P4P Preterm Birth
[00:00:50] Dr. Alicia Power: Welcome to the Pregnancy for Professionals Podcast. Dr. Michelle Morais is joining me today from Hamilton, Ontario, where she works, well she might be in Burlington in her [00:01:00] home, and we are going to do a podcast today on preventing preterm birth. So Michelle, why don't you get started on telling us a little bit about yourself? And what you like to do outside of medicine as well.
[00:01:10] Dr. Michelle Morais: Thank you so much for inviting me to join you today. So I work as a high risk obstetrician. And so that means that I focus my practice on either patients who have underlying issues that may make their pregnancies more complex, or babies who have complications in pregnancy that might need some specialized care after birth. I have been working at McMaster for almost 10 years in that capacity. And one of the other hats I wear is as the Program Director of the obstetrics and gynecology residency program. So really invested in education and interprofessional care and so glad to be here to foster that interest that I have myself here today. Outside of the hospital, I am a mum to two boys and we also have a golden retriever. One of my interests outside of work is a reading for fun. So I always have a book on the go and just like to use that [00:02:00] as a little escape. From the day to day just realities of work. So like to explore lots of different areas of fiction when I'm not working at the hospital.
[00:02:09] Dr. Alicia Power: Awesome. Thank What's your book on the go now.
[00:02:13] Dr. Michelle Morais: Right now I'm reading a book by Kristin Hannah called Firefly Lane. It's it was actually a Netflix series, which I didn't realize when I started reading but it's a, just a fun book about the journey of a group of friends over the course of their life.
[00:02:29] Dr. Alicia Power: Oh, awesome. So far so good?
[00:02:31] Dr. Michelle Morais: Yeah, it's a very compelling, I would say.
[00:02:34] Dr. Alicia Power: Perfect. All right why don't we get into it? So first let's talk a little bit about preterm birth and how do we define preterm birth?
[00:02:43] Dr. Michelle Morais: Yeah. So preterm birth is any delivery that takes place prior to 37 weeks in a pregnancy. And it can be for a variety of different reasons. The most common reason why people deliver preterm is because they've gone into labor on their own. So spontaneous, preterm birth. The other [00:03:00] group that accounts for the biggest proportion of people who deliver preterm, or people who break their water early and then go on to deliver. Other complications like preeclampsia, et cetera, make up the rest of the group, but spontaneous preterm labor and PPROM would be the two largest contributors to preterm birth.
[00:03:19] Dr. Alicia Power: And then, so the hypertense or the preeclampsia might be that we would recommend they go into preterm birth, or help put them into preterm birth. Right.
[00:03:27] Dr. Michelle Morais: Yeah,
[00:03:27] Dr. Alicia Power: If they're so sick or baby's not growing and it's safer for mom and baby to have baby out, then we would recommend an induction of labor or Cesarean section whatever the mode of birth would be from a health point of view. So that is iatrogenic preterm birth. I messed that up in our last podcast. So I learn sometimes. Okay, awesome. Thank you. Less than 37 and zero weeks gestation.
[00:03:49] Dr. Michelle Morais: Correct.
[00:03:50] Dr. Alicia Power: So why do we care? Why do we care if somebody has preterm birth? What are the risks of that?
[00:03:56] Dr. Michelle Morais: One is just the proportion of the population that experiences [00:04:00] preterm birth. It's not a small proportion. You know, preterm birth in different areas of the world can be significant. In Canada with access to healthcare that we have, it's still around 8% which is a significant proportion of pregnancies. And the reasons why we care is for a number of different reasons, one of which is the impacts that prematurity can have on the baby who delivers and the complications, both from just a a survivability point of view. And then being alive with potential for longterm impacts related to that. So certainly less than 28 weeks, which would be considered or sorry, 28 weeks or less, which would be considered an extreme preterm the risks of survival, and risk of longterm complications are really significant to be considering. And then we also have to consider the impacts from a cost of care perspective. So the weeks and months that these children will spend in intensive care settings and the significant level of care [00:05:00] that they require is all quite fast.
