that we’re talking about with interpregnancy intervals, which is basically the time…people define it differently, but basically the time between pregnancies. So, you can either say the time between the day you deliver and the next time you deliver, or you could say the time between the day you deliver and the time that you get pregnant the second time.

And with interpregnancy intervals, the first conversation, which was not your question, but I’m going to answer your question second, the first conversation is just in general. For anyone who has a baby, is there an optimal time to wait before getting pregnant with your next baby? And this is something we’ve covered in the podcast before, but it’s really interesting because there’s a lot of data that suggested that you should wait. And interpregnancy interval is ideally something like 18 months or more. And number one, this was misinterpreted by people to say that you shouldn’t get pregnant until your first baby is 18 months old. That’s actually not what the data was talking about. It was actually saying your babies should be 18 months apart, meaning that you deliver a baby, you should wait about 6 to 9 months before you get pregnant. So, when the next one is born, he or she will be 18 months younger than the first one, as opposed to having a baby and then waiting 18 months before you get pregnant. And then your babies will be two to three years apart. Fine.

So, the data said that the optimal time is 18 months or more between babies. But interestingly, that data has been subject to question because it’s…there’s a lot of factors that go into how far apart babies are. And one of the thoughts was that, in the studies, women who had babies closer together and had worse outcomes, it may not be because their babies were closer together, but maybe it was because women who had babies closer together were more likely to have other issues, like they didn’t have access to good care, they didn’t have access to birth control. And, you know, maybe there was other factors that were the cause of the worse outcomes as opposed to just the time between deliveries.

And in fact, they did some pretty insightful studies where they looked at, let’s say, a woman who has three children. So, if you have three children, you have two interpregnancy intervals, the interval between child one and two, and the interval between child two and three. And they looked at women who had three children, where there was difference in timings between the intervals. Right? If, let’s say, the first interval was short and the second interval was long. And in those studies, they found no difference. It didn’t matter how long there was a break between pregnancies. And since it’s the same woman, right, in all these studies, that sort of controls for who the mother is. And so, when you look at it that way, there was no difference.

So, what I tell people is there is data that maybe 18 months is the best time, but that data is pretty weak, probably not real. And it probably does not make a big difference. Most people are not clamoring to have another baby within six months of the first baby being born anyways. And so, usually, even if people are trying pretty quickly, their kids are going to be close to 18 months apart. Sometimes it happens earlier than that. And usually it’s not an issue whatsoever.

Okay. Your question was specific about Cesarean. And there’s separate literature about how far apart should your second pregnancy be after a C-section if you’re trying to labor, TOLAC, VBAC, whatever acronym you want to use, and the risk of uterine rupture. And it does appear that, similarly, if your pregnancies are a little bit further apart, the chance of uterine rupture is a little bit lower. The times, again, different studies look at different times. I usually quote the studies that also look at 18 months. It’s just an easier thing. So, if you have a C-section and your second baby is born 18 months or later, then the risk of uterine rupture is sort of the baseline, which is around 1% or slightly less than 1%. If it’s less than 18 months, I mean, you got pregnant sooner and you’re trying to labor, the risk of uterine rupture seems to be a little bit higher, but not markedly higher, sort of in the range of instead of slightly less than 1%, maybe 1% to 2%.

So, ideally, if you’re going to try to TOLAC, you want to wait and have your babies about 18 months apart. But if someone got pregnant earlier, either because they did or because they really wanted to, because, again, maybe they have other reasons or maybe they feel they’re getting older and they don’t want to wait or whatever, and they got pregnant earlier, I don’t tell them that they can’t TOLAC. I would just tell them that they need to know they have a slightly higher risk of TOLAC, of trying to VBAC compared to if they waited a little bit longer. Not much different than if, let’s say, they got induced versus went into labor on their own, that also slightly increases the risk.

So, I would say, for you, if you’re trying to, like, optimize your chances of everything, maybe just wait, you know, around nine months until you get pregnant again so that your kids are about 18 months apart. But if it happened earlier, it’s, in my opinion, not a deal breaker, but you may have some slightly increased risk compare to if you waited.

All right. Last question is from Miriam [SP]. “Hey. First of all, I would like to say I absolutely love and appreciate your podcast.” Thank you, Miriam. Thank you for all of you, by the way, for saying nice things at the beginning of the questions. I would say that I’m more likely to read your question on the air if you say nice things. That’s not true. I’ll do it anyways, but I really do appreciate it. It’s really sweet. Thank you all very much. Okay.

