Pre-term labor, which is defined by experiencing contractions with a change in cervix dilation, occurs during more pregnancies than people might think. Dr. Nathan Fox and Dr. Jessica Spiegelman explain the difference between this and preterm contractions, and why in most cases, it either stops on its own or results in a normal full-term delivery. In some situations though, there are simple protocols they’re able to perform to help reduce the risk of complications.
“Diagnosis and management of preterm labor” – with Dr. Jessica Spiegelman
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Dr. 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 am 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. Dr. Jessica Spiegelman.
Dr. Spiegelman: Hello.
Dr. Fox: Spiegs, welcome. How are you doing?
Dr. Spiegelman: I’m good.
Dr. Fox: Wonderful. So we podcasted a few weeks ago, but as I was telling you before, I think, as it turns out, that podcast is gonna drop after this podcast. So today is gonna be like the teaser for you. And if people want to find out more about you and your background and your, sort of, life and how you got onto all this, they’re gonna have to tune into the next one. So here it’s just like, who the hell is Dr. Jessica Spiegelman? So the brief intro is you’re wonderful, you’re an MFM, you work with us. And then, for the full story, they’ll have to tune into the podcast that was recorded but will be dropped after this.
Dr. Spiegelman: I’m gonna try to stay mysterious otherwise.
Dr. Fox: But we are gonna be talking today about a really, I don’t wanna say basic like easy, but sort of like elemental concept in obstetrics, which is preterm labor. How do we diagnose it? How do we manage it? It’s something that is on a lot of people’s minds throughout pregnancy or on the labor floor and triage. Or, we see people in the office, are they in preterm labor? Are they gonna be in preterm labor? What do we do about preterm labor? And I thought it’d be nice for you and I to maybe go through this and talk about it and give our listeners a chance to see what’s going on in your head when we talk about preterm labor.
Dr. Spiegelman: Yeah. And it’s really important because it’s pretty common. Preterm birth is common, but preterm labor is actually probably even more common than that. Not all preterm labor ends in preterm birth, but it’s an experience that a lot of people might have in their pregnancy. And so to just kind of have the framework of what is your doctor thinking when you are experiencing preterm contractions and maybe your cervix is dilating. Like, what’s the thought process that your doctor has?
Dr. Fox: So I think let’s start just with, like, the definition. What is preterm labor?
Dr. Spiegelman: So first I think it’s important to define what is preterm, which is basically being under 37 weeks of pregnancy. We have kind of like subdivided all of the gestational age ranges into different terminologies. But sort of, basically, anything under 37 weeks is considered preterm, and then anything after 37 weeks is considered variations on term, early term, full term.
Dr. Fox: Right. So you need to be preterm.
Dr. Spiegelman: Correct.
Dr. Fox: And then the other thing is…
Dr. Spiegelman: You have to be in labor.
Dr. Fox: …you need to be in labor. I think we usually find it easy to figure out if someone’s preterm or not, right? Just look at their gestational age. The labor part is harder than one might think to know if someone is in labor. And the reason is, you know, a lot of people have contractions, a lot of people have cramping. Some people, their cervix is a little softer, a little dilated. But how do we define, sort of, labor such that we can tell someone they’re in preterm labor?
Dr. Spiegelman: Yeah. So labor actually does have a definition, which is contractions causing cervical change. And then when you go into the preterm period, we kind of add the additional definition of if you are two centimeters dilated, that you’re also in preterm labor. And actually, I remember you teaching me this when I was a resident, which is just one little hint drop of my background.
That preterm labor, you need to be preterm with cervical change caused by painful contractions or 2 and 70 is what you said. But I think, you know, there’s some variations because when people have had prior vaginal deliveries, sometimes they can be dilated preterm without actually being in labor. But two centimeters dilated I think is kind of a good benchmark.
Dr. Fox: Right. And I think the reason is when, you know technically, right, to be in labor, like you said, you have to be having regular painful contractions and that is dilating your cervix. Meaning there are people who have contractions whose cervix doesn’t open.
Dr. Spiegelman: A lot of people.
Dr. Fox: Yeah, most people with contractions, their cervix doesn’t open so they’re not in labor, they’re just contracting. And there’s people who walk around maybe a centimeter dilated or two centimeters dilated, even, usually it’s later in pregnancy, but they’re not in labor if they’re not contracting. So if someone shows up either to the office or to the hospital and they’re having regular contractions, you don’t know if their cervix is changing unless you check ’em, wait X amount of time…
Dr. Spiegelman: Check ’em again.
Dr. Fox: …and check ’em again. So if you don’t wanna sort of wait two, three, four hours to figure that out, one of the rules is, all right, if they’re contracting painfully and they’re preterm and they’re dilated already, the assumption is that their cervix has changed from something to two centimeters dilated.