[00:05:02] Dr. Alicia Power: Yeah, And the other piece of the puzzle is the parental kind of stress associated with it, right? Having a baby in the NICU is, is not an easy thing. And if you are in a more remote community or a community that doesn't provide care to, doesn't have the capacity to provide care to preterm babies, then that means that you're also moving into a different community without your supports around you. My second was born at 37 and zero. My first went post dates and I was induced. My second was at 37 and zero, and was in the NICU for three weeks. Right? Like it adds a ton of stress onto parents as well. So I think that's, you know, from a medical point of view, the biggest risk is to the baby. But from a parental point of view, that's a huge stressor as well. And so I think it's really important that we also recognize that, that side of the picture as well. And obviously the, the closer to term that baby is born, the the better the outcomes. The less time they spend in the hospital, the less costly their [00:06:00] care is, less stressful it is for the parents. So getting a baby to closer to term is a really valuable thing from every point of view. So not just avoiding 28 weeks, but if we can get somebody to 36 and a half, as opposed to 33 in their first pregnancy, that's a huge improvement.
[00:06:15] Dr. Michelle Morais: Yeah, absolutely.
[00:06:17] Dr. Alicia Power: What are risk factors for preterm birth?
[00:06:19] Dr. Michelle Morais: In obstetrics and gynecology, the first answer is always a previous history of preterm, so if it's happened before, there can be a risk of it happening again and it does seem to be correlated with when in pregnancy it happened before. So the earlier in pregnancy, you had a preterm birth before, the higher, the risks are that there is a chance for recurrence in a future pregnancy. I think also the risk factors can include, why did that delivery happen before is it something that has a risk of recurrence and often it can so spontaneous labor, breaking your water early, having high blood pressure complications, growth restriction, all of those things do have a risk of happening again. And so it's [00:07:00] important to consider what interventions might be available to help reduce that risk of recurrence or what monitoring you can do to identify pregnancies that are at increased risk again. Otherwise, in addition to past pregnancy history risk factors, there are general risk factors that people can have. So we know that people who have Mullerian anomalies, which is where the shape of the uterus might be different than usual. So you may have just a unicorn rate uterus, which is where the uterus is sort of half of what it would usually be or bicornuate uterus, which is where it's divided into two, that can limit the ability to grow and maintain a pregnancy to term. People who have had procedures on their cervix. So whether they've had abnormal pap smears and they needed to have a leep or cone biopsies, those can be risk factors for preterm birth, so factors like that. In addition to people who have underlying chronic medical, complex medical issues. Those can all be their own independent risk factors for things that can lead to preterm birth, whether it's Iatrogenic or whether it's [00:08:00] spontaneous.
[00:08:01] Dr. Alicia Power: Can we talk a little bit more about cervix, the cervix, like cone biopsies and leeps and what the actual, I don't know if you'd actually know the numbers off the top of your head, but in terms of kind of the risks.
[00:08:10] Dr. Michelle Morais: So in and of themselves, they probably don't increase the risk, a lot, just having had just one procedure. But they can. So I think it's important that when somebody identifies that history, that at least getting a baseline assessment of the survey, at the time when you're doing an anatomy, ultrasound is a perfect opportunity to stratify that level of risk. So if somebody has had a previous cervical surgery and at the time of the anatomy ultrasound, their baseline, cervical is looking normal, which would be over 25 millimeters on ultrasound, then probably you can be more reassured that their risk is probably a bit lower compared to somebody who's flagging with a short cervix at that stage of their pregnancy.
[00:08:54] Dr. Alicia Power: Thank you. And then just another point that we sometimes see is we don't, can't always see [00:09:00] uterine differences, I like to call them, on ultrasound, right? And so sometimes at the time of Cesarean section, if you went into labor at 35 weeks and had fetal distress and ended up with a Cesarean section, that's sometimes when we diagnose those uterine differences. And then bring that information forward to the next pregnancy.