“I was hoping you can answer my question. I’m 27 years old. I’m currently 17 weeks pregnant with my sixth pregnancy. I have two live children. With my first pregnancy, I went into preterm labor at 30 weeks. They stopped it with magnesium. I was put on an nifedipine until 36 weeks. The day I got off it, I had a baby. By my second, I went into labor at 32 weeks. They stopped it. Didn’t put me on any meds. And I went into labor at 34 weeks and 2 days, and ended up giving birth at 35 weeks. After that, I had a chemical pregnancy, and early miscarriage, and a fetal demise at 16 weeks.” I’m sorry to hear that. “I was told that medically each of my losses falls into a different category, and there’s no connection between the three. Is that the case? My doctor says that, medically, there isn’t anything to do to prevent preterm birth. And I should expect to have even earlier than 35 weeks this time around. In your experience, is that true? Is there anything I can do differently this pregnancy and in general? Is there anything to do medically to prevent preterm birth? Thank you for your time.”

Okay. So, in terms of your first question related to the losses, that’s a much more…well, they’re both complicated, but that’s a complicated topic. Hard for me to know without knowing a lot more details, and getting a lot more information on you, and maybe running some tests and this or that. But I would agree that, typically, a chemical pregnancy, early miscarriage, and a fetal demise in 16 weeks…I don’t know about typically, but they’re often not related. But sometimes there are. And that might be something to look into. For example, something like antiphospholipid syndrome is something you can develop that could cause those three things. And so, it’s quite possible that your doctor is right, that those three things have nothing to do with each other, but it’s not definitive. And you might want to look into that.

In terms of your preterm births. So, again, your first pregnancy, you had labor at 30 weeks, they gave you medication, and then you delivered at 36 weeks. The second pregnancy, right, you went into labor at 32 weeks. They didn’t put you on any medication afterwards, and you ended up delivering at 35 weeks. Right? So, one week difference between getting medicated and not getting medicated. And the question is, what to do in this next pregnancy? Are you at risk for preterm birth? What can we do and whatnot?

So, that is itself a very complicated topic. But to put in broad strokes, if you had preterm labor and preterm delivery, yes, you are at increased risk for it happening again. It does not mean it will happen. Definitely are people like you in their next pregnancy without any treatment, without anything, will go full term. But the odds are if you’ve had it twice, that you’re going to go into labor early and deliver early.

Now, once someone goes into labor, the medications that we use are not very effective. Right? The medications we use to stop contractions, the data shows they’re not terrific. We do them, we give them, we try, but usually they don’t work. And usually the outcomes are very similar. Right? So, for you, just one person, two pregnancies, one pregnancy, you got medication, one you didn’t. There was a weak difference. Was the weak difference because of the medication? I don’t know. Maybe yes, maybe no. But it’s not a huge difference. Right? You would think that it should be much better than that.

Okay. So, waiting to go into preterm labor and trying to stop it is not a great strategy because it doesn’t typically work. So, can we prevent it? Well, sometimes yes, sometimes no. There are things that we do in the next pregnancy to try to prevent preterm birth. One of them, which is a little bit controversial, is progesterone. We used to give injections of progesterone once a week, starting at around 16 weeks. There was a study that showed that it was very, very effective, then a follow-up study that showed it wasn’t effective. And so, we had one that showed it’s effective, one that shows it isn’t. Based on that, the FDA decided doesn’t work. We’re not making this anymore. That itself is a decision that’s questionable. But whatever, that’s the situation. We don’t give the injections anymore.

There is a form of progesterone that’s vaginal progesterone that does seem to have some effectiveness. Different people strategically do it differently. Some people automatically started at 16 weeks. Just probably what I would recommend for you. Other people just check the cervical links, the length of your cervix by ultrasound. And if the cervix gets short, they start the progesterone. That’s a fine strategy. Also, checking your cervical length in the second trimester several times might be helpful because if it gets short early, you might be someone who benefits from a cerclage. Again, each of these things is a discussion in of itself. So, I wouldn’t take this podcast and say, this is what I should do. This is just food for thought, so to speak. There is some data about checking, doing a screen for something called bacterial vaginosis in the next pregnancy, whether that’s effective or not is debatable.

But ultimately, what I would say is…broad strokes to your question is based on your history, you definitely are at increased risk for complications in your next pregnancy. Now, will it happen? Not necessarily. Again, you could do nothing and everything go perfectly fine. But what I would recommend as an overarching recommendation is if your doctor is saying that there’s nothing to do, I would get a second opinion, preferably with a maternal-fetal medicine specialist or at least in OBGYN that has a tremendous amount of experience to go over your history in detail, very thorough, and come up with a specific plan for you that might be helpful. There may be tests to do between pregnancies, and there may be things to do in your next pregnancy, just so you have a really well thought out plan. Again, this is something that we do in our practice every day for situations just like this. It’s definitely, in my opinion, worth your while to do that, just to make sure that you get all your questions answered properly and not just over a podcast. But thank you for the question.

All right. Everyone, thank you very much. We’ll see you all next week.

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The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.