Dr. Nathan Fox talks with Dr. Simi Gupta today to talk about a common high-risk birth situation, giving birth after having previously having a preterm birth event. The risks are higher for another preterm delivery but not guaranteed. There are a lot of possible outcomes, risk factors, and reasons to deliver early a second or third time, and our doctors are here to make sure both mother and baby stay healthy and enounter the fewest complications possible during their care.
“Pregnancy with a prior preterm birth” – with Dr. Simi Gupta
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics and women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB/GYN 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. Simi Gupta, Dr. Gupta, welcome back to the podcast. How goes it today?
Dr. Gupta: I’m good. Thank you and happy to be back.
Dr. Fox: Wonderful. So we’re gonna be talking about…it’s an interesting topic and it really comes up a lot in our practice, I would say, which is either recurrent preterm birth, or prior preterm birth, essentially, is someone’s previous pregnancy or one of her prior pregnancies delivered preterm. What do we do in this pregnancy? How often are you seeing patients with this?
Dr. Gupta: We see it very commonly, I feel like, you know, a significant percentage of patients who come to us for high risk care are coming to us because they had a prior preterm delivery. So this is definitely one of the most common things I talk to patients about.
Dr. Gupta: Yeah, I mean, overall, the rate of preterm birth is ballpark 10%, maybe 11%, somewhere like that. So, you know, just if you’re in any standard OB practice, 1 out of 10 of your, you know, patients are gonna have this, but then usually they’re gonna come and get a consultation with us or transfer care to us. And so we see way more than 1 in 10 who had prior preterm birth, and we’re talking about this all the time, essentially.
Dr. Gupta: That’s right. That’s right.
Dr. Fox: Now, when someone comes to you with a prior preterm birth, what’s that concern me? What is the likelihood she’s gonna deliver preterm again? I mean, without intervention, sort of why… Is it it’s not 1 in 10 again? Is it higher?
Dr. Gupta: Yeah, so it’s about double. So I agree with, you know, what you just said that the baseline rate for anybody to have a preterm delivery is about 10%, 11%,12%. And then with a next pregnancy, if we don’t do anything, then the risk is about double. So say anywhere between 20% to 30% chance of having another preterm delivery.
Dr. Fox: Yeah. And that’s just sort of all comers. And there’s definitely, you know, situations where it’s higher meaning if someone you know, their last pregnancy, they delivered preterm or just a little bit preterm then their rate is gonna be, you know, increased. But if it was like really preterm, then it’s gonna be even higher. And so there is some maneuvering with those statistics, but it’s at least double, which is pretty high, if you think about it. And then just to sort of be clear with what we’re talking about, what exactly is preterm? Like, how do we say or define a preterm birth?
Dr. Gupta: Right. So this is something that is always kind of nice for people to know. So, as you know, when we talk about somebody’s due date, then that is technically 40 weeks of pregnancy, and any pregnancy that delivers between 37 weeks and later is considered full-term. So deliveries before 37 weeks are what we’re considering preterm deliveries. And, you know, there could be deliveries that are 34, 35, 36 weeks that we kind of call late preterm deliveries. And then there are the deliveries before 34 weeks, so we kind of call early preterm deliveries.
I think the other thing to mention is, you know, part of what we were gonna talk about today is what we call spontaneous preterm deliveries, meaning people who just go into labor or break their bag of water on their own, as opposed to people who have to be delivered early for some medical reason, which is considered an indicated preterm delivery.
Dr. Fox: Right, if someone’s preterm birth was, let’s say, 36 weeks because they had a placentaprevia or something like that they have a history of a preterm birth. But we don’t really think of it the same way as someone who went into labor at 36 weeks, which makes a lot of sense sort of logically for people, but it’s it’s own, sort of, it’s a different category. And sort of if someone had to be delivered preterm for a medical reason or something like that, there is a conversation about the chance of it happening again, but sort of the statistics are different, and the treatments are different. And you know, someone delivered because of preeclampsia, we’re not gonna treat them the same way as if they delivered early because their water broke. Because there’s such different reasons why someone would deliver early, we don’t wanna put them in the same category. They’re like totally different conversations for us.
Dr. Gupta: Right, exactly. So that’s why it’s…when we’re talking about this, it’s always, you know, kind of important to know, the first thing we try to figure out is, did someone go into labor on their own or was a medical provider recommending delivery for them preterm in a prior pregnancy?