So I would modify what Nathan Fox back in time told you, is that if someone is, let’s say you knew they were two centimeters dilated yesterday, and then they come in the next day contracting and they’re two centimeters dilated, I would not say they’re in preterm labor. I would say, actually, they’re probably not in preterm labor because their cervix hasn’t changed.
Or if they’re just walking around two centimeters, they’re certainly not in preterm labor unless they’re contracting painfully. It’s a lot of words. But basically, you have to be contracting regularly, painfully, that is causing your cervix to change. And sometimes we don’t have time to figure that out, so we sort of say, “All right, if you’re dilated, we’re just gonna assume you’re in preterm labor.”
Dr. Spiegelman: Yeah. And that’s important because there’s a lot of interventions, which I’m sure we’re going to talk about, that we like to start initiating. We don’t necessarily want to wait depending on the situation.
Dr. Fox: Right. And then there are a lot of other things, and we’re gonna talk about that in separate podcasts, which sort of puts someone at increased risk for preterm birth, like having a short cervix on ultrasound or a positive fetal fibronectin or, you know, history, preterm birth, things like that. And we might use those in part of our, like, decision tree analysis of whether to admit them to the hospital or not, or whether to give them certain medications or not, or whether to send them home or not. But technically, having a short cervix or having those things does not mean you are in labor.
Dr. Spiegelman: Correct. Yeah. So those are different processes. And preterm birth, in general, is probably the end result of multiple different, kind of, ideologies, multiple different things that are happening, and then just the end result is delivering early. And preterm labor is one of those. So short cervix is probably a different thing, and breaking your water early is another thing, and preterm labor is kind of its own category.
Dr. Fox: Right. And so what we’re gonna be talking about today is sort of diagnosing and managing someone with exactly that, the preterm labor. And I think another really key point is, and we said this earlier, is many if not most pregnant women will have contractions in the preterm period, and the majority of them will never have preterm labor. And that’s actually interestingly more common as you have more kids, right? So, like, someone on their first baby doesn’t usually have a lot of preterm contractions, maybe here and there, but when on your second, third, fourth baby, they happen all the time.
Why that is, we don’t exactly know, but it’s a known phenomenon that, you know, women who are walking around, and they’re like, “I’m on my fourth baby, I’m contracting all the time, like, what’s going on?” But that does not mean that someone’s in preterm labor. And there’s different ways we assess that obviously is that, you know, we do an exam, we do an ultrasound, you know, we check the cervix and these things and also the frequency and the intensity. But it’s common to contract not as common to have labor.
Dr. Spiegelman: Yes, exactly. And so our job is to figure out is this labor, is it not labor? And if it is labor, then we have sort of some interventions that we might do to try and optimize the outcome if we think somebody is headed towards a preterm delivery.
Dr. Fox: Right. And the other thing that’s really interesting is even if we’ve diagnosed someone correctly with preterm labor, meaning they come in, they’re contracting, their cervix goes from closed to two centimeters dilated, in the preterm period, it’s much different from someone in the full term period. Meaning someone comes in on their due date and they’re contracting regularly and their cervix goes from closed to two centimeters dilated, they’re gonna deliver, right? They’re gonna progress at some pace, slow, fast, whatever. But interestingly, in the preterm period, that’s not the case.
Probably about 50% of people, it just stops on their own without even any interventions. And it’s one of these things we just don’t understand why that is. Like why at 30 weeks, if someone has regular contractions, you know, they’re in a lot of pain, they come in contracting, you know, they’re 2 centimeters dilated and we do all these things and it stops, and then they just sort of hang out for another month or 5 weeks or 6 weeks. And that would never happen at someone’s due date. And so we don’t really know why that is.
Dr. Spiegelman: It’s an interesting phenomenon. And it’s something, yeah, like half of people with preterm labor arrests in their preterm labor spontaneously and then another, something like a third of patients who have preterm labor end up delivering at term.
Dr. Fox: Yeah. It is really fascinating, and, again, it’s humbling how little we understand about this. We know very little about why people go into labor when they do. We know it happens, but we don’t know why it happens and why it happens when it happens. And so, therefore, we also don’t know why it would just stop. And that is, you know, when we talk about these interventions, one of the reasons it’s difficult to know if they’re helpful or not helpful is so many people, even without intervention, are gonna do fine. And so it’s harder to find a benefit when most people or many people do fine without it.
Dr. Spiegelman: Yeah. It makes it hard to study because you don’t know the counterfactual. Like you don’t know if somebody hadn’t gotten this intervention, would they have stopped on their own? Would they have progressed? We have very few ways to know that information.
Dr. Fox: Right. And I just wanna make a note, sort of, that you used the word counterfactual, which is really impressive to me. That’s an Ivy League term.
Dr. Spiegelman: I was an English major.
Dr. Fox: Yeah. So there we go. Good works. For our listeners out there who are Googling the counterfactual, that’s a Spiegelman term. So I would never drop that because I don’t… Yeah.