[00:09:16] Dr. Michelle Morais: That's a yeah, that's a great point.
[00:09:19] Dr. Alicia Power: Imaging is not always perfect. Sometimes people know going in they've had imaging for whatever reason, or they've had an MRI and it's clearly defined. You know, the uterine difference. But sometimes we just find out at the time of Cesarean section usually, cause you can't really tell vaginal delivery. But then we can use that information for subsequent pregnancies as well.
[00:09:34] Dr. Michelle Morais: Yeah, that's an important point. In pregnancy, it's really hard to identify some of those differences in shapes of the uterus. You know, you might see a septum or you might have a sense of something outside of pregnancy is actually the most accurate time to diagnose those things, but you need to have a reason to look.
[00:09:49] Dr. Alicia Power: And then other reasons maybe for preterm birth is multiples.
[00:09:53] Dr. Michelle Morais: Yeah, that's right. Exactly. Twins. Twins have a 50% risk of being born, preterm. And then the higher order [00:10:00] multiples like triplets and beyond will be expected to deliver preterm.
[00:10:04] Dr. Alicia Power: And then the other thing is what about so I always think of it, if anything that makes the uterus way bigger than it was at then the average, right? So polyhydramnios is that have an increased risk of preterm birth?
[00:10:16] Dr. Michelle Morais: Yeah, so it can, for a couple of reasons. So one, the reason why there's extra fluid, it could be that there's something about the pregnancy. That's not. Progressing as expected. And so that can be a risk factor. also, just as you mentioned, just sort of the physical impact of having extra fluid and extra pressure on the uterus can predispose people to going into labor, breaking their water early as well.
[00:10:40] Dr. Alicia Power: Awesome. Great. So we've chatted about what is preterm birth. Why do we care? Impact on the newborn, and the family associated with said newborn, and kind of risk factors. Anything else that you wanted to add in for those points before we get to the next nitty gritty of how do we prevent preterm birth? The magic question.
[00:10:56] Dr. Michelle Morais: I think we've covered most of the, the [00:11:00] information that I can think of related to that, although it looks like you just have a new question.
[00:11:03] Dr. Alicia Power: What about fibroids?
[00:11:05] Dr. Michelle Morais: So fibroids may, they may for different reasons. One one could be, if they're impacting normal growth of the baby, then you're more likely to have growth restriction and more, more likely to potentially need to deliver early. So where in the uterus, the fibroids located can be important. So if it's impacting the cavity of the uterus where the pregnancy is implanted. Otherwise, some fibroids, as you mentioned for other reasons, you know, anything that makes the uterus sort of bigger and more stretched, out may potentially have a risk for predisposing people to early delivery. So that can be a different reason as sometimes fibroids can degenerate in pregnancy. It's unclear, if that can be an independent risk factor for early birth, but it might be.
[00:11:50] Dr. Alicia Power: And then the other thing we touched on the iatrogenic is the kind of the placenta, and if there's, you know, vesa previa, sometimes recommendations are to deliver a little bit early. Cause [00:12:00] you don't want that risk of rupturing, et cetera. So there's a few other kinds of things that, again, that's more of an iatrogenic cause of preterm birth. Okay. Perfect. So how do we prevent preterm birth Dr. Morais?