Dr. Fox: Yeah. And it’s interesting. I mean, when they’re our own patients, we obviously know which one of those two it is, but sometimes people come to us and it’s not that easy to sort out because, you know, when people are in the throes of delivery, you don’t have to remember every detail and some of its fuzzy and they’ll say, “Yeah, it came and I was contracting and I was bleeding a little bit. And they said, the heart rate dropped, and so they did a C-section, and I was 35 weeks.” And you’re kind of like, “Huh, like, were you in labor? Like, were you not in labor? Was there an abruption? Was the baby growth restricted?”
Like it’s hard for us sometimes to know exactly what happened. And so, you know, if someone has a preterm birth, it’s really important, if not at the exact time maybe like the day after or two days after, to really sit down with your obstetrician and say, “Hey, what happened? Can you, like, clear this up for me? Exactly what happened? And just so I know for my next pregnancy.”
And this is something they should be doing with you. But sometimes people deliver at a hospital where they don’t know the doctor, different practice, different hospital, or the person on call is not somebody they know, and they don’t always get the story. And they think, like, “Who cares? My baby’s born, my baby’s fine. We’re all going home.” But it might have implications for the next pregnancy. And so having as much detail as possible from that preterm birth, A, to figure out what kind it was, but even for us, there are details about it that will help us maybe determine the cause or something like that. So trying to get a lot of information is really helpful in our end.
Dr. Gupta: That’s definitely true. And if you’re kind of looking to see a high risk doctor to talk about a future pregnancy, you know, definitely having the story or if you’re able to get records, those are also very helpful for the doctor that you’re seeing to kind of help you talk through what happened and what we can do next time.
Dr. Fox: So, someone comes to you and they have a history of a preterm birth. And, you know, it’s pretty clear that it was a spontaneous preterm birth, they went into labor on their own. What are the types of things you’re gonna elicit from them in your history taking, or getting the story from them, or an exam, or whatever it might be, that would help you determine, A, what happened, and B, what you might do in the next pregnancy?
Dr. Gupta: Right. So, you know, there’s a couple of things that are very important. And the first one is trying to see if the person had risk factors for the preterm delivery because that may influence what I think their chances are of having another preterm delivery and what I could do in a future pregnancy. So for example, if somebody had a twin pregnancy and delivered at 36 weeks, I might feel differently about that pregnancy than someone who’s pregnant with one baby or a singleton. So twins are a risk factor for preterm delivery. If they had bleeding, that would be something that’s interesting to me if they had, say, an infection like a kidney infection. So kind of running through the story of what happened in their prior pregnancy to see if there’s any risk factors for the pregnancy is very important.
Dr. Fox: Yeah, I mean, it’s really interesting because you hear so many different stories of what happened. And it’s nice for us to try to figure out why someone delivered early. We frequently don’t know, like, frequently something was early, we have no idea like, “Why is this person going to labor? Why did their water break?” And we don’t know. But there’s certain possible causes. And sometimes if we know the cause, it’s gonna help us make a plan for the next pregnancy. Like what you said, like, one of the simplest things for people to wrap their heads around is, all right, someone had triplets and they delivered at 35 weeks. And they come to us, and we’re like, “Well, if you don’t carry triplets, you’ll probably be fine.”
And so, like, that was easy, right? Carry one baby, and if you got to 35 weeks of triplets, you’ll probably go full-term with the singleton. And we don’t think too much about them. And so that’s sort of, like, the easiest one to wrap your head around. That makes a lot of sense. But other than something like that, that’s so obvious. What are the possible causes of preterm birth, preterm labor, PPROM, you know, or your water breaks early? Sort of in a categorical standpoint, like what are the categories of reasons why someone might deliver early and sort of how do we differentiate those?
Dr. Gupta: Right. So, you know, some things or things like we spoke about that happened during the pregnancy. So multiple gestation like twins or triplets, you know, some kind of trauma like a car accident, some type of infection. Those are things that may happen just in that pregnancy. And then there are the other group of things that we may do an evaluation for. So for example, if somebody has an abnormal shape to their uterus, for example, something called like a bicornuate uterus or septate uterus, that puts them at an increased risk for preterm delivery.