Dr. Spiegelman: It’s the sliding door. It’s the alternate reality, the what if.
Dr. Fox: The what if. All right. So let’s start with that. So someone comes, and we’re confident that they have preterm labor. They come in contracting, their cervix is either dilated already or it’s dilating over time, what do we do? What happens at that point?
Dr. Spiegelman: So, I guess now we’re presuming we’ve made the diagnosis of preterm labor. And so what we do next really depends on the gestational age. In general, if somebody’s preterm, one of the most important things we wanna do is give them a course of steroids. And that is for neonatal benefit to help with lung maturity and decreases some of the other comorbidities associated with preterm delivery.
Our decision about steroids depends on a few things, the gestational age, whether they’ve gotten steroids before, some other comorbidities. But in general, that’s gonna be one of the earliest things that we think about doing when we think somebody’s in preterm labor.
Dr. Fox: Right. So let’s talk about the steroids. A lot of people hear steroids, and they think, you know, baseball players or they think something, you know, for medical conditions. So what exactly is going on here? How do we give these steroids? You know, what do they do? What’s the purpose?
Dr. Spiegelman: So the steroids, they’re injections. They are not gonna make you hit a baseball harder, but they do help to accelerate fetal lung maturity, and then they also help decrease risks of some other prematurity complications like bleeds in the brain, gut issues, and overall kind of mortality risk with prematurity. We give them as injections.
They’re usually 2 doses, 24 hours apart, and they’re kind of most effective given within 48 hours to 7 days of delivery. And so that’s why we need some lead time with the steroids. And that’s kind of why we’re a little bit more eager to give them if we’re suspicious of preterm labor or any reason why someone might deliver early because they need a little bit of time to work.
Dr. Fox: Yeah. And it’s really interesting because it’s a very short course. You know, two injections one day apart is almost never what would be given to, like, an adult for some reason you would get steroids. Usually, you get them for five days, for a week, for two weeks, chronically. Like, the only time you ever really get one steroid injection is, like, if you’re injecting it into like a joint.
Dr. Spiegelman: In like the spine, yeah.
Dr. Fox: Yeah, like an inflamed joint to like stop pain or something like that. But to act what we call systemically, like within the whole body, usually, it’s a longer course. But for whatever reason, for the fetuses, if you give the mother, and it’s a specific steroid, either it’s betamethasone or there’s also dexamethasone, that’s actually 4 injections, 12 hours apart, but basically, it’s over 2 days, and there’s minimal side effects to the mother. But these are the steroids that do, you know, go through the placenta and to the baby, and, for whatever reason, that burst of steroids really helps the babies after birth.
And I think that’s something that is conceptually something that people have to sort of grasp, that we’re giving something now to the mother for the baby to help after birth. It doesn’t help the baby in utero, it doesn’t help the baby like wow, you know, inside, it’s just for after birth. And it needs some time to kick in. And then the effect seems to wear off a little bit, which is why, as you said, we do try to get it in advance so we don’t miss that time to kick in.
But we also don’t wanna give it too far in advance, we wanna sort of time it, you know, just within a week. And so we’re always sort of [inaudible 00:13:26]. Is it too early, is it too late? Is it too early, is it too late? And we might err on the side of giving it early so we don’t miss it, but we don’t wanna give it too early as well. And so a lot of our thought process is deciding when to give the steroids.
Dr. Spiegelman: Yeah. I feel like I spend a lot of time thinking, “Steroids, now?” Yeah.
Dr. Fox: “Now? Later?”
Dr. Spiegelman: “Now? Later? Can we wait?”
Dr. Fox: You know, there is an opportunity to give steroids again if you sort of gave them or had them for another reason and now it looks like you’re gonna deliver, but you get one second chance, and that’s it basically.
Dr. Spiegelman: Yeah. So, basically, if you’re pre-34 weeks and you’ve gotten one round of steroids, one round being 2 doses, if it’s been methasone or if it’s dexamethasone and at least 7 days, usually 14 days, has gone by since that first course, you can get another course and that’s it. So we’re, I think, more liberal with the first course than the second course. We really kind hold that second course to a time when we really think there’s a high likelihood of delivery. And then after 34 weeks, we don’t really have evidence to say that there is a benefit to that, what we call rescue course of steroids.
Dr. Fox: Right. Right. And the reason we don’t give more than the second course, it’s not because it’s expensive, they’re very cheap, and it’s not because it’s dangerous to the mother, it’s because there is some potential for having a negative effect on the fetus. If you have someone on like chronic steroids, there could be a problem to the fetus. And so we don’t want them to get boatloads of it. And so it seems to be that two courses is where you could continue to…
Dr. Spiegelman: It’s the sweet spot.