[00:12:13] Dr. Michelle Morais: The real answer is where we're only successful at predicting people who are going to deliver preterm about 50% of the time. It's a challenge for sure. I think we know preterm birth as we have alluded to has a number of different pathways. So things like inflammation, things like structural issues to do with the uterus and the cervix, things like other factors related to the pregnancy multiples, et cetera, they all have a role in leading to preterm birth. So when I see somebody in my clinic and I know that they've delivered early, we really want to make sure that we dig into the details of what happened before to understand it as fully as possible. For people who are in that category of spontaneous, unexplained preterm birth, you know, we don't know what happened, why it happened, we just know that it did happen. Some of those [00:13:00] strategies I like to implement at the start of the pregnancy are to make sure that we have a urine culture to confirm that there's no evidence of a urinary tract infection. Because we do know, with good quality evidence that urinary tract infections, particularly if untreated can predispose people to preterm birth. So screening and treating early in pregnancy is important. Also doing swabs, particularly for bacterial vaginosis is probably what has the highest evidence. So for people with a previous unexplained, preterm birth and occurrence, finding a bacterial vaginosis, even if they don't have symptoms of it, have benefit for treating. So I will make sure that we offer a swab to all patients at the start of their pregnancy, even without symptoms to screen for bacterial vaginosis so that we can treat it.
[00:13:45] Dr. Alicia Power: And just in terms of the treatment recommendation for our physicians and midwifery and nursing colleagues who do more remote stuff and are caring for pregnant people early in pregnancy. What are we using? What is the recommendation timing wise and actual [00:14:00] treatment wise for bacterial vaginosis in somebody who's screened positive, who has a history of preterm delivery.
[00:14:07] Dr. Michelle Morais: Yeah. So you want to treat it at the time when you identify the bacterial vaginosis. The best evidence is to use oral metronidozole to treat it. The exact dose, I think is 500 milligrams twice daily for a week. But confirming the SOTC guideline would help me to make sure I'm giving correct information
[00:14:27] Dr. Alicia Power: That sounds right in my brain
[00:14:28] Dr. Michelle Morais: Sounds right. Yeah. There are some vaginal preparations, but for the prevention of preterm birth, the oral preparation has the best evidence behind.
[00:14:36] Dr. Alicia Power: Perfect. Thank you.
[00:14:36] Dr. Michelle Morais: And then you can also look at doing a test of cure afterwards to make sure that you actually have had resolution.
[00:14:42] Dr. Alicia Power: Perfect. So you've done a urine early in pregnancy. Make sure there's no asymptomatic bacteria and treated that if that, if the case. You've done a swab for bacterial vaginosis and treated that if that is present. And again, these are in the population who has a [00:15:00] history of preterm birth. We're talking about specifically here, That's unexplained preterm birth, maybe explained.
[00:15:05] Dr. Michelle Morais: Yeah.
[00:15:06] Dr. Alicia Power: Okay.
[00:15:06] Dr. Michelle Morais: And then we start to try and identify. Okay. So for the person with unexplained preterm birth, we often don't have much information about what their cervix looked like in a previous pregnancy, but we can look prospectively in a future pregnancy to get more information on that. So we would recommend usually doing a serial assessments of the cervical length. Transvaginal ultrasound would give us the most clear pictures of the cervix. So we do recommend trans vaginal over trans-abdominal imaging. And we would want to make sure that we're watching the cervix, on a regular basis in a window where it may potentially shorten and that we have interventions that we can use to basically impact what's going on. So from a cervical length screening point of view it's probably not valuable to look much before 16 weeks. Of course, taking in mind an individual patient's history and the timing of when things [00:16:00] happened before. But 16 to 18 weeks is probably the timeline that you would want to start doing some cervical length monitoring. And then depending on what their cervical length measurement looks like, that can guide sort of the frequency of ongoing monitoring, but probably every about two weeks or so is a reasonable interval to follow up and see again, always guided by a patient's previous history of what's happened.
[00:16:20] In addition to that, another strategy that can be helpful to reduce the risk of unexplained previous preterm is considering the use of vaginal progesterone. So vaginal progesterone has evidence to suggest that it is probably the most effective strategy when you compare it to things like cervical cerclage, or cervical pessary versus expected management. And so vaginal progesterone would be the other kind of standard recommendation for patients to consider using, alongside doing a cervical length monitoring.