So sometimes we will do an ultrasound or something called a saline infusion sonogram to look for abnormalities in the shape of their uterus. Another big category are people who have issues with their cervix, for example, there’s something called cervical incompetence, where their cervix starts to dilate early. And you can sometimes figure this out based off of their history, sometimes by examining their cervix or kind of looking at it through an ultrasound. So those are two other big groups of patients that might have risk factors for a preterm delivery.
Dr. Fox: Yeah. And then there’s the woman of none of this. And you’re just, you know, they just went into labor at 28 weeks, the uterus is fine, their cervix seems fine, they didn’t seem to have an infection. And we really don’t know what happened. And, you know, it could be something that was there that we don’t know about, right? There could have been some sort of infection or inflammation that was otherwise not seen. Or sometimes, you know, we think that sometimes people just the clock is off, right? That whatever, you know, what I tell people is we don’t really understand why people go into labor at term, like we don’t understand why someone goes into labor that Tuesday night at 3 a.m. Why they suddenly start contracting or their water breaks.
And if we don’t know why it happens at a certain time at the end of pregnancy, we certainly aren’t gonna know why it happens early. Like we know what happens when someone goes into labor, we don’t really know why. And there’s probably some people who for whatever reason, that biological clock that’s, you know, set between the mother’s brain, the placenta, the fetal brain, like all those hormones that sort of go back and forth, somehow got, you know, off, the time was off. And you’re sort of like left with, “I don’t know, if that’s gonna happen again next time? Or is it not gonna happen again next time?”
And we just don’t know. And I think that’s probably the most common that we run into that we’re just sort of dealing with, you know, a situation where we don’t know why someone delivered early. And that’s tough. And so we ended up probably covering a lot of possible causes because we just have no idea what’s gonna happen, which can be frustrating for people.
Dr. Gupta: Right. It is true. Unfortunately, the most common answer we come to is, “We don’t know why you had a preterm delivery.” And so we will kind of look for different things that may cause it, and then we’ll, you know, do some kind of standard things we do for everybody with a prior preterm delivery. But unfortunately, most of the time, we don’t come to a reason for why someone has one.
Dr. Fox: So what are the things that you might recommend for someone who had a previous preterm birth and it’s not obvious what the cause was? That we can’t direct their treatments?
Dr. Gupta: The primary thing that we talk about is progesterone. So progesterone, as you know, is a naturally-occurring hormone. But we talked about giving patients a synthetic version of it. And that there’s different ways of giving progesterone either through injections or through vaginal progesterone. But, essentially, it has been studied and it has been shown to decrease the risk of having another preterm delivery in patients who had a prior spontaneous preterm delivery. So that’s the number one thing that we speak about with patients
Dr. Fox: Yeah, and totally true, yet it is really complicated now with progesterone because people are hearing different things. And there’s, you know, sort of with the injections use one company, or another company, or not at all, and then the vaginal use in everybody or just with the short cervix. And it’s hard to sort through all of this. I think that there was a massive study that was done a while ago, where they took women who had a history of spontaneous preterm births, sort of the type of situation we’re talking about, and they randomly divided them into groups and give half of them these progesterone injections, we call it 17P, which is short for something really long, 17-alphahydroxyprogesterone caproate, whatever. 17P injections every week, starting at 16 weeks.
And the other group, they gave injections of everything that was the same minus the progesterone, right. That’s sort of the oil that was in, so no one knew what they were getting. And the group that got the progesterone injections did better. They have fewer preterm births, they stayed pregnant longer.
And then, for basically 20 years, you know, everybody’s given the progesterone shots. And there was a whole lot of, like, hoopla around that because from sort of a financial and intellectual property situation, the company that had it was charging a lot of money in that can you do the…it was whatever. So that was its own separate mess. But then they repeated the study, mostly in Ukraine, actually, and it was not beneficial. And so now we have one study that shows it works. One study that shows it doesn’t work. And there was a lot of debate about that. And at the same time, vaginal progesterone, which was mostly used for women with the short cervix was also being used for women with the prior preterm birth who couldn’t get the progesterone injections that it seems to be helpful for them. So now we have what seems to be very simple as, again, very complex, which is just delightful for those of us who do consults.