Dr. Fox: …yeah, maximize your benefit. But past that, there might be some downside. And, you know, when they were first sorting this all out, there were studies where they would give it, they were like, “Well, if it wears off after a week, let’s just give ’em weekly.” So someone’s always within a week, and there seem to be some downside to that with fetal growth. So we don’t give ’em weekly, we don’t give ’em every two weeks. We just give ’em…
Dr. Spiegelman: And we don’t give them to everyone, right?
Dr. Fox: Yeah, yeah.
Dr. Spiegelman:So there was no downside. You could make an argument for just why we give it to everyone just in case, you know, preterm birth affects 12% of pregnancies, not everyone.
Dr. Fox: Right. Yeah. And people have made that argument, “Oh, let’s give it to all twins,” or this, but there does seem to be potential for downside. There really doesn’t seem to be much with one course. You know, it really hasn’t been shown to have a big problem on the downside, and there seems to be so much more upside, particularly if someone’s gonna deliver pre-term. So we do that. So that’s one of the things, and I’m glad that you listed that first because, in terms of all of our management of preterm labor, it’s really interesting because you would think that our management is gonna be focused at curing it, stopping it, fixing it. Like, someone’s in labor, let’s halt that.
Dr. Spiegelman: Yeah, we can’t do that.
Dr. Fox: Let’s arrest that, let’s stop that. And we try and it’s been tried, but we seem to be pretty poor at that. And so the things that we seem to be better at is preparing for a preterm birth. So if someone has preterm labor, a lot of the things we do and we’re gonna talk about are really more so, “All right, assuming we can’t stop this or we’re not great at stopping it or we might not stop it, let’s get this baby prepared for a possible pre-term delivery.”
And so sort of the strongest thing we have or the thing that has the most evidence that it helps is that course of steroids. And it’s been shown in many, many, many, many, many, many studies to be helpful to preterm babies to have been exposed to steroids prior.
Dr. Spiegelman: Yeah. It’s one of the few things in pregnancy that has, like, really good evidence behind it. Like, excellent evidence for steroids.
Dr. Fox: Okay. So in the same vein, what is another thing we might give that, again, doesn’t seem to prevent the preterm birth but does improve outcomes for the baby should he or she be born early?
Dr. Spiegelman: So another medication we’ll often give is something called magnesium sulfate, which some people might have heard of in the context of preeclampsia. We give it for that indication also. But when we’re giving it in the context of prematurity, we’re giving it for fetal neuroprotection. And it’s been shown to potentially reduce the risk of cerebral palsy in babies who are born preterm and especially when given under 32 weeks.
Dr. Fox: Right. It’s sort of conceptually like steroids that it’s given to prevent an outcome. But one of the interesting things about magnesium is, like you said, it’s used in preeclampsia for a different reason and that’s to protect the mother against seizures, but it used to be used as a medication to stop contractions, right? So it used to be used for the same reason preterm labor with the thought that it’s gonna prevent her from delivering, right? So it’s gonna stop your contractions and…
Dr. Spiegelman: But it doesn’t do that.
Dr. Fox: Right. People thought it worked and then most of the good studies have shown it does not work. It does not prolong pregnancy. But sort of on the back end, they said, “Huh, these babies, even though they delivered at the same gestational age, it seem to have less incidents of cerebral palsy.” And so then that was subsequently restudied specifically for that reason that seems to help. It’s a little bit different than steroids because it’s an infusion rather than injections. It’s like a given IV.
Dr. Spiegelman: As opposed to giving it beforehand, magnesium really kinda has to be in your system at the time of delivery, or in the baby’s system really, at the time of delivery to be effective. And so sometimes we’ll turn it off if we think somebody isn’t progressing and then we’ll turn it back on. And so we’ll do like the mag dance, like turn it on, turn it off, turn it on, turn it off to, you know, have it sort of be working at the time of delivery.
What’s tough about magnesium also is the studies that looked at it all have kind of slightly different protocols, different gestational ages that they gave it up until different doses. And so a lot of the, kind of, regimen for magnesium for fetal neuroprotection ends up being a little bit hospital-based or practice-based, but, in general, before 32 weeks.
Dr. Fox: Yeah, the earlier you are, the more likely it is to be helpful for a couple of reasons. Number one, as you get past 32 weeks, the chance of the baby having cerebral palsy is so much lower, that it’s hard to get it better. And whether, you know, the fetal brain responds to it as well, you know, that could be another issue. And the other thing about magnesium, which is really important as opposed to steroids, it’s usually pretty miserable for the mom to be on it. You know, steroids don’t tend to have side effects. Maybe that night she won’t sleep as well, maybe she’ll be hungry, like sort of a steroid effect.
