The Preterm Birth Prevention Program is funded by the South Carolina Chapter of the March of Dimes.

MUSC is pleased to offer a specialized Preterm Birth Prevention Program staffed by board certified specialists in Maternal-Fetal Medicine and Certified Nurse Midwifery and sponsored by the South Carolina Chapter of the March of Dimes.  The program is dedicated to the prevention of preterm delivery among high risk women.

Preterm birth now complicates more 12% of all pregnancies and accounts for a disproportionate share of the neonatal mortality and morbidity in the United States.  At least 75% of neonatal deaths not caused by birth defects result from preterm delivery. Additionally, prematurity is responsible for the vast majority of newborn and chronic childhood illnesses. Complications include chronic lung disease, visual and hearing disabilities, neurobehavioral impairment, and cerebral palsy.

Disturbingly, the incidence of preterm birth has continued to increase over the past decade in the United States.  Fortunately, as specialized clinicians we are rapidly improving our understanding of the complexity of the pathways that lead to preterm birth.  The process of preterm birth is not as simple as once thought. Potential mechanisms for preterm birth may include uterine and cervical weakening, uterine contractions, infectious or inflammatory processes, hormonal variations, and varying degrees of interactions of these processes.  It is obvious that one therapy for all is not going to work. By applying newer diagnostic and therapeutic modalities, available through the Preterm Birth Prevention Program at MUSC, we try to develop individualized strategies to assist women in the prevention of preterm birth.

Obstetrical care at the MUSC Preterm Birth Prevention Program is provided by a select team of nationally recognized experts in preterm birth prevention. This team approach will ensure that every aspect of your care will be thoughtfully addressed to develop a comprehensive prevention strategy specifically tailored for each woman.  This program has received the endorsement and support of the South Carolina Chapter of the March of Dimes.  We share the same goal of giving you your "whole nine months".  While stressing the importance of the team approach for optimal care, we would like to convey our recognition of the importance of continuity of care from our select few obstetricians and our commitment to providing this service.

Why would a patient choose the MUSC Preterm Birth Prevention Clinic?

Expertise:
The Preterm Birth Prevention Program has been developed and is run exclusively by specially trained high-risk obstetricians. These physicians include the only full-time, formally trained Maternal-Fetal Medicine specialists in the LowCountry and the only Obstetrician-Gynecologist specifically trained in obstetrical infectious diseases in the state.

Commitment:
Members of the Preterm Birth Prevention Program team have specific interests that are related to the prevention of preterm birth. We emphasize a proactive rather than reactive patient care philosophy stressing risk assessment using newer techniques not widely available to the general practicing obstetrician. These tools include detailed history evaluation and assessment, specialized risk scoring systems, home assessment, fetal fibronectin testing, transvaginal cervical ultrasonography, and comprehensive 4-D ultrasound techniques, to cite a few.  The newest therapeutic option to prevent preterm birth are weekly injections of 17 alpha hydroxy progesterone.  This therapy was introduced to the Charleston area through our Program and we continue to be the major provider.

Experience:
Members of the Preterm Birth Prevention Program at MUSC are nationally recognized for their expertise in the area of prematurity prevention and therefore have developed or been involved in many ground-breaking research trials both regionally and nationally. This has afforded us the opportunity to offer many therapies that are not available to the general public and gain expansive firsthand experience. Various research trials include the validation of risk assessment techniques, antibiotic therapy protocols, cervical and abdominal cerclage surgeries, prenatal steroid therapies, and neonatal surfactant therapy for improving lung mechanics in premature neonates.  Currently, we are involved trials using the new hormonal therapy (progesterone) for recurrent preterm birth prevention.

Support:
The Preterm Birth Prevention Center is located on the campus of the Medical University of South Carolina with easy access and ample free parking. We have a very strong and collaborative relationship with the MUSC Children’s Hospital and the members of the neonatal intensive care unit and specialized nurseries that has been in existence for over 30 years. Further, all of our patients have immediate access to the specialized services offered by all of the subspecialties at MUSC including expert care from the neonatologists, pediatric cardiologists, and pediatric surgeons to name a few.  Our program also maintains a close relationship with Matria Hone Healthcare services who offer a home assessment to all patients cared for in our Preterm Birth Prevention Program.  Lastly, as a result of our collaboration with the March of Dimes we are able to provide all the available patient educational materials expertly provided by that group.

Who is potentially at risk for preterm birth?

While some cases of preterm birth occur in pregnancies without any identifiable risk factors, there are several categories of preterm birth risk factors that are listed below.