Dr. Gupta: Right, and so, you know, all of us are trying to kind of figure out what the next steps are now that we have this more recent study that says the 17P injections may or may not work. And I think we all are, you know, somewhat on the same page. Whereas, if a patient received 17P in the past and it was helpful, we may recommend that they take it again. Or if they are very, very high risk for another preterm delivery, for example, had multiple prior preterm deliveries or had very early preterm deliveries, we would consider giving them the 17P. Whereas patients who kind of don’t meet either those criteria, now we’re talking about giving them vaginal progesterone, which has been shown to decrease the risk of having another preterm delivery, it just wasn’t studied in as many patients as the 17P injections.
Dr. Fox: Yeah. And it’s also there’s some logistics involved. The 17P is not available at every pharmacy. It requires an injection, right? Which needs someone’s got to do it, right? You got to figure that out. It’s obviously more painful, whereas vaginal progesterone is pretty easy to get, but it’s every day. And so, you know, I’ve never had either, but I don’t know what people would even prefer, right? Would you prefer to have an injection once a week or have to, you know, put in a vaginal medication once a day? And I’m sure some people prefer one, some people prefer the other. But there is sort of, you know, that level of it.
And so there is a lot of, I would say variation now. I would say probably five years ago, there was a lot less variation. And pretty much everyone was getting 17P or being recommended that. And now there’s a lot more people either doing neither, doing the injections, or just doing the vaginal progesterone. This is probably a lot more variation now than there used to be.
Dr. Gupta: Right, I would agree with that. And I think that kind of leads into the second thing that we recommend for patients with a prior preterm delivery, which is measuring the length of their cervix by ultrasound. Kind of the way I explain it to patients is your cervix normally gets shorter and then starts to open or dilate when you’re in your eighth or ninth month of pregnancy as your body kind of prepares for going into labor. But we know that women whose cervix shortens earlier in the pregnancy, they have a higher chance of having a preterm delivery. So the second big thing that we can do for patients with a prior preterm delivery is measure the length of their cervix by ultrasound to help determine their risk of having another preterm delivery.
Dr. Fox: Right. And then, when do we do those measurements or that measurement?
Dr. Gupta: Right. So we usually start around 16 weeks, and we usually stop somewhere at the beginning of the third trimester. I think for our patients, it’s usually around 32 weeks.
Dr. Fox: Yeah. And there is variation in this as well, whether this is something that should be done once in the second trimester, whether it should be done serially, and if you do it serially, when do you start? When do you finish? And how often do you do it? And there’s a lot of options there. And people do it differently, because no one knows the optimal thing. Obviously, the more you check sort of in theory, the better it is, because you’re more likely to catch something but…you know, find something and not catch like disease, you might find something. But on the downside, you have to have a lot more ultrasounds, which is a lot more time, cost, you might find things that don’t matter and so now you’re overtraining.
And so there’s all this balance between doing it too frequently versus doing it too infrequently. And no one knows the exact right balance between those two. And so you’ll see a lot of variation of how that’s done. But I’d say you’re gonna find that pretty much everyone does ultrasound to measure the cervical length in some manner, right? Whether that’s once, whether that’s twice, whether that’s every x amount of weeks. We do it every couple of weeks. I think people are coming to the office anyways, and it’s just sort of logistically the way it works out for our practice. But that doesn’t mean it’s the best way to do it. That’s just how we do it. And then what if the cervix does become short? You were mentioning that there’s a link with progesterone there.
Dr. Gupta: Right. So what we know is…or from what the data shows that if someone does have a short cervix and they are given vaginal progesterone, that also has been shown to decrease the risk of having a preterm delivery. So for some of our patients who may be are not on progesterone, just from the beginning of the pregnancy, if we noticed that they have a short cervix, we may then start vaginal progesterone for them.
Dr. Fox: Yeah. Now, if someone has a short cervix and a prior preterm birth, other than let’s say they weren’t on progesterone, and now this might put them on progesterone. There’s also the option for a cerclage.
Dr. Gupta: Right, exactly. So that’s our kind of second big treatment option besides progesterone. So what cerclage is it is a surgical procedure. Essentially, someone comes into the hospital and is given a spinal anesthesia so they’re numb from the waist down. And we literally put in a little stitch around their cervix to help keep it closed. And then they go home, you know, usually a few hours after the stitch is placed.
Dr. Fox: Right. Now cerclage is its own separate podcast. And it’s a complex procedure, not surgically, but it’s complex in terms of who needs it and who doesn’t, and how do we make that decision? But one of the sort of categories of people who it really seems to be helpful for are women with a prior preterm birth, particularly in early preterm birth, who also have a short cervix in the next pregnancy. So one of the things we’re doing in that subsequent pregnancy by measuring the cervix is not just predicting, but if we find that short cervix like, “Ah, there’s really good data that if I put a cerclage in now I’m gonna help you.”