Dr. Spiegelman: Injections [inaudible 00:19:25]
Dr. Fox: Yeah, you know, getting injection hurts. Here at the magnesium, people are on it. Some people feel fine and have no issues, but many feel like crap while they’re getting the magnesium. Like they feel like they have the flu, they have the headaches, they’re dizzy, they’re weak. It’s kind of annoying. And so it’s one of the reasons we’ll frequently try to turn it off just to give the mother a break from it. And then, again, you could always give it again. There isn’t an issue of giving it on-off, on-off…
Dr. Spiegelman: Unlike steroids.
Dr. Fox: …unlike steroids where there is, potentially, that concern. So magnesium is another one. And again, the data’s pretty reasonable, that it’s helpful to the babies, particularly to these very preterm babies. And so it’s something that we do consider. Magnesium is something you need to be hospitalized to get. Steroids, you know, somewhat sort of like a borderline case of preterm labor. This you can potentially give it and send them home and have ’em come back the next day for an injection. But magnesium, it’s an intravenous, you’re in the hospital.
Dr. Spiegelman: Yeah, you’re in bed.
Dr. Fox: Yeah, it’s pretty miserable. So it’s something that’s really only done as an inpatient. I don’t know anyone who does it as an outpatient.
Dr. Spiegelman: No, I don’t know how you could even achieve that.
Dr. Fox: Yeah, that’d be pretty tough. Okay. What about antibiotics?
Dr. Spiegelman: So antibiotics are interesting because there’s a lot of theories that preterm labor might be caused by, sort of, like an occult infection. And so if that’s the case, then maybe giving antibiotics could stop preterm labor. That does not seem to be true, but antibiotics are helpful for prophylaxis against Group B strep infection. So a lot of people carry Group B strep, it’s a bacteria, carry it on their skin. You would never know you had it.
It doesn’t affect adults if we didn’t test for it. And so we actually test universally towards the end of pregnancy to see if people need antibiotics during labor to prevent the baby from getting a Group B strep infection. In the preterm period, we often don’t have that information about whether somebody has Group B strep. And so if somebody’s in preterm labor under 37 weeks and we don’t know their Group B strep status, we will give treatment for Group B strep almost presumptively, a penicillin derivative.
Dr. Fox: Yeah. And again, a lot of people thought antibiotics would be like the savior for preterm labor. And a lot of studies, and all of them show it does not work. So sadly, you know, and even if it is caused by some sort of subclinical infection, giving the antibiotics do not seem to be helpful. The only exception seems to be is if their water’s broken, which is a different story again.
But for someone who just comes in with contractions and their water’s not broken, we don’t give antibiotics unless they have Group B strep or we don’t know if they have Group B strep, so we give it until we find out. So we usually send a culture at the same time we admit them, and once it comes back negative, we stop antibiotics typically.
Dr. Spiegelman: Yes. So antibiotics might be turned on, but it’s for Group B strep specifically. The intent is not to stop the labor with antibiotics.
Dr. Fox: Right. And then, so let’s talk about trying to stop the labor. So what are the options, and why don’t they work?
Dr. Spiegelman: So I was gonna say when you say what are the options is that there really aren’t… So we can’t really stop true preterm labor. What we can sometimes do is like quiet the uterus down enough to try and get some of these interventions on board, specifically steroids. So there’s a class of medications called tocolytics. Those are medications that stop contractions, toco-contractions, let it stop, and they don’t…
Dr. Fox: Again, the language major. All right.
Dr. Spiegelman: I think it’s helpful to know the root of the word to understand what’s going on. So they don’t really work to stop labor, but they can, sort of, counteract some of the contraction activity that the uterus is having with the idea that they can maybe delay delivery by about 48 hours so that we have time to give steroids.
Dr. Fox: Yeah. This is again one of these things where, from the very beginning when people were giving these medications, sort of, everybody knew they didn’t help that much, but the thought was, “You know, well, maybe, you know, hopefully, the studies aren’t perfect, they’re small.” And so there’s a lot of medications that have been tried.
And you know, we sort of say now, “Well, you know, they don’t seem to work that well, but maybe they’ll delay delivery by 48 hours.” Interestingly, there are some places that don’t give them ever. They just don’t give them, and their outcomes seem to be the same as the rest of us. So whether they work at all, like 0% versus some small percent, versus whatever is probably not much.
Dr. Spiegelman: Yeah. And these medications do have side effects, so that’s why we really don’t wanna give them long term.
Dr. Fox: Yeah. Y you know, and a lot of them have come and gone. You know, magnesium was a really popular one when I was training, and there were people admitted to the hospital on intravenous magnesium for weeks thinking that it was the thing that stopped their labor. But again, as we said, even with no treatment, over 50% or 50% of people, their labor is gonna stop.
So if you put everyone on magnesium, and you say, “Wow, it works 50% of the time, this is great.” But if you give them nothing, it’s also 50%. And then that’s sort of with time was realized, A, not to work and, B, not to be so safe, you know, test on magnesium for all that time. So that sort of has come and gone. There used to be a medication we gave a lot called tributyltin. Tributyltin is still around and there are indications for it.