[00:16:51] Dr. Alicia Power: And when would that start, that recommendation? You have to, I know it's very patient specific, but...
[00:16:55] Dr. Michelle Morais: It is. Yeah. In general, the earliest, I would usually start vaginal progesterone is [00:17:00] sort of 16 to 18 weeks or so, certainly by the time you're doing your anatomy ultrasound is a reasonable time to start the vaginal progesterone. And then I would usually continue it to about 34 to 36 weeks. Just to try and reduce the risk of having a preterm birth. So if we get to pre, get to 36 weeks and we're still on the progesterone, that is reasonable to come off at that point.
[00:17:21] Dr. Alicia Power: And any kind of, any risks, side effects? The goopiness is what I hear all the time. It's a very goopy. But any other kind of concerns from a risk factor point of view of using vaginal progesterone?
[00:17:33] Dr. Michelle Morais: Yeah. So for the most part, most patients don't comment on kind of systemic symptoms related to the, using a progesterone suppository. I have had a few patients that do seem to be more prone, and so some of them note that they have increased constipation or increased fatigue, or bloating. And when they're not on the progesterone, they do notice a difference in those symptoms. But for the most part, as you mentioned, that the main thing that patients will comment [00:18:00] on is a change in their discharge and sometimes just some irritation in the vaginal area.
[00:18:05] Dr. Alicia Power: Yep. Fair enough. Okay, thank you. I am going to go back to the ultrasound question. A question around the ultrasounds I should say is when do you stop doing those serial ultrasounds? Because in our center, usually it's about 32 weeks that we would stop doing those serial ultrasounds. Is that consistent with what you are doing in your center?
[00:18:23] Dr. Michelle Morais: So I think, the best evidence suggests that probably beyond 28 weeks, the length of the cervix is less helpful to predict the patient who is more likely to deliver preterm. I think part of that is we know over the course of time, the cervix naturally does start to change in terms of its length. And so the number in and of itself probably gives you less information about that particular patient's risk compared to a short cervix that's flagged at the mid trimester.
[00:18:52] Dr. Alicia Power: Perfect because I know there's a lot of patient anxiety when they get discharged from those kind of regular surgical [00:19:00] ultrasounds. But it's actually nice to know that it's even earlier than what we're doing. So I can say we're like, being super cautious with you, right. People love to hear that. So it's good to know that kind of, that evidence after 28 weeks is not really there for continuing on with those serial cervical length ultrasounds.
[00:19:17] Dr. Michelle Morais: Yeah. Yeah, there are actually some groups that, some groups are probably even more conservative because some people think, the role for the cervical length monitoring is to identify the patient who may benefit from a cerclage. And usually beyond 24 weeks or so, people are not interested to do a cerclage. And so there are some people who would even debate, what's the real role for doing it after 24 weeks. If you're not going to intervene. Now the counter to that is while you may identify the person who is starting to see some signs of cervical length shortening, that isn't identified with symptoms that they have. And so is there a person that you might just keep a closer eye on, you know, sometimes people would consider admission to hospital for observation. [00:20:00] There's a lot of debate about the role of that, but, you know, but certainly at 28 weeks, the predictive value of the cervical length probably declined a fair amount.
[00:20:09] Dr. Alicia Power: Just because we've talked a little bit about cerclage for our colleagues who may not know what a cerclage is, or have a good sense of kind of the evidence around it. And when you might use it or not use it. A cerclage is essentially a stitch that is placed in the cervix, to keep the cervix closed. And there's different ways of doing it. Yeah. But when might you consider it? Again, I know this is very, a very nuanced discussion and it's very much patient specific about their history and what's going on now and whether their cervix is open or not, whether there's membranes bulging out, But- ish again, general kind of information. When might you consider a cerclage? And you don't need to discuss about the different types of cerclages, cause I don't think that's something that our, our listeners need to know specifics around, but just the general guidelines recommendations. When might you do it? When not, how do you take [00:21:00] it out, when to take it out, et cetera, et cetera.
