The World Health Organization estimates that every year, 15 million babies are born before 37 weeks of pregnancy. According to the Centers for Disease Control and Prevention, preterm birth affects 1 in 10 infants born in the United States.
The final weeks of pregnancy are imperative for the baby’s development. Preterm birth, especially that before 32 weeks gestation, leads to higher rates of infant death and disability. Dreaming of Baby speaks with Dr. Howard Mandel, Managing Partner of Century City Women’s Health, and Attending Physician Cedars-Sinai Medical Center, Los Angeles. Dr. Mandel discusses preterm birth, the symptoms to look out for, and a novel test available for managing the risk of premature birth.
Daniela: Good morning, Dr. Mandel, it’s a pleasure to welcome you on Dreaming of Baby today. With many parents having experienced premature birth, we’re very much looking forward to our conversation on this important subject. Before we start with our discussion, grateful if you could introduce yourself as well as your experience in this area to our readers.
Howard C. Mandel M.D., FACOG: Good Morning. I’m Dr. Howie Mandel and I have been a practicing OB/GYN for over three decades. I’m an old school doc, the kind available 24/7 so not only do I deliver babies but I know my patients very very well. I also have taught medical students, residents, and nurses in high-risk obstetrics as well as health economics. With 10% of babies in America being born premature, it is a personal as well as a public health problem.
What is Premature Birth?
Daniela: Many thanks for this impressive overview, Dr. Mandel. To start our discussion as well as present a clearer picture of our subject today: What is premature birth?
Howard C. Mandel M.D., FACOG: As most people know, pregnancy is on average 278 days from the last menstrual period until delivery or what most people say 40 weeks of gestation (pregnancy). This means 38 weeks from conception until delivery. Any delivery prior to 37 weeks LMP is by definition premature, also known as preterm. Any delivery after 42 weeks is called post-term.
Howard C. Mandel M.D., FACOG: The preterm (premature) deliveries are of concern for us as they often lead to neonatal complications (problems in the baby) that can be lifelong and extremely costly to the family as well as the health system.
Daniela: Thank you for this very informative overview. In terms of health economics, we can now see how premature birth affects the health system as a whole. How early in a pregnancy can a baby be born and survive?
Howard C. Mandel M.D., FACOG: Our colleagues who run neonatal ICU’s [NICUs] can often save babies born in the 24th week of gestation. Unfortunately, almost all of these babies who survive will have significant life-long medical problems as well as learning and other neurologic injuries. On average, a preterm baby costs the health system 10X as much as a full-term baby but when we look at the very preterm it is multiples of that. Based on previous cost estimates published by an Institute of Medicine study in 2006, today, preterm birth costs the United States approximately $31.5 billion. This did not include educational costs, social costs or the psychological costs of having a baby that was premature.
Dr. Howard Mandel: “Based on previous cost estimates published by an Institute of Medicine study in 2006, today, preterm birth costs the United States approximately $31.5 billion.”
Why does premature birth happen?
Daniela: The figures are indeed significant. You have also noted earlier that 10% of babies in America are born prematurely. Do current research and data offer any indication as to the ‘why’ of this phenomenon? In other words, are there any indications available why premature birth happens so often?
Howard C. Mandel M.D., FACOG: There are many factors involved and numerous different reasons. This has made it difficult for OBs to really answer your question. 40% of premature babies are born to first-time moms and most women who give birth preterm do not have classic “risk factors”. Only 6.511% of women who give birth preterm have previously given birth early. There are many theories and more likely than not, there are many independent causes. We do know that inflammation within the uterus, uterine contractions, weakened cervix, uterine distension and placental issues all play separate roles. Combinations of these issues dramatically increase the risk.
Can premature birth be prevented?
Daniela: In connection with this informative answer, are there any symptoms which pregnant women can look out for that may indicate that their baby will be born prematurely? Is there anything moms-to-be can do to prevent premature birth?
Howard C. Mandel M.D., FACOG: Regular rhythmic and progressive uterine contractions, lower pelvic pressure, changes of the normal vaginal discharge [increased clear liquid, pink or red coloration or thinning of mucous] as well as symptoms that most women associate with a bladder infection [UTI] are classic symptoms that warrant calling or being seen by the doctor or midwife taking care of the pregnancy. Unfortunately, most women who deliver prematurely in America do not demonstrate these classic symptoms. There is a novel blood test that has been clinically validated that can be done during 19 or 20 weeks of gestation [LMP] that can show those women who are at significantly higher risk from those that are at low risk. This novel test should help us OBs manage those women at higher risk with the goal of giving these babies the best possible start in life.