And that’s important, because that is something that can really change someone’s outcome in pregnancy. And it’s also a good way to determine if they need it. Because if you put a cerclage in everybody who had a prior preterm birth, that’s a lot of cerclages and a probably a lot of unnecessary surgery. But, you know, we find that there’s x percent that end up having a short cervix and get a cerclage, and it seems to be helpful. So that’s something that we definitely do. So we mentioned the progesterone, the cervical length screening, those are the big ones, what else might we do?
Dr. Gupta: Right, the last potential treatment option is something called a pessary. What a pessary is, is it’s a little bit of it’s like a plastic doughnut that we put around the cervix to help keep it closed. And a pessary there is much less data on pessary use than there is for cerclage or progesterone. So it’s not something we commonly use, it’s not necessarily our first choice, but it’s something that we keep in mind as another option if a patient is not a good candidate for progesterone or cerclage, or need something in addition to one of those two treatments.
Dr. Fox: Yeah, that is definitely also is its own podcast, the management of the short cervix or pessaries. And there’s a lot of debate about that whether they work or whether they don’t work. They tend not to be particularly harmful, which is good. I mean, it’s, you know, cerclage isn’t typically harmful, but it is surgery, whereas a pessary is not. And so the stakes are lower, I would say, which is good, but it is something that we do keep as a possible treatment for some of the short cervix. So someone’s getting progesterone, we’re screening their cervix. There’s also a lot of controversy overdoing a test called fetal fibronectin. So can you explain what that is and why it’s controversial?
Dr. Gupta: Right. So a fetal fibronectin refers to a test where, essentially, a Q-tip is placed into the vagina below the cervix, and some of that fluid is sent off to the lab. So it looks for a protein that’s released from the cervix. And it has been shown to show who may be at an increased risk for a preterm delivery in the few weeks after it’s sent. So the general data is if it comes back negative, the chance of a preterm delivery in the following two weeks is less than 1%. And if it comes back positive, there’s approximately a 20% chance of going into labor in the next 2 weeks after that swab is sent.
Dr. Fox: And how might we use that practically?
Dr. Gupta: Right. So people use it in different ways. So for example, if someone is actually having symptoms of preterm labor, that will often get sent as part of their evaluation. We use it routinely for patients who have a short cervix. So if they have a short cervix on the ultrasound, and we send the fetal fibronectin, and it is positive, and we have a very high concern that they may go into preterm labor in the next few weeks, we will usually recommend that they get betamethasone. And what betamethasone is, it is a steroid shot that has been shown to help the baby’s lungs mature if the baby is born early.
Dr. Fox: And if it’s negative, then what do we do, the fetal fibronectin?
Dr. Gupta: Right. So if it’s negative, then we say now we would say the chance of a preterm delivery in the next two weeks is fairly low. And it allows people a little bit of reassurance, but then also, they can go about their normal days if they are thinking of traveling or different things, and it provides the reassurance that we are less concerned.
Dr. Fox: Yeah, and this is something that there’s also a lot of variation. Some people use it all the time. Some people use it never and everything in between. And again, it’s one of those things where it’s complex because a negative test and with fetal fibronectin negative is good, positive is bad. We do that to intentionally confuse people. But, you know, a negative test does not mean you won’t deliver, and a positive test does not mean you will deliver. It doesn’t work like that. It just ranges your risk from a certain percentage, whatever your percentage is. It either makes it lower or higher. Now, how you use that information some people argue, “That’s meaningless. It doesn’t help me, it doesn’t change what I’m gonna do, why would I start doing all these tests and give people either false reassurance. Maybe not false but reassurance that I can’t guarantee. Or scare them when they may not be a situation.”
And that’s fine, like, that’s legitimate. Whereas, others would say, “Well, listen, you know, a lot of medicine is just about predicting risk because you risk 10%, 2%, 20%, 80%. And people might behave differently, or they may make different decisions based on that, or like you said, give steroids or not. And so there’s definitely different ways people use this or don’t use this test.