[00:21:02] Dr. Michelle Morais: Yeah. So there are a couple of different pathways that we would consider cerclage. So one of them would be a planned cerclage in the late first trimester, and that would generally be based on somebodies history that sounds very consistent with cervical insufficiency. So that would be where, you know, painless, cervical dilation is identified either through ultrasound or, you know, somebody might come into labor and delivery because it just notice a big difference in their discharge, or they felt lots of pressure, and then lo and behold, their cervix is quite dilated and there's no evidence of contractions or bleeding or other predisposing factors. The guidelines suggest. You probably should have a history of a preterm birth related to cervical insufficiency up to three times before you consider putting a cervical cerclage upfront, but frankly I can't, I find the, sort of the moral distress around that to be very difficult to reconcile. The evidence bears out that even doing [00:22:00] nothing, most people will not have a recurrence. And so they say you might be exposing people to a surgery that they don't need. But, I think it's very difficult to reconcile that there is an intervention that you can do that has risks, but also is it's a reasonably safe surgery, at a time in pregnancy when the cervix is long and closed. That you, you, may, might've missed an opportunity to do when it had its lowest risk. So I, my personal approach is that when patients have a history that seems quite consistent with cervical insufficiency, I would be prepared to offer a cerclage earlier that in their next pregnancy, based on a good history.
[00:22:36] Dr. Alicia Power: And that's when you have a good informed discussion with your patient, right? You talk about the risks or benefits of doing it. You talk about the risks and benefits of not doing it, and you give them the option, right?
[00:22:46] Dr. Michelle Morais: Yeah, exactly. So that would be one category of people who would benefit. And then there's always the person who comes to you, having had a successful pregnancy with the cerclage before. So that would usually be another group of people that you would generally feel [00:23:00] comfortable offering a cerclage too early. The subsequent group of people who benefit from the cerclage are, as you're doing your monitoring, or if you weren't doing monitoring, but you notice it incidentally. If their cervix is short and dilated, so it doesn't matter whether they've had a term birth before, or preterm birth before if you have a short dilated cervix before 24 weeks, those people probably benefit most from having a cerclage, if it's safe and technically feasible to do and again, based on the conversations you have about the patient about pros and cons. And then for people who have had an unexplained, preterm birth before, and to have an incidental finding of a short cervix, even if it's not dilated, but just a short cervix, that's another group of patients who there's a good evidence to suggest that they may benefit from a cervical cerclage. There's some debate about very short cervix. So if your cervix is less than 15 millimeters is that a group of people that may benefit? There's pros and cons again and debate in the literature. But the [00:24:00] best evidence is related to a dilated cervix or a history of a short cervix in the setting of a previous unexplained preterm birth.
[00:24:07] Dr. Alicia Power: And technically those dilated, I've assisted in a few, technically, it looks quite challenging. The dilated, but the membranes coming out. And again, There's no, medicine is not black and white, right. It's shades of gray. And there's lots of things that we don't necessarily appreciate about the complexities of different decisions, and decision-making when we are looking either from patient or from an outpoint outside point of view. Just always remembering when you're having discussions with patients, if you're not the one actually doing the procedure, you may not understand all of the complexities and things that we really need to take into consideration and have discussions with patients around when we're having those conversations.
[00:24:44] Dr. Michelle Morais: Yeah, absolutely. It can be a very technically challenging surgery. And, you know, we go into it with the do no harm approach. So if your membranes are significantly passing through the cervix and I'm very concerned, I'm actually going to create a problem by doing the surgery. [00:25:00] Then I'll be very open with patients about that and that, you know, sometimes doing nothing. What feels like doing nothing I should say, is actually the better course in certain circumstances and you know, you'll read literature about many different approaches, you know, does that help to drain some of that fluid so that there's less pressure. And you know, they're small case series that suggested that can be beneficial, but certainly you need some specialized expertise if you're going to be considering that for sure.