And we do use it sometimes in labor if someone’s contracting a real lot to sort of slow it down before we do an external cephalic version. You know, actually, interestingly, it’s an asthma medication. And so that was used to be given, you know, as pills or as injections. And then that was also found, in some rare cases, to be very dangerous to the mother. So the FDA put a black box on it and said, “No moss [SP]. Don’t do that anymore.” So that’s out. You know, we’re left with one medication called nifedipine that we use. So sort of, the brand name is Procardia, some people might have heard that. So what is that and how might that work?
Dr. Spiegelman: So nifedipine or Procardia is a calcium channel blocker. It’s basically a blood pressure medication. We actually also give it in preeclampsia at the time. And it sort of works on calcium. It’s a calcium channel blocker, which are part of the sort of pathophysiology of preterm contractions. And so the idea is that it kind of stops that for a time. You know, I don’t know. Does it work?
Dr. Fox: Yeah. I mean, it’s meant to relax certain smooth muscles. So if you have high blood pressure, it’s supposed to relax your blood vessels, so to lower the pressure. And then the thought is, “Oh, you know, the uterus has some smooth muscles, see if it works.” And you know, it’s one of these things where, again, most of the studies don’t show it has much benefit, but maybe it slows down contractions in some people.
For some people, it’s given only just like for symptomatic relief. Like without the medication, they feel more contractions. With the medication, they feel fewer contractions, and, you know, that’s nice. And, you know, I mean, listen, it’s so not a headache and it’s not a dangerous headache. I’d still be happy for them to take something to make them feel better.
And so, you know, that is something to feel better and maybe to get better night’s sleep, maybe to stop, you know them from feeling they have to come to the hospital 2 in the morning for contractions and there’s benefit. You know, and I prescribe nifedipine usually, again, if it’s in the acute process of preterm labor. I’ll say, “Listen, this might not work at all, but maybe it’ll help keep you pregnant for two days, you know, at a higher rate than if I didn’t give it to you to get you the steroids.”
And then after that, I’ll say, “Listen, there’s no evidence it does anything beneficial in terms of the baby or delivery, but if it makes you personally feel better, I’m okay with you taking it periodically as long as it’s not dropping your blood pressure to the point that you’re dizzy and weak and passing out because that would be bad.”
Dr. Spiegelman: Yeah, or raising your heart rate really high.
Dr. Fox: Right. So, you know, it’s one of these things where you have to…it’s very individualized. Some people think, “Oh, I need to be in this medication forever and this,” and all the evidence shows it does not make a difference.
Dr. Spiegelman: Yeah. And the other thing with nifedipine is when you give it at the same time as magnesium, theycan kind of potentiate each other if there are side effects. And so it’s kind of a “use with caution” if you’re gonna use ’em together.
Dr. Fox: Yeah. And there are people, you know, around the country who feel differently. Some people will never, ever give it, period. Like, “Done, we’re not giving it.” Some people say, “I will give it, but only for 48 hours. And after that,…
Dr. Spiegelman: After 32 weeks. Yeah.
Dr. Fox: …forget it, you’re done.” Others will sort of say, “Well, I’m gonna give it no matter what until they deliver.” And then there’s others who are sort of, I think I fall into this boat where it’s much more, you know, case by case, individualized, you know, how do they respond? How do they feel? And again, with all the caveats that this could all just be, you know, made up in a sense. But, you know, I do think that there’s so much variation in humans that you have to sort of try to individualize these things, but, again, with the honesty that it’s not like this is a magic pill because it’s not. You know, we know that. It’s not a magic pill.
Dr. Spiegelman: Yeah. Another time sometimes we’ll give nifedipine is like, let’s say somebody has, like, surgery in the second trimester or something like that where we think they might be at risk of preterm contractions and we just kind of wanna like quiet things down for a little bit. But yeah, I mean, I would say the jury’s kind of out on it how well it works. But you know, if you’re giving something for symptomatic relief, a placebo will work.
Dr. Fox: So let’s talk about indomethacin. So what is indomethacin or Indocin?
Dr. Spiegelman: So indomethacin is an NSAID, kind of in the same classes like aspirin, and ibuprofen, and those sorts of medications, which you’ve probably heard you should not take ibuprofen in pregnancy. But Indocin has effect of also quieting down the uterus, and we’ll often give that in kind of earlier pregnancies that are in preterm labor again for short courses, 48 hours, kind of, at the max, again, because there are some side effects associated with Indocin.
Dr. Fox: Yeah. I mean, Indocin’s really interesting one because the data’s not terrible in terms of it working for at least 48 hours, I think it’s a little better than some of the other medications, but I would say the risk is a little bit higher. So we don’t give it late in pregnancy, which is why you said we don’t usually, you know, recommend taking Motrin, your ale, or ibuprofen, those things during pregnancy. It’s not so much that they’re automatically dangerous, it’s that late in pregnancy, they can have an effect on the fetal heart.