1) General Risks

• Prior history of preterm birth
• Previous preterm labor treated with medication to allow term delivery
• Previous history of preterm rupture of the membranes
• Previous history of second trimester miscarriage
• Prior pregnancy treated with cerclage placement
• Fetal abnormalities
• First or second trimester vaginal bleeding
• Multiple gestation

2) Anatomical Risks

• Uterine or cervical malformation
• Prior cervical surgery including cone biopsy, laser therapy, or freezing
• Prior cervical trauma including D&C
• Prior uterine surgery
• Large fibroid tumors of the uterus
• Placental abnormalities
• Placental abruption

3) Environmental Risks

• Work fatigue/High stress
• Poor nutritional status
• Poor weight gain
• Dehydration
• Tobacco use
• Cocaine use
• Adolescent pregnancies
• Advanced maternal age pregnancies
• Late or limited prenatal care

4) Infectious Risks

• Vaginal infections
• Sexually transmitted diseases
• Urinary tract infections

How can we recognize those at risk before it is too late?

Prevention services provided by the Preterm Birth Prevention Program:

Preconceptional counseling:
Preconceptional counseling may serve as an opportunity to identify potential risk factors and/or review any previous obstetrical complications. This may also provide the opportunity for the initiation of specific therapies (folic acid/prenatal vitamins), vaccinations, nutritional counseling, and commencement of lifestyle modifications that may improve future obstetrical outcomes.

Early prenatal care:
Similar to preconceptional counseling, early prenatal care allows you and your obstetrical provider to identify any potential risk factors that may become problematic as the pregnancy progresses. Additionally, this provides the opportunity for your physician to detect any cervical and/or uterine abnormalities by physical examination or to identify any infectious risks and recommend all appropriate interventions early.

Comprehensive Ultrasonography:
Comprehensive ultrasonography provides the opportunity to evaluate the fetus for the identification of any possible birth defects. Many uterine abnormalities that are risks for preterm birth are not easily diagnosed by physical exam or by traditional ultrasound. The availability of six state of the art ultrasound machines in the Preterm Birth Prevention Program along with experienced AIUM-certified ultrasound technologists allows for the early detection of potential malformations of the fetus, placenta, and uterus.

Transvaginal Cervical Ultrasonography:
Studies have demonstrated a very strong association between a shortened cervical length measurement and an increased risk for preterm birth. Transvaginal cervical ultrasonography allows the entire length of the cervical canal to be measured and the internal cervical os (opening) to be evaluated for early dilation. This would otherwise be impossible as most of the cervical canal is within the abdominal cavity and unable to be entirely assessed by a traditional digital cervical examination.

Patients at risk for preterm delivery can be promptly and accurately evaluated allowing for more timely and appropriate advisement and interventions.  The Preterm Birth Prevention Program routinely uses cervical sonography on all at risk patients to assist with risk assessment.

Fetal Fibronectin:
Fetal fibronectin (Ffn) is a multifunctional protein substance that is located between the uterine wall and the placental membranes and is presumed to have glue-like responsibilities.  It is presumed that the presence of Ffn in cervicovaginal secretions between 22 and 35 weeks gestation is an abnormal finding and may signify a disruption of the membrane surfaces either from uterine contractions or inflammation.

Several studies have demonstrated an association between the presence of Ffn in the vagina and an increased risk for preterm delivery both in women with preterm labor symptoms and in asymptomatic at-risk patients. Specifically, 1 in 6 women with a positive Ffn who present with symptoms will deliver within the next 14 days.  In this clinical scenario, interventions including hospitalized observation and tocolytic therapy may be appropriate. Conversely, the absence of Ffn serves as a better predictor that a pregnancy is not at imminent risk. More than 99% of symptomatic women with a negative Ffn will remain undelivered in 14 days. This advancement in technology has allowed the obstetrician the ability to provide early intervention as well as limiting unnecessary therapies.

Initially Ffn results were not available for 24 hours and therefore it’s utility was somewhat limited. However, now through the Preterm Birth Prevention Program and the Medical University of South Carolina hospital laboratory these results are available in about 1 hour.  The Preterm Birth Prevention Program is located on the MUSC campus which provides us with results expeditiously thus allowing us to develop treatment strategies more effectively.

I lost a baby at 5 months and I have been told that my cervix is weak. What can I do?

Cervical cerclage:
Cervical cerclage involves the placement of a stitch around the cervix to close the canal or to help maintain the strength of the cervix. It is usually performed as an outpatient procedure depending on the degree of dilation. The cerclage is left in place until about 36-37 weeks at which time it is removed to allow normal labor and delivery.

The need for cervical cerclage can be determined based on either clinical history of a previable pregnancy loss or by current clinical evidence of internal dilation of the cervix without contractions. This condition has been historically phrased as cervical incompetency, but should be more appropriately referred to as cervical insufficiency. Sometimes this dilation can occur painlessly until it is too late to save the pregnancy and women miscarry in the second trimester. This is considered a “classic history”. These patients are best treated with a cerclage placed prophylactically at about 13-14 weeks gestation before the dilation occurs again. With the advent of cervical sonography (see above) we are now able to diagnose early dilation internally in patients with less obvious histories or in those patients at-risk before further cervical change occurs. This is referred to as a "rescue cerclage". Our expertise at MUSC in this area is evident by the many referrals we receive to perform rescue cerclages and by the number of patients that we are subsequently asked to continue providing prenatal care for until delivery.