We use it in our practice, it’s not an edict. It does not mean, again, that you will deliver, you won’t deliver, but it just helps us make management decisions and other decisions that people want. Like, “Should I go on that trip to Bermuda? Or should I not go on that trip to Bermuda?” And there’s no perfect answer to that. You could tell everybody, no Or you could tell everybody, yes. And if you wanna sort of get some sort of precision and try to tell some people, no, some people, yes. How do you make that decision? And this is sort of one of the data points we use. But, again, it’s just part of an overall evaluation.
Another thing that’s on the list of things that are controversial and that’s done by everyone is screening for infections, vaginal infections. So specifically bacterial. So what’s going on there?
Dr. Gupta: And as you said, this is, you know, something that is a little complicated. So we know that in some cases, having a vaginal infection, specifically something called bacterial vaginosis has been associated with having a preterm delivery. And so, one option is to screen everybody for this bacterial infection in their first trimester. And if they have this bacterial infection, then to treat them with antibiotics with the hope that it decreases their risk of having a preterm delivery. But as you said, it gets a little bit complicated because the data is mixed as it is for so many of these things, that if you have it and you treat it, are you actually decreasing their risk or not? Do you have to check again different things? But I think this kind of falls into the category of it’s something fairly straightforward that we can treat as needed. And if it helps, great, and if it doesn’t help, there’s very little harm done.
Dr. Fox: Yeah. I mean, it’s tough because we don’t understand this so well, meaning why would someone…I mean, there’s always bacteria in the vagina like 100% of the time, right, it’s not a sterile place. And so the question is, like, what’s normal, what’s abnormal? And what are the factors that might lead some of the bacteria to sort of crawl up into the cervix and the uterus and cause inflammation and preterm birth, and we don’t quite know. And it is known that women with this bacterial vaginosis, there is a higher chance of preterm birth. But it’s never really panned out that if you screen everybody for it and treat those who have it for, that you end up helping them because there’s this thought that if, you know, the one person who gets antibiotics, who needs it, great, but the nine people who get the antibiotics maybe who didn’t need it, maybe some of them, you’re gonna sort of mess up the normal bacteria in the vagina and then cause a problem.
And so it doesn’t seem to help. But, you know, in our practice, we do it not routinely, but we do it for women who have a history of preterm birth, or for many women with a history of preterm birth based on their story. Because the data seems to be a little bit better in that category, but this is definitely an area of controversy, and not everybody does it. But we do it in our practice, and we just treat them once and then we don’t check 100 times because you can sort of over treat, but this is a tough one. Because again, people, you know, around everywhere disagree on this.
Dr. Gupta: Right. And, you know, as you’re saying, this is one of the hard parts for treating all patients with, you know, prior preterm delivery is there’s a lot of mixed data on a lot of things. And so we try to take every patient and do what we think is best for them. But it’s sometimes hard to know right now, what are the best options.
Dr. Fox: Yeah. And I think, you know, what sometimes happens when we don’t know the best options, at least in our world, is the people that make these sort of sweeping recommendations that are meant to be sort of general that everyone can sort of follow in some fashion will frequently write in something like, “Well, this is a place for shared decision making,” right? When we don’t really know. So can you explain what that means? And then I’ll say why I find it confusing.
Dr. Gupta: Right. The idea of it is good right? Shared decision making basically means that, you know, we can sit down with our patients, we can tell them the different options and the controversies about it. And we can, together, kind of decide what works best for a patient and which kind of direction of how many things she wants done versus doesn’t want done, or what works for her. The idea of it is very good.
The reason it gets very complicated, as you said, is two things. One is this is very complicated, even for us. And it’s sometimes hard to be the patient and be asked what you wanna do when you may feel like you don’t understand all of the ins and outs of these choices. And the second thing is, it’s always easiest for everyone. If someone says, “This is the right thing to do, this is what you should do.” And when there’s not that clear cut answer, it can put a little bit of the burden on the patient, which you don’t wanna have that burden sometimes.
Dr. Fox: Yeah, I think, you know, on the one hand, like you said, it’s a really great concept, because it sort of, you know, highlights the idea that we need some humility, we don’t know everything from everything, we don’t know what’s best for everyone. And people should have a say in their medical care. And when there’s choices, they should obviously be the ones making choices about their own health, and their own bodies, and their own care. And that’s true, yes. Like, I’m on board with that, that makes a lot of sense.