[00:25:29] Dr. Alicia Power: Yes. So thank you for being it. I don't have to make the decision for my patients, somebody else going to have those discussions who are- that is their area of specialty and focus, right? Okay, so we've chatted. And when did the cerclage generally get taken out?
[00:25:43] Dr. Michelle Morais: Yeah. So the cerclages that we put in our things that were, would be removed. So if we put them in, we generally would take them out assuming that there's no earlier indicator for birth, usually around thirty five, thirty six weeks or so of a pregnancy. The rationale is that we want to take it out, [00:26:00] timelined with when labor may set in so that we're not potentially risking having any tearing or damage of the cervix by having the suture in place at the time.
[00:26:09] Dr. Alicia Power: And is that the apply also, if somebody is having a planned Cesarea section? Or would you take it out at the time of Cesarean section?
[00:26:17] Dr. Michelle Morais: In that circumstance we usually offer the patient the choice between the two. We would give them the opportunity to take it out ahead of time or wait to do it at the time of their surgery, whatever their preferences is.
[00:26:27] Dr. Alicia Power: Perfect. Thank you. All right. Anything else that we need to cover? I was going to ask you a question. So I have colleagues who work up Northern Vancouver island. I live in Victoria, so there are Northern Vancouver which is relatively remote and they don't, they can't, they don't have the past day to care for patients under 37 weeks. So anybody who goes into preterm labor has to go to a different community to deliver. Which we've chatted about in our previous podcast around the stress for families and for people around that, being away from your support system, especially if you're going to have a baby preterm. One of the [00:27:00] strategies they've employed and is having people, even if they don't have back to urea, urinary tract infection early in pregnancy, having them do monthly urines to ensure that they don't in fact, get a UTI or urinary tract infection that might precipitate preterm labor. So these are people in remote communities that are not, or either there's no physicians there or there's a nurse there who's caring for them. But they can't access urgent and emergent care or specialty care very easily. And so they're doing monthly urines to help screen for those people. Is that something that we would recommend to the general population or is that kind of a very specific case because these people are very remote. It's hard for them to access care and if they do access care, it means they're really leaving their community for a long period of time. What are your thoughts around that?
[00:27:46] Dr. Michelle Morais: Yeah, I think as a general population screening approach there, there's probably not sufficient evidence to recommend in all contexts that would be something that would be a high yield. Though certainly in people who may have a history of urinary [00:28:00] tract infection related to preterm birth, doing regular screening of urine cultures during pregnancy is a very reasonable approach, and then I think as you highlighted, there may be some contexts where that approach makes a lot of sense, because you're trying to make sure that people receive care that can be very impactful in a timely way, and that they're able to receive care within their own communities to avoid a lot of the distress and implications of needing to travel elsewhere if that, that can't happen. So I think in that context it would make a lot of sense to identify things that can have a significant impact and to be able to be in, if you do find and also I think from just a costly perspective, a urine culture for a small number of people for, on a monthly basis, over a short period of time, it's not a huge draw on the healthcare system. Whereas when you consider needing to travel somewhere else, deliver somewhere else, costs of prematurity and so on, on the balance of everything [00:29:00] you wouldn't need to prevent many preterm birth for that to be a very impactful approach of helping to manage a patient care.
[00:29:06] Dr. Alicia Power: Okay. Michelle. Thank you so much. Really appreciate it. We got through a lot today, anything else that you wanted to add to today's podcast?
[00:29:14] Dr. Michelle Morais: Just thank you again for having me here to chat about some things that are near and dear to my heart. I'm a big proponent of trying to help get patients access to interventions that can make a real and so hopefully this will help to spread the word of some of those things.
[00:29:31] Dr. Alicia Power: Thank you so much for joining us today.