Program for Prevention of a Considerable Number of Premature Births
Erich Saling, Monika Dräger
Keywords :
Prematurity prevention,vaginal pH measurement,vaginal infection,self-care,early total cervix occlusion,protective lactobacillus system
Citation Information :
Saling E, Dräger M. Program for Prevention of a Considerable Number of Premature Births. Donald School J Ultrasound Obstet Gynecol 2008; 2 (2):48-56.
Prevention of prematurity by a prematurity-preventionprogram, including “Self-Care”-measures for the pregnant women.
Introduction
Prevention of early prematurity (< 32 gest.w.) and of very low birthweight infants (< 1500 g) is one of the most urgent tasks of perinatal medicine. Particularly ascending genital infection is the most important avoidable cause of early prematurity. For the prevention of these infections the “protective lactobacillus system” plays a crucial role. Bacterial vaginosis and/or ascending genital infection start mostly with a disturbance of this vaginal milieu–which we consider as a “precursor”.
Our program is based on an anamnestic assessment of prematurity risk, the early detection of warning signs (including screening for preinfection respectively infection signs by regular measurement of the vaginal pH) and, if necessary, the appropriate therapeutic measures. The program includes “Self-Care”-measures by the women themselves (preferably for all pregnant women) and additional special measures for women at risk, for example, the ETCO for women with recurrent premature births.
Design and method
The Self-Care—measures for pregnant women are an additional measure to regular prenatal care. In our own study, we had 1120 multiparae and we compared the outcome of the pregnancy with self-care activities with the outcome of the immediate previous pregnancy. Our program was then used in the entire state of Thuringia (Germany). In the second half of the year 2000, the Self- Care Program was employed and the statistically evaluated results for the entire state were compared with those from the first half of 2000 without the program (in each half-year there have been more than 8.000 births). After that, several German health insurance companies used our prenatal-care self-examination program in a pilot project to their pregnant members.
The early total cervix occlusion (ETCO) is a preventive measure particularly for cases with two or more late abortions (> 12 + 0 gw) or early premature births (< 32 + 0 gw) in the patient's history with either infection as cause for these events or when no other cause has been found, but when for instance premature rupture of membranes occurred. The Total Cervix Occlusion creates a complete barrier against ascending infections within the cervical canal (as opposed to the cerclage).
Results
With regards to the Self-Care—measures: In all studies the rate of premature births could be considerably reduced. Most interesting are the results of the prematures at particularly high risk. In our collective, the rate of very low birthweight infants (< 1500 g) could be reduced from 7.8% in the immediate previous pregnancy to 1.3%. In Thuringia, the rate of infants born < 32 + 0 gw was reduced from 1.36 to 0.94% respectively in infants < 1000 g from 0.61 to 0.38%. After the campaign in Thuringia had been finished, the prematurity rates monitored in 2002 were again as high as before. The first evaluation of a health insurance company in the German state North-Rhine-Westfalia (NRW) shows that the insured patients had a prematurity rate of 7% compared with the overall prematurity rate in NRW of 9.6%.
After an ETCO the rate of surviving infants was about 80% in our own population (as opposed to 17% in the pregnancies before the ETCO in the same group). Similar good results have been obtained by other clinicians. With ETCO in multiple pregnancies Schulze (2008) was able to achieve a prematurity rate of only 17% as against a rate of 29% in cases without ETCO.
Conclusion
The Self-Care Program for pregnant women proved to be a very efficient method for the prevention of prematurity and should be recommended to every pregnant woman. In cases where this is not possible, at least doctors and midwives should measure the vaginalpH at each prenatal care examination. The Early Total Cervix Occlusion is an effective preventive measure for women with recurrent late abortions or prematures births and it seems to be also a good measure to prevent premature births in multiple pregnancies. More research in this area is necessary.
The epidemiology of preterm birth. In: Kurjak A (Ed): Textbook of Perinatal Medicine. London, New York: 1998;1331-36.
Epidemiology of preterm birth. Epidemiol Rev 1993;15(2):414-43.
at http://www.bkk-nrw.de/service/presse/index.php?dbt_mode=view&id=250 (07.02.2008).
bqs-outcome.de/
Das Scheidensekret und seine Bedeutung für das Puerperalfieber. Verlag von Eduard Besold, Leipzig.
Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis: aerobic vaginitis. BJOG 2002;109:34-43.
Perinatal reflections (Editorial). Prenat Neonat Med 1998;3:367-70.
School-age outcomes in children with birth weights under 750 g. N Engl J Med 1994;331:753-59.
Outcomes in young adulthood for very-low-birthweight infants. N Engl J Med 2002;346(3):149-57.
The relationship of hydrogen peroxide producing lactobacilli to bacterial vaginosis and genital microflora in pregnant women. Obstet Gynecol 1992a;79(3):369-73.
Erste Resultate der Erfurter Frühgeburten-Vermeidungs-Aktion. Z Geburtshilfe Neonatol 1998;202:247-50.
Ergebnisse und mögliche Konsequenzen der Thüringer Frühgeburtenvermeidungsaktion 2000. Geburtshilfe Frauenheilk 2002;62:257-63.
Effiziente Frühgeburtenvermeidung. Das Thüringer Modell. Gynakol Geburtshilfliche Rundsch 2004;44(1):2-9.
Die Effizienz der Thüringer Frühgeburtenvermeidungsaktion 2000 wird durch die Perinatalstatistik der Jahre 2001-2003 bestätigt. Geburtsh Frauenheilk 2005a;65:284-88.
Efficient Prematurity Prevention is possible by pH-self measurement and immediate therapy of threatening ascending infection. J Perinat Med 2005b;33 Suppl. 1-Oral presentations.