On the other hand, it can go overboar. You know, if my plumber said to me, like, you know, “What kind of piping do you want in your walls?” I’d be like, “I don’t know, like how the hell would I know what kind of piping I want. You’re the plumber, you tell me what’s good.” And so those are extremes. And the problem is, there’s so much in between that it’s hard to know which way to go, right? Is this one of these situations where I should be saying, “Listen, this is what I do. Like, this is my life, I study this every day, you need to be going in this direction. And you don’t have to, it’s not a…you know, there’s no law that you have to but this is what I recommend is what you should do.” Versus should I be going, you know, “Hey, listen, there’s a couple of choices. They’re both reasonable. Here’s the pros and cons of choice A, here’s the pros and cons of choice B. How do you feel about this?”
And I think that each situation is gonna be different. And each personality is different. And it’s just there’s so much like human complexity that’s involved with this, that it’s not simple to just say shared decision making. And it’s not simple to just say, “You decide doctor,” and I think that it has to be very nuanced.
Dr. Gupta: Right. I agree. And I think as you feel and I feel and many of us high risk doctors who do this, we can kind of feel out with patients, do they want us to make a recommendation? Do they wanna make their own choice? Do they wanna do something in between? And this is what we do, we help them.
Dr. Fox: Yeah. And I think that one of the important lessons from this, you know, I don’t expect our listeners to come away from this being, you know, experts in management of prior preterm birth, that’s not the point of this podcast or any of these podcasts. It’s just to give people sort of, A, if they’re interested, just sort of, “Hey, this is an interesting topic,” but B, it’s sort of just a working understanding of like, what are the things we’re thinking about? What are the possible things that might happen?
And for someone who has a prior preterm birth, have a conversation with your doctor, with your midwife. And maybe that means a referral to an MFM. Maybe it doesn’t. I mean, sometimes it’s very straightforward what needs to be done. And I’m not saying everyone needs to see an MFM for this, and maybe yes, maybe no, but, you know, whatever. It sort of depends on, you know, the comfort level of the provider you have, but this does require conversation, and the conversation is gonna include, what exactly happened? Why did it happen? What’s the chance that it might happen again? What are the things we can do? What is the chance they’re gonna work? You know, what are my options? And that is a long conversation, like when we have these consultations with people, we book an hour, right? And we do this every day, and we book an hour. And so for someone who doesn’t do it every day, it might take even longer.
Dr. Gupta: Right. I think that’s true. You know, there’s a lot of things to think about. And we’ve been focusing, you know, a lot on the medical aspects of how we can evaluate and treat somebody. But then there’s also a lot of questions that, you know, we can or can’t answer about lifestyle, you know, what we call lifestyle choices, which is a, you know, as a way of just saying things that people do in their daily life, and how much does that affect their risk of preterm delivery or having another preterm delivery? And that’s another thing that, you know, kind of we could talk about at these visits.
Dr. Fox: Yeah, it is tough. And I think that, in addition to having that long conversation sort of either before pregnancy, I would say, ideally, before pregnancy or at least at the beginning of pregnancy, this is ongoing, right? These has, you know, or these treatments are not just like a one time thing. They’re frequently ongoing over the course of pregnancy. And so the tenor of the conversation or the direction we’re going might change, right? If someone has a prior preterm birth and their cervix is short from the very beginning, this is gonna be a much more intense pregnancy so to speak, than if every time they come the cervix is nice and long, they have no contractions, they’re feeling great. And then it’s gonna be much different, potentially, the frequency of visits, sort of the recommendations or conversations. And so it’s not just like, you know, a one-shot conversation. This is ongoing pretty much until either the birth or until it’s pretty clear you’re not talking preterm anymore.
Dr. Gupta: Right. That’s true. That’s true.
Dr. Fox: Yeah, Simi, thanks for coming on to talk about this topic.
Dr. Gupta: Thanks for having me.
Dr. Fox: Again, this comes up having comes up a lot, and I think a lot of people listening, either had a preterm birth or know someone who had a preterm birth. And I think that this is important. Also, this is something that evolves. Like our understanding our thought about this is different now from when it was 5 years ago, 10 years ago, 15 years ago. And it’ll probably be different five years from now as we continue to learn and to work through this.
Dr. Gupta: Right. I agree. Yeah.
Dr. Fox: Thanks for coming Simi.
Dr. Gupta: No problem. Take care.
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 H-E-A-L -T-H-F-U-L W-O-M-A-N.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 firstname.lastname@example.org. Have a great day.
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