In rare cases when there is a major cervical abnormality many times due to cervical trauma from a cone biopsy or LEEP procedure an abdominal cerclage must be placed. Unlike the cervical cerclage, this requires an incision like a cesarean to place the stitch internally. Here at MUSC with the assistance of our advanced laparoscopic specialists we are performing many of these through several small incisions as an outpatient (laparoscopic surgery).
Patients with an equivocal history of prior pregnancy loss may benefit from serial cervical length evaluations and placement of a cerclage if early changes of dilation are identified. The Preterm Birth Prevention Program’s implementation of transvaginal sonography and early cerclage placement has drastically reduced possibility of such poor obstetrical outcomes.
 
What are those shots that can develop the baby’s lungs before it is born?

Steroid Therapy:
Women at risk for preterm delivery should be considered candidates for antenatal steroid therapy between 24 and 34 weeks gestation. Antenatal steroids stimulate fetal development and maturity especially with regards to the developing cardiovascular and respiratory systems. A single course of steroids has been shown to decrease the frequency of the preterm neonate developing advanced intracranial hemorrhages, respiratory distress syndrome, MICU admission and death. 
There has been significant debate over the optimal timing of administration, the duration of steroid effect on various tissues, and the safety and efficacy of repeated courses. Recent studies suggest that repeated courses of steroids may not provide an improvement in neonatal outcomes. Several members of the Preterm Birth Prevention Program team are nationally recognized for their efforts and expertise in this area. 

Are there any new medications that can be used to stop preterm contractions?
 
Tocolytics:
There are several medications that have been used with varied success in attempts to stop preterm labor. Collectively these medications are referred to as tocolytic drugs and work by various mechanisms to stop uterine contractions. Some are administered by intravenous routes and require hospitalization, while others are administered by continuous subcutaneous pump or orally and therefore, may allow for therapy to be continued on an outpatient basis.  The Preterm Birth Prevention Program specialists have excellent firsthand experience with all the available tocolytic medications and are aware of their capabilities and side effects.

One particular class of tocolytic drugs is the prostaglandin inhibitors that block the formation of substances called prostaglandins. Prostaglandins are produced normally in the body, but are produced in increased concentrations under certain conditions including stress, infection, and injury. Prostaglandins an unquestioned role in the propagation of preterm labor. Blocking the formation of these substances may provide a means for stopping preterm labor. Another new and effective therapy is the use of a category of drugs called calcium channel inhibitors.  These drugs (i.e. Nifedipine) are usually used as anti-hypertensive agents but have also been shown to relax the uterus.  An advantage of these drugs is the ability to use orally on an outpatient basis.

What is all the new information in the press about giving hormone shots that could keep me from having a preterm birth again?

Progesterone therapy:
Recently there have been two studies that have raised the possibility of using weekly injections of 17 alpha hydroxy progesterone to prevent recurrent preterm birth. All women had a previous history of preterm birth and were started on the medication prior to any symptoms of preterm labor after about 16 weeks in pregnancy. Studies have suggested that a decline or deficiency of the naturally occurring hormone progesterone that assists in supporting the pregnancy is associated with the initiation of labor. The published data suggests that progesterone injections will reduce the risk of recurrent preterm birth by 40%.  No harmful material or fetal effects were seen with the therapy.  Our program has been the regional provider with offering this therapy and can arrange for multiple ways to obtain the treatment; at the Prenatal Wellness Center, by self injection at home or through a home care nurse.

Listing of physicians involved with the Preterm Birth Prevention Program:
Roger Newman, M.D.
Scott Sullivan, M.D.
Charles Rittenberg, M.D.
William Goodnight, M.D.
Amelia Rowland, CNM

Location and Hours:
Cannon Place
135 Cannon Street
2nd Floor
Charleston, SC 29425

Hours: Wednesday 8:00am -4:00pm

 Maps and driving directions

Parking Information:
Parking is provided free of charge to patient's of the Women's Center. Parking is available in the parking lot located directly across the street from Cannon Place. See map below for more information.





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Appointment Scheduling:
Telephone (843) 876-1200
Toll Free Number: 1-866-859-6101(outside of the Charleston Area)
Representatives are available from 7 a.m. to 7 p.m. Monday through Friday

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In the News:
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MUSC Online Health Library Resources:
 What is prematurity?

Other Online Resources:
 Premature Babies- National Library of Medicine
 Premature Labor- March of Dimes Birth Defects Foundation

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