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    Rising preterm birth rates: Time to double down on our efforts

     

     

    1. Increasing use of low-dose aspirin in women at risk for preeclampsia. As noted, increasing maternal age and obesity are both risk factors for preeclampsia.3 Preeclampsia is, in turn, a major risk factor for indicated PTBs. It is known that low-dose aspirin therapy, ideally started at the end of the first trimester, decreases the occurrence of preeclampsia by 24%, intrauterine growth restriction (IUGR) by 20%, and PTB by 14%.4 Thus, the US Preventive Services Task Force (USPSTF) recommends use of low-dose aspirin (81 mg/day) after 12 weeks’ gestation in women who are at high risk for preeclampsia.4  Patients are considered to be at high risk for preeclampsia if they have one or more of the following features: prior preeclampsia, multiple gestation, chronic hypertension, type 1 or 2 diabetes, renal disease, and autoimmune diseases such as lupus or antiphospholipid antibodies. The USPSTF also recommends considering low-dose aspirin if a patient has several moderate risk factors, including nulliparity, BMI >30, first-degree relative with a history of preeclampsia, African-American race, low socioeconomic status, age ≥35 years, prior IUGR or other adverse pregnancy outcome, and >10-year inter-pregnancy interval.

     

    1. Reducing smoking in pregnancy. Between 2000 and 2010 there was a modest drop in the prevalence of smoking during pregnancy from 13.3% to 12.3%, however, smoking still accounts for 5% to 8% of PTBs.5 Increasing smoke-free zones, raising cigarette taxes, and implementing aggressive public awareness campaigns have shown success but these efforts must continue.5 In addition, we need to be more aggressive in our counseling and efforts to assist patients in stopping tobacco use.

    1. Reducing multiple births through assisted reproductive technologies (ART). The majority of higher-order multiple gestations now result from ovulation induction and super-ovulation medical therapy rather than in vitro fertilization (IVF).6  However, while most twins are naturally conceived or result from ovulation induction, IVF does significantly contribute to our high US twin gestation rate, which currently stands at 33.9 per 1000 births.7 Thus, ob/gyns should preferentially refer their patients to IVF practices with lower multiple gestation rates and/or those that favor use of single embryo transfers (SETs) whenever feasible because this strategy has been shown to reduce the risk of multiple pregnancy without a substantial decrement in live born rates.8,9 Moreover, insurance companies should preferentially reimburse SET cycles. Finally, selecting a single euploid embryo to transfer based on preimplantation comprehensive chromosomal screening using trophectoderm biopsy, newer genetic testing methods, and cryopreservation of tested blastocysts with subsequent SET may represent the long-term solution to ART-associated multiple gestations.

     

    1. Encouraging women to prolong inter-pregnancy intervals to >18 months. There is a nearly 4-fold increase in spontaneous early PTBs among women whose interval between a prior delivery and the last menstrual period preceding their next pregnancy is ≤6 months.10 The mechanism(s) for this association remain unproven but could include persistent inflammation and nutritional deficiency. In a retrospective cohort study of 111,948 women seen at least once by a provider within 18 months of delivery, every month of contraception coverage reduced the risks of PTB by 1.1% (OR of 0.989; 95%CI: 0.986–0.993).11  Moreover, provision of long-acting reversible contraception (LARC) in the immediate postpartum period has been shown to increase contraception use at 6 and 12 months, thus decreasing the incidence of unintended pregnancy during this time.12 This approach may be one of the most effective single strategies we can employ to reduce PTBs, although it will have less applicability in older women who are approaching the limits of fecundity but want to have more children.

    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...

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