The Edith Louise Potter Memorial Lecture this year considered an effective way to identify the risk of and prevent premature birth.
Monday morning’s “Universal Cervical Length Screening — A Debate” featured Roberto J. Romero, MD, FACOG, Hutzel Women’s Hospital, Detroit, and chief of the Perinatology Research Branch and head of the Program for Perinatal Research and Obstetrics in the Division of Intramural Research of NICHD, supported universal adoption of ultrasound screening for short cervix and vaginal progesterone as a simple, inexpensive way to reduce premature births and save the American health care system $500 million.
Jay D. Iams, MD, FACOG, Frederick P. Zuspan Endowed Chair and professor and vice chair of the Department of Obstetrics & Gynecology at Ohio State University, presented the reasons against, saying that while screening was an admirable way to combat disease, too many snags remain in the execution to apply the research to real world medicine.
Dr. Romero said that cervical length screening compares well with other medical screening tests. Data shows that for every 357 patients screened, he said, one preterm birth was prevented. That compares with 1,140 pap smears to prevent one death, 543 mammographies in women 50 years of age and older to prevent one death, and 3,000 mammographies in women 40-49 years of age to prevent one death.
Once identified, a woman with a short cervix has one of the most effective interventions available in progesterone. It reduces preterm birth risk by 45 percent with no known major side effects, Dr. Romero said.
“If you, your wife, your sister, and your daughter had a short cervix in the mid trimester, would you or your family member like to be treated with progesterone?” Dr. Romero said.
Programs for universal cervical screening have started in Detroit, where Dr. Romero works, and also in the Western Australia town of Perth and surrounding areas.
Dr. Iams agreed with most of Dr. Romero’s points but emphasized that the path to universal cervical screening and progesterone for those at risk still has many obstacles.
The ultrasounds require proper technique and continuing quality assurance, but of the more than 40,000 registered ob-gyn sonographers in the United States, fewer than 1,000 have received credentials from either the Fetal Medicine Foundation or the Cervical Length Education and Review Program.
Progesterone, no matter which compound used, is still not accepted by many insurers, pharmacists — especially those in hospitals — struggle with regulations, and patients sometimes have a reluctance to accept the treatment, Dr. Iams said.
A pilot project of 23 Ohio clinics found that out of a group of eligible women based on either history or short cervix, the rate of premature birth before 37 weeks was high both at the start and after 15 months of progesterone use.
About two-thirds of the women eligible for treatment were treated before 20 weeks, the point where much of the literature says treatment with either vaginal or injectable progesterone should begin.
“In practice, we have trouble finding these women, getting them into care, getting their insurance approved, getting a prescription made for one product, fighting with the insurance company or the pharmacist to get the product, and the next thing you know, you’re at 24 weeks,” Dr. Iams said.
Both debaters ask clinicians to resolve to do more to identify and treat preterm births.
“We’d like you to do something more than what you’re doing now,” Dr. Iams said. “You can’t wait for prematurity to fall into your lap at labor and delivery or with a phone call in the middle of the night. You have to go looking for it. On that, we clearly agree.”