There’s it blood vessel and the fetal heart that’s supposed to stay open, and if you give it, it can close and that cause problems. But that really is an issue in the third trimester. And so we don’t give indomethacin, you know, after, pick your time, some people 32 weeks, 30 weeks, you know, somewhere in that range. And then prior to that, it’s like “use with caution.” Yeah.
Dr. Spiegelman: Yeah. And one of the things that it also has a kind of effect of doing is it can mask a fever. And so if you’re worried about somebody in preterm labor being at risk of infection, and this would again be pretty individualized, but if you have a high suspicion that maybe somebody really has an infection that just kind of hasn’t manifested itself yet, you wanna know if they’re gonna spike a fever. And if you’re giving them a medication that might mask that, that could potentially be detrimental.
Dr. Fox: Yeah. So, I mean, indomethacin, again, varies around the country. Some people it’s their first line, some people don’t use it at all, some people, you know, again, person by person, but it is something that typically would be more likely to be given the earlier in pregnancy you are.
Dr. Spiegelman: Right. Yeah. So I think for kind of very early preterm labor, I like Indocin for that. I think, as a tocolytic, it’s my favorite in the sense of tocolysis to get steroids on board. But it is a “use with caution” and just kind of have a healthy respect for Indocin.
Dr. Fox: I like that. A healthy respect for Indocin.
Dr. Spiegelman: Yeah, we respect each other.
Dr. Fox: There are other medications out there that I would say are more experimental or, you know, that maybe in Europe and this and, you know, there’s these oxytocin blockers and, you know, there are some, but these are the main ones in the U.S., the ones we mentioned. And again, just as a review, they might not work at all. If they do work, it seems to be just sort of briefly maybe to hold off labor enough to get steroids on board.
After that, it’s really just individualized, mostly, I would say for symptomatic relief if that. And there’s others who won’t even do that. They’ll just say, “It’s not worth the risk. I’m not gonna prescribe it. You know, Good luck.” Tell me, what are your thoughts about bed rest for this? Not in general.
Dr. Spiegelman: Well, in general, and for this, I am against. So bed rest was very popular, like, back in the day. And it was thought that, “Okay, if we just have a pregnant person, like, sit still and do nothing, maybe nothing will happen.” And it really hasn’t been shown to work. It has not improved outcomes in terms of prolonging pregnancy in the studies that have been done. And then it also has some detrimental effects, like an increased risk of blood clots, muscle deconditioning, a pretty serious mental health toll.
And so, in general, I don’t recommend bed rest. What I’ll sometimes recommend is like a modified bed rest, which is like, just kind of take it easy. Like, maybe don’t run a marathon, maybe don’t, you know, go too crazy with your physical activity, mostly for patient’s own kind of reassurance to just feel like, “Okay, like I’m just treating my body well in this situation.”
Dr. Fox: Right. Right. It’s interesting when you talk about mental health. I think a lot of people incorrectly think, like, “Wait, I could just stay home in lie in bed all day. That sounds awesome. I could be on Netflix.” And, yeah, it’s probably good for like…
Dr. Spiegelman: A day.
Dr. Fox: …an afternoon. And then, by the next day, you’re like, “Wait, I can’t go out and see my friends. I can’t do this, I can’t do that. Like, I really have to just lie here. You know, I can’t walk.”
Dr. Spiegelman: Yeah, and some people got other kids. It’s terrible.
Dr. Fox: Yeah. No, it’s a big deal. It is a big deal to be put on bed rest and it doesn’t seem to help. You know, I’m similar to you. You know, we’ll talk about, I say, “Listen, lying in bed all day is not a good thing. Running a marathon for you is probably not a good thing.” There’s somewhere in the middle that’s the right way, and we don’t know what it is, and it’s probably different for each person. And so, you know, a lot of it for me is, you know, “If you do this amount of activity and that’s what causes you to start contracting, back off.”
Dr. Spiegelman: Stop.
Dr. Fox: Do less than that,” right? So for you, it’s, “If I walk six blocks, that’s when, you know, I feel it.” All right, don’t walk more than five blocks. And then for someone else, that might be one block, for someone else, that might be a mile. It really has to be individualized, and you have to use some level of common sense because medicine just does not have the answer for you, it just isn’t there, and because probably it’s either no answer or it’s different for each person. Yeah.
Dr. Spiegelman: Every’s different. I usually tell people in general when they ask about exercise in pregnancy, if you feel good while you’re doing it, then you can do it. If you don’t feel good while you’re doing it, don’t do it.
