Ep 163: What You Should Know About Preterm Birth

Ep 163: What You Should Know About Preterm Birth

Nicole: In this episode, you are going to learn about preterm birth. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OBGYN who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy in birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Hello there. Welcome to another episode of the podcast. This is episode number 163. Thank you for being here with me today. So this is an episode that I've had in the works for a while now, and folks have definitely asked for it. So I'm excited to bring it to you today. This episode is about preterm birth, so you're gonna learn what is preterm birth. There are some specific definitions, I'll tell you about the numbers, how frequently it occurs, and then we'll go through a bunch of risk factors. And if there's anything you can do about those risk factors. Now fair warning. This episode is gonna feel a little bit frustrating. It certainly has been frustrating for me putting it together because so many of the risk factors are things that cannot be modified. However, it's still important to know the risk factors, because maybe you'll pay more attention to the things and the way that you're feeling in your body.

Nicole: You'll just be more aware of things and prepare just in case. So again, fair warning, there are tons of risk factors, but we don't necessarily have a lot of interventions or things that we can do to modify those risk factors. I'll talk about where we can change things, but, um, there's not that that many places that we can change and that's reflected in the numbers. You'll see that also, um, honestly, the numbers about preterm birth have stayed the same for quite some quite some time, have actually gone up a little bit in recent years. Now I'm going to follow up this episode with episodes on the two most common causes of preterm birth, which are preterm labor and preterm premature rupture of membranes. So stay tuned. Those episodes are coming as well. Now, before we get into the episode, quick listener shout out. This is two oh, it's Ladi that's O H underscore I T S L O T T Y.

Nicole: And the title of the review says knowledgeable and comforting. And the review says, love, love, love this podcast. I listen to this podcast with my first baby and it helped me feel super knowledgeable about going into birth, pregnant again, and revisiting all the episodes. And I feel like I'm learning all over again. Dr. Rankins gives great info and covers so many good topics. Can't recommend this podcast and the birth class enough feeling so good about going into my birthing time with baby. Well, I am so glad that you enjoyed the podcast and you are back for a second time. It is hard to believe I've been doing this enough that I have people coming back. So thank you for that kind review. And I'm so excited to have you back in the community. Now Ladi mentioned, or Oh It's Ladi rather, mentioned the birth class Def definitely check out my birth plan class.

Nicole: It's drnicolerankins.com/register. It's a great class to help you make a birth plan that works to help you have the birth that you want. Makes helps you make a birth plan the right way. And again, the right way is one that actually works. The way typical birth plans are done, template, form, checklists, they just don't work. And I talk about that more in the class, so you can check out all the details of that class and join me there, drnicolerankins.com/register. All right, let's talk about preterm birth. So preterm birth refers to a birth that occurs between 20 weeks and 36 weeks and six days of gestation, the Centers for Disease Control and prevention and the American College of Obstetricians and Gynecologists. That's the CDC. And also ACOG. Further define preterm birth as late preterm, which is between 34 weeks and 36 weeks and six days.

Nicole: And then early preterm, which is anything less than 34 weeks. So preterm in general is less than 37 weeks. And then late preterm is between 34 weeks and 36 weeks and six days. Early preterm, less than 34 weeks. Now, preterm birth is relatively common worldwide. It happens in anywhere from five to 18% of births in the United States, approximately 550,000 infants are born preterm each year. That is a lot. So it's about 10% of all live births in the US. And that number has been pretty steady, actually going up a little bit. About 3% of those are less than 34 weeks. And as I said, they have been increasing the most recent rates in 2019. The preterm birth rate got up to 10.2% and it's thought that this increase is related to an increase in late preterm delivery. So between that 34 and 36 week gestation, whereas the early preterm birth rate has remained largely unchanged since 2014.

