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By Tracy Wheeler
Beacon Journal medical writer
Published on Tuesday, Jan 29, 2008
Dr. Justin Lavin has seen too many babies born too early.
It's one of the few areas of modern medicine where the trends have grown worse, creeping up in the past 25 years from about one in every 10 pregnancies to one in every eight.
As the director of maternal/fetal medicine at Akron Children's Hospital, Lavin wants to see that trend reversed. And he believes doctors now have the tools at their disposal to make that happen.
Those tools consist of a special ultrasound to measure the length of the woman's cervix in the 20th to 24th week of pregnancy, and — if the cervix is deemed too ''short'' — treatment with progesterone.
''I'm trying to get the word out to as many women as possible,'' Lavin said. ''You're going to have an ultrasound anyway. This is just going to take a little longer, about three minutes, so you might as well do it.''
Instead of the typical ultrasound outside the belly, this ultrasound is performed vaginally. In most women, a short cervix would be considered 15 mm or less, then progesterone would be recommended to ward off premature birth. In high-risk women, a cervical length of 25 mm or less would be a warning sign.
In Britain, this intervention was found to reduce preterm delivery by almost half, according to a study published in the August 2007 issue of the New England Journal of Medicine. In that study, researchers found that progesterone treatment reduced preterm delivery in women with a short cervix by 34 percent, compared with 19 percent of those treated with a placebo.
A French study in 2003 had similar results, finding that progesterone reduced the rate of preterm births by 44 percent in women with a short cervix. And a 2007 Italian study found that progesterone slowed the shortening of the cervix during pregnancy.
''We know of no other intervention that is anywhere near as effective,'' Lavin said. ''Every obstetrician in Akron should start to screen'' the cervical length of their pregnant patients.
Lavin's idea has supporters in high places, including Roberto Romero, chief of the perinatology research at the National Institute of Child Health and Human Development.
In an October 2007 editorial in the journal Ultrasound in Obstetrics & Gynecology, Romero wrote: ''Cervical ultrasound is a powerful tool in risk assessment for spontaneous preterm birth. It is simple to perform, inexpensive when performed at the time of second-trimester screening, informative, and can provide an estimate of risk for preterm delivery . . . We believe that measuring cervical length should be a standard part of sonographic examination in the mid-trimester.''
Not everyone agrees, though.
Dr. Jay D. Iams, a maternal/fetal medicine specialist at the Ohio State University Medical Center, believes it's too soon to start measuring the cervical length of every pregnant woman in the United States.
More clinical trials are needed,
Iams said, especially some set in the United States, because most of the research has come from other countries.
''It's very promising,'' he said. ''It's very exciting. It's very interesting. But it's not quite ready for application in this country.''
One problem, Iams said, is that not everyone is equally well-versed in reading ultrasounds. While doctors who specialize in high-risk pregnancies like Lavin have experience reading these ultrasounds, not all OB/GYNs do, potentially creating a situation where problems would be missed or over-estimated.
Beyond that, though, screening every pregnant woman might not make sense, because so few women would be found to have a short cervix.
In the British study, just 413 women out of 25,000 were found to have a cervical length of 15 mm or less, Iams pointed out. That's just 1.6 percent.
''That's an extremely small number of women relative to the number of women who needed to be screened,'' he said. ''That's a big issue right there. Is that a feasible thing to do in the United States?''
Someday, maybe, Iams said. But not right now.
For now, he said, it's best to limit cervical-length testing to women who have had prior preterm deliveries.
''The best predictor that's easy and cheap is if you had a preterm delivery before, between 16 weeks and 36 weeks,'' he said. ''That's a red flag. You should see your obstetrician or a high-risk specialist before you conceive.''
Lavin understands that the probability of a woman having a short cervix is low. But waiting for a woman to have one preterm delivery before taking action is waiting too long.
''Once you go into preterm labor, there's not a lot we can do to treat it,'' he said. ''We may be able to delay for 72 hours or give the baby steroids for lung develop, but we're not very successful at stopping it.''
So, he said, if women can be identified and treated before a preterm delivery, young lives will be saved, and the quality of those lives will be improved.
A preterm birth is defined as one that occurs at less than 37 weeks of pregnancy. A full-term pregnancy is 38 to 42 weeks.
Babies born before 32 weeks have the greatest risk of death and severe illness, though ''near-term'' or ''late-preterm'' infants born between 32 and 36 weeks — which make up the greatest number of preterm births — are still at higher risk for health and developmental problems than full-term newborns.
Lavin just recently began utilizing cervical-length measurements coupled with progesterone in the last couple of months, he said. Thirty-five-year-old patient Laura Miller, of Medina, is one of his first patients to benefit from it.
Her situation is typical, because she's expecting twins, but the cervical-length tests still have had a role in putting her on bed rest and starting her on progesterone. She is now at 32 weeks and hoping to get to at least 36 or 37 weeks.
The new approach is ''helpful,'' Miller said, ''only because I was concerned about miscarrying, and so if this is the way to prevent something like that from happening, then I'm absolutely for it.''
Tracy Wheeler can be reached at 330-996-3721 or tawheeler@thebeaconjournal.com.
Dr. Justin Lavin has seen too many babies born too early.
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