Dr. Fox: Right. And so that’s about bed rest. What about keeping people in the hospital? How do we decide if someone should stay in the hospital? Like, they have preterm labor, they come in, they’re getting treated, and it seems to have stopped, right? Do you send ’em home immediately? Is there, like, a washout period? Like, what do you do?
Dr. Spiegelman: So it’s hard. That’s a hard decision to make, and it is very dependent on a few things. One is the gestational age. So the earlier you are in preterm labor, kind of the more uncomfortable, I think, it becomes to send you home if it’s been a real preterm labor scare, if your cervix is really dilated, especially if the baby is breached, which is more common in the preterm period.
The closer you get to what’s called the late preterm period, which is that 34 weeks to 36 weeks and 6 days period where the outcomes for delivery are very good, and most hospitals around the country can handle a baby born at that gestational age, I think it becomes more comfortable to send somebody home if they’ve really kind of stopped preterm labor. But earlier, if you’ve kind of had this scare, things have maybe stopped, I usually like to watch people off tocolytic.
So if they’ve been given Indocin or any of these other medications to see what happens when they’re not on those medications to see if things start up again and then kind of base it on, “Okay, have you really been stable for a day or two and nothing has happened? Do you live close to the hospital? How far do you have to travel to get to a hospital that could handle your baby, your very preterm baby, if you were to deliver?”
And you know, in terms of mode of delivery, if the baby is not head-down and you would potentially need a C-section, that’s also something that, you know, affects how quickly you have to be delivered basically, or how quickly people have to spring into action if you’re progressing. So these are kind of all the factors that go into deciding whether we feel comfortable sending somebody home.
Dr. Fox: Yeah. I mean I think the general principle that I tell people is whether you stay in the hospital or not is not gonna affect when you deliver.
Dr. Spiegelman: Oh, no.
Dr. Fox: I mean, there’s nothing magical about being in the hospital.
Dr. Spiegelman: No, no.
Dr. Fox: If anything, it’s…
Dr. Spiegelman: Unmagical.
Dr. Fox: …the opposite of magic. It’s really all about logistics and, “Okay, you are at high risk for going into labor and delivering, you have a preterm baby. The baby’s gonna need NICU care.” And like you said, the baby’s breach, might need a C-section. And there’s all these things. So logistically, we have to sort that out. So someone who lives across the street from the hospital I’m gonna feel a lot differently about as compared to someone who lives, you know, 64 miles from the hospital that has to take three buses and, you know, a horse to get to the hospital.
And so, obviously, I’m gonna feel differently about that and I’m gonna have different recommendations. And so this is where it’s really individualized. Not everyone needs to stay in the hospital the entire time and not everyone should go home immediately after two days or whatever it is, and there’s everything in between. And so it’s a very individualized discussion based on, you know, what is the chance they’re gonna deliver, right?
How big a deal is it if they deliver somewhere else compared to where you are now? How hard is it for them to get to the hospital? How awful is it for them to be in the hospital compared to at home? You know, is it driving them crazy or not driving them crazy? Some people wanna stay in the hospital and other people wanna get the hell out of the hospital. That is valuable to me.
I would like to know that because it’s gonna change potentially what we do and that’s reasonable. It doesn’t have to just be like a rule, right? There’s also a lot of this. You know, again then anxiety kicks in, and how does that affect? And the stress levels, does that affect the risk of preterm? There’s so much that goes into this. And so, ultimately, I would say the best way to describe it is it’s a conversation.
Dr. Spiegelman: Yeah. And then another thing we haven’t really mentioned is we also have to make sure the baby’s okay. So in preterm labor, you know, preterm contractions, sometimes it can stress a fetus out. . And sometimes we’ll see changes in the fetal heart rate tracing that might make us more concerned. And so we also have to kind of check that element before we feel comfortable sending someone home.
Dr. Fox: Excellent. All right. I think we covered preterm labor. So we went over the diagnosis, we went over what happens, sort of, in nature that a lot of it just sort of resolves. And then after we diagnose it, what do we do? All the things that we give and try to do and what we do for them. Spiegs, thank you. Thanks for coming on.
Dr. Spiegelman: Oh, my pleasure. I’d say we’ve covered preterm labor, but we have not cured preterm labor.
Dr. Fox: No, we still have a ways to go on that one, but we try. I tell you, we always try. We try very, very hard, but unfortunately, there’s still a lot to learn and a lot more to hopefully develop to improve outcomes even further. So I know that everyone is now like, “Wow, who is this Jessica Spiegelman? She’s awesome. I wanna hear more from her.” So there’s definitely another podcast coming because we already recorded it, so I know that, and there will be more to come. So thanks for stopping by to talk.
Dr. Spiegelman: My pleasure.
Dr. Fox: Thank you for listening to the “Healthful Woman Podcast.” To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at email@example.com. Have a great day.
Disclaimer: The information discussed in “Healthful Woman” is intended for educational uses only and 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.