Dr. Howard Mandel: “40% of premature babies are born to first-time moms and most women who give birth preterm do not have classic “risk factors”.”
Daniela: This information is very helpful for moms-to-be. It’s great to hear that there is testing available to analyze the risk of preterm birth. Can you please elaborate on this blood test? How does it work and is it done on a routine basis or it’s up to the mom-to-be to request it?
Howard C. Mandel M.D., FACOG: As traditional predictors of preterm birth fail to identify over 80% of women at risk, I believe that every woman with a singleton pregnancy should be offered this new test. Remember 40% of women who deliver preterm are on their first pregnancy. Scientists looked at thousands of proteins that circulate in the mom’s blood to develop this novel test. Based on prior studies they narrowed down a ratio between the overexposure of one protein [called a growth factor: IBP4] and the underexpression of a protein that interacts with hormones [SHBG]. By looking at the relationship between these proteins we can now identify those women at higher risk.
Howard C. Mandel M.D., FACOG: The ideal time to perform this test is during 19 and 20 weeks of gestation. In my practice, I educate my patients at the first OB visit and, as often times there is so much information given to people at that visit, go over it again several times before we get to the target weeks.
Managing the risk of preterm birth
Daniela: Thank you for sharing this very important information. In other words then, and to further clarify, this test provides the opportunity to react to the possibility of a preterm birth before labor actually starts?
Howard C. Mandel M.D., FACOG: Definitely. Education is empowering. Doctors/midwives can manage patients who are at higher risk. There are established medical treatments for her and her doctor to consider to address her risk with the goal of giving her baby the best start in life. As the test is cutting edge, it is possible that some doctors have not included this novel risk-analyzing blood test in their daily practices. Women should discuss with their doctors if they have either known risk factors or if none [as 80% of women do not show either of the top two risk factors] the availability of doing this novel “PreTRM” blood protein test.
Daniela: Thank you for clarifying this. If the test indicates that a woman is indeed at risk of going into preterm labor, what kind of care program is followed? Would bed rest be a must in such cases?
Howard C. Mandel M.D., FACOG: Bed rest is complicated. In fact, some studies have shown that bed rest can increase the risk of blood clots in women’s legs during pregnancy so like many things in medicine there are risk and benefits to what we prescribe. I prefer modified bed rest to high-risk women. Administering progesterone and monitoring the length of a woman’s cervix has been shown to positively impact the problem of preterm birth.
Dr. Howard Mandel: “Administering progesterone and monitoring the length of a woman’s cervix has been shown to positively impact the problem of preterm birth.”
Howard C. Mandel M.D., FACOG: Studies are ongoing looking at alternative approaches to women who are at higher risk based upon proteomic analysis.
Daniela: Thank you, and how would monitoring work? Would this involve hospital stays or individual appointments at an Ob/Gyn?
Howard C. Mandel M.D., FACOG: Outpatient appointments, increased telephone conversations, educating women on subtle changes in normal contraction patterns, screening women’s urine for bacteria and measuring the length of the cervix [usually with ultrasound, but some physicians also do pelvic examinations]. When appropriate, injections or vaginal progesterone supplementation has also been shown to lengthen the time the baby stays in utero.
Daniela: Thank you. If a woman has already had a full-term pregnancy, is she still at risk that a subsequent child will be born prematurely? In other words, should second-time moms still seek to have this test done?
Howard C. Mandel M.D., FACOG: Yes.
Daniela: Is the PreTRM test normally covered by insurance?
Howard C. Mandel M.D., FACOG: As most new tests, the PreTRM test is not currently covered by insurance.
Daniela: What about side-effects? Does the PreTRM test have any?
Howard C. Mandel M.D., FACOG: PreTRM is a simple blood draw so the risks are extremely low. Generally speaking, most side effects associated with blood draw include injection site pain, bruising, redness or swelling.
Daniela: Great, thank you for your time today Dr. Mandel. On a final note, what would be that one piece of take-home advice that you’d always share with expectant moms in relation to this subject?
Howard C. Mandel M.D., FACOG: Ask your doctor or midwife about the “PreTRM” test. Go online and learn more at www.PreTRM.com. Know that there are 1750 LabCorp patient service centers across the country that currently and conveniently can draw the blood test. Most importantly don’t ignore your body and always communicate changes with your physician.
Daniela: Many thanks for your time today and the insight you have shared with our readers. It’s been a pleasure speaking with you on this very important subject!
Howard C. Mandel M.D., FACOG: Wonderful. Thank you for what you are doing to educate women and helping to prevent preterm delivery.