Der totale Muttermundverschluss. Prävention von Spätaborten und Frühgeburten, Gynäkologe 1995;28,181-86.
The preterm prediction study: recurrence risk of spontaneous preterm birth. Am J Obstet Gynecol 1998;178:1035-40.
Preterm Birth: Causes, Consequences, and Prevention http://www.iom.edu/CMS/3740/25471/35813.aspx
Recurrence risk for preterm delivery. Am J Obstet Gynecol 2007;196:567.e1-567.e7.
The Preterm Prediction Study: Effect of gestational age and cause of preterm birth on subsequent obstetric outcome. Am J Obstet Gynecol 1999;181 (5, Part 1):1216-21.
Mid-and longterm outcome of 89 premature infants weighing less than 1000 g at birth, all appropriate for gestational age. Biol Neonate 1996;70:328-38.
National Vital Statistics Reports 2005;54(2), Hayattsville.
Role of periodontitis in systemic health: sponstaneous preterm birth. Journal of Dental Education 1998;62(19):852-58.
Probiotic agents to protect the urogenital tract against infection. Am J Clin Nutr 2001;73(Suppl):437S-443S.
Die Entwicklung gefährdet geborener Kinder bis zum fünften Lebensjahr. Die Arvo Ylppö-Neugeborenen-Nachfolgestudie in Südbayern und Südfinnland. Enke-Verlag: Stuttgart, 1995.
The role of cervical cerclage in obstetric practice: Can the patient who could benefit from this procedure be identified? Am J Obstet Gynecol 2006a;194:1-9.
The preterm parturition syndrome. BJOG 2006b;113(suppl 3):17-42.
Prevention of spontaneous preterm birth: the role of sonographic cervical length in identifying patients who may benefit from progesterone treatment. Ultrasound Obstet Gynecol 2007;30:675-86.
Decreased disability rate among 3-year-old survivors weighing 501 to 1000 grams at birth and born to residents of a geographi-cally defined region from 1981 to 1984 compared with 1977 to 1980. J Pediatr 1989;114:839-46.
Der frühe totale Muttermundverschluß zur Vermeidung habitueller Aborte und Frühgeburten. Z Geburtsh u Perinat 1981;185:259-61.
Prevention of habitual abortion and prematurity by early total occlusion of the external os uteri. Eur J Obstet Gynecol Reprod Biol 1984;17:165-70.
Zusätzliche aktuelle Maßnahmen zur Vermeidung von Spätaborten und Früh-geburten. In: Dudenhausen JW, Saling E: Perinatale Medizin, Bd. XIII (14. Deutscher Kongreß für Perinatale Medizin, Berlin 3.-6.10.1989). Thieme, Stuttgart-New York, 1990.
Der totale operative Muttermundverschluß zur Vermeidung habitueller Spätaborte und sich wiederholender Frühgeburten-Fortentwicklung der Technik, weitere Erfahrungen und Ergebnisse. In: Dudenhausen JW, Saling E (Hrsg): Perinatale Medizin, Bd. XIII. (14. Deutscher Kongreß für Perinatale Medizin, Berlin, 1989). Thieme: Stuttgart, New York, S 1990;65-67.
Vermeidung von Spätaborten und risikoreichen Frühgeburten -für die Routine geeignete Maßnahmen. Z Geburtsh u Perinat 1991;195:209-21.
Program for the Prevention of Prematurity. In: Hirsch HA: Infection and Preterm Labor (International Symposium Tübingen, 1990) Thieme, Stuttgart-New York 1991.
Infektiologische Spätabortursachen und operativer Muttermundverschluss. Arch Gynecol Obstet 1993;254: 1265-71.
Der operative Totale Muttermund-Verschluß (TMV). Erhebung von Daten einiger Kliniken, die den TMV einsetzen. Z Geburtshilfe Neonatol 1996;200:82-87.
Efficient and simple program including community-based activities for prevention of very small prematures. In: Kurjak A (Ed): Textbook of Perinatal Medicine. London, New York 1998;1337-44.
Basic aspects of prematurity prevention and results achieved by a suitable, simple program. J Perinat Med 1998;26:466-68.
A simple, efficient and inexpensive program for preventing prematurity. J Perinat Med 2001;29:199-11.
Role of operative early total cervix occlusion for prevention of late abortion and early prematurity. In: Carrera JM, Cabero L, Baraibar R: The perinatal medicine of the new millennium. Proceedings of the 5th world congress of Perinatal Medicine, Barcelona, Spain, September 2001;23-27. Monduzzi, Bologna 2001;602-07.
Efficient and simple program including community-based activities for prevention of very early premature birth. In Kurjak A, Chervenak FA (Eds): Textbook of Perinatal Medicine. Second edition. Informa Healthcare 2006a;1401-11.
Operative early total cervix occlusion for prevention of late abortion and early prematurity. In Kurjak A, Chervenak FA (Eds): Textbook of Perinatal Medicine (2nd edn). Informa Healthcare: 2006b;1412-16.
[Results of Early Total Cervix Occlusion (ETCO) According to Saling in Multiple Pregnancies–a retrospective study of the period 1995-2005.] Ergebnisse des Frühen Totalen Muttermundverschlusses nach Saling (FTMV) bei Mehrlingsschawangerschaften–eine retrospektive Studie der Jahre 1995-2005 Z Gebutrtsh Neonatol 2008;212:13-17.
Do screeningpreventative interventions in asymptomatic pregnancies reduce the risk of preterm delivery—A critical appraisal of the literature. European Journal of Obstetrics and Gynecologgy and Reproductive Biology 2006;127:145-59.