Nicole: So when we look at causes of preterm birth, about 70 to 80% of preterm births are spontaneous resulting from preterm labor. So that's about 40 to 50% of preterm births. And then another 20 to 30% are from preterm pre-labor rupture of membranes. Also preterm, also known as preterm premature rupture of membranes. And then the remaining 20 to 30% of preterm births are actually caused by us inducing labor, because there's a condition in mom or a condition in baby that jeopardizes the health of the mom or baby. So preeclampsia, placenta previa, placenta abruption, growth restriction, where the baby isn't growing well sometimes when you have multiple gestations we in initiate labor early. So again, about 40 to 50% of preterm birth is from spontaneous preterm labor. Another 20 to 30% is from preterm pre-labor rupture of membrane. So water breaking very early in pregnancy, and then the rest are, we cause the preterm birth, because we believe that birth will help improve the health of a mother or baby.

Nicole: So now I'm gonna talk about many, many of the risk factors for preterm birth. And as I go through, I'll talk about the things that are modifiable and then the things that are non MiFi non-modifiable again, most things are not modifiable, but it's good to know. So you can be on the lookout for things in case you feel something different or new in your body that causes you to be concerned about preterm labor. So, first thing we're gonna start out with is reproductive history. Now a history of spontaneous preterm birth. So a history of having a prior preterm birth is a major risk factor for having another preterm birth. And often the preterm birth is going to occur at roughly the same age. You are at a highest risk. If you don't have a term pregnancy between those pro spontaneous preterm births and the current pregnancy.

Nicole: So if you have an early preterm birth and then you have a term birth, then after that, you're at less likely of a chance to have a preterm birth, then if you have preterm preterm, then you're more likely to have a preterm birth. Again, when we look at the specific numbers, if you had a prior preterm birth, so if you had one prior preterm birth, then you have a 15 to 30% chance of having a recurrent spontaneous preterm birth. So I think that's good in a sense that actually you have as high as a, you know, 85% chance of not having another preterm birth the next time around, but obviously that's going to be higher than if you hadn't had a preterm birth before That number does go up. If you have two spontaneous preterm births. So the more spontaneous preterm births you have with each pregnancy, your risk is going to get higher for having another spontaneous preterm birth. Now, if you had a prior indicated preterm birth, meaning that you had to give birth early because of a medical condition, not because you had spontaneous labor, that actually still does slightly increase your rate of recurrent preterm birth.

Nicole: And you're at risk of having a recurrent indicated preterm birth. So that's gonna be anywhere from 10 to 20% or so if you have a history of what's called an indicated pre-term birth, meaning it was for your health or your baby's health, you do have a slightly increased risk of having another pre-term birth. And for it being another indicated preterm birth, okay? Some other things in reproductive history or in your reproductive lifetime that can increase your risk of preterm birth. If you had a spontaneous preterm birth of twins, you will have a slightly increased risk of spontaneous preterm birth and subsequent pregnancies, even if it's just one baby, the next time. Also, if you have a short inter-pregnancy interval, particularly less than six months, that is going to increase your risk of preterm birth and inter pregnancy interval is the time between when you have a baby and then when you get pregnant with the next one. So if that interval is less than six months, that is going to increase your risk of preterm birth. And then the final thing that I will talk about in regards to reproductive history and the association with preterm birth is a history of abortion. And in some reviews, some studies do show a slightly increased risk of preterm birth if you have a surgical abortion, meaning you have a procedure, a surgical procedure to remove the pregnancy. That risk is very slightly increased. Though, in one study of over 900,000 patients, it was 5.4% versus 4.4%. So not, not much of an increase there, but it is a slight increase.

Nicole: We do not see that same slight increase for the slight increase for those who have a medication abortion that does not seem to increase the risk of preterm birth.

Nicole: Now, as far as things that can be done in regards to reproductive history and changing, or being able to reduce your risk of preterm birth, progesterone supplementation, either vaginal progesterone or injections of progesterone can reduce the risk of preterm birth by approximately 20% in women who have a history of a spontaneous preterm birth or a short cervix. So progesterone supplementation can reduce that risk by about 20%. Also, if you have a history of preterm birth and you have a short cervix identified on ultrasound, a cerclage may help reduce your risk of preterm birth. And a cerclage is a stitch that gets placed around the cervix.

Nicole: It's basically like a, a purse string stitch, for lack of a better way of putting it where you essentially stitch the cervix shut. And it helps to provide some extra strength to the cervix. So if the cervix is short and noted to be very short on ultrasound, and there's some specific numbers for that, I'm not gonna go into detail what those numbers are, but if it's very short and by short it's typically millimeters, then a cerclage may help. Also, if you have a history of multiple second trimester pregnancy losses or preterm birth, and you have what's called painless cervical dilation, that's an indication that the cervix is weak for some reason, or it's called cervical insufficiency. Then you may benefit from a cerclage in order to help prevent previous preterm birth. But that's certainly something that you should discuss with a high risk pregnancy doctor to see if you are a candidate for those types of interventions.

Nicole: Okay, moving right along. When we look at genetic factors, there are some what's called genetic polymorphisms that appear to contribute to the length of pregnancy. There's all kinds of letters and numbers. I'm not even gonna go through it, cuz they they're meaningless. Just hearing all those letters and numbers, um, spouted with the various genetic polymorphisms. But there are some genetic things that may be associated with preterm birth, but nothing that's like a slam dunk. If you have this gene, then you are going to have a preterm birth. We do know that preterm births are certainly more prevalent in some family pedigrees. So when you look through a family tree, you may see higher instances of preterm birth. Also in women who were born preterm themselves. If you were a preterm baby yourself, you have an increased risk of having a preterm baby yourself. Also, if you have a first degree, female relative who had a preterm birth, then you may be at a slightly increased risk of preterm birth. Interestingly, there's no paternal genotypes or paternal associations that we have seen thus far that have an association or an effect on preterm birth. All right, we know that race and ethnicity also show significant differences for preterm birth. Preterm birth rates are higher for non-Hispanic Black and indigenous women than for white, Asian or Hispanic women in the United States. In 2018, the preterm birth rate was 14%, 14.1 for non-Hispanic Black infants, 9.7 for Hispanics and 9.1 for non-Hispanic Whites.

Nicole: It is multifactorial what causes these differences, but we know that a good portion of it is due to racism. Race is a social construct. It's not a biological construct. And we think that it's due to the differences in the way that people are treated within the healthcare system, as well as chronic stress playing a role as well.

Nicole: Okay, let's talk about age. The rates of preterm birth are higher at the extremes of maternal age. So very young teenagers are at a higher risk of preterm birth and women over 40 are also at a higher risk of preterm birth. This is again, one of those things that is not modifiable. We can't change it, but it is something to be aware of. When we look at cervical surgery and what's called trans cervical procedures, like a DNC, a cold knife cone, or a loop electrosurgical excision procedure. Those are procedures that are done to treat abnormal cells of the cervix, um, related to HPV infection, then that can lead to an increased risk of preterm birth. And we thought that maybe just to, um, the cervix being weakened because of those procedures, essentially those procedures remove a portion of the cervix. So it's thought to potentially be weaker because of that.

Nicole: Now the bright side is that these procedures are done less and less because of the HPV vaccine, cervical cancer pre-cervical cancer cells are caused by HPV. So if you have the HPV vaccine that you are at a much, much, much less likely, um, risk of having those type of procedures done, if you've had a DNC for reasons other than a pregnancy termination. So say you've had, um, abnormal bleeding and you had a, a DNC, if you had a polyp or something and had a DNC that does also slightly increase your risk of preterm birth. Not very much, but just tiny, tiny, slight increase. And I, and I wanna say like, that's not a reason to not have a DNC. You know, if you need the DNC, you need it, but it is however something to be aware of. If you experience signs or symptoms of preterm labor, if we know that you had a prior DNC, then that may like, cause some red flags or cause us to think a little bit like, hmm, is this preterm labor.

Nicole: But to be honest with you, those things don't significantly increase your chances. It's just a tiny, tiny bit. Okay. Let's talk about uterine malformations. As you might imagine, if the uterus is shaped in a way that makes it more challenging for a pregnancy to stay, then that is going to risk increase the risk of preterm birth and the increased risk of preterm birth really depends on the shape of the uterus. So the abnormality, uh, of the uterine shape. So we'll start with the least likely uterine shape to cause any issues related to pregnancy. And that's called an arcuate uterus. An arcuate uterus is a uterus that has a slight midline indentation. So when you look at the uterus from the outside at the top, you can see like just a slight indentation towards the top. It's really classified as a normal variant, not really associated with any adverse pregnancy outcome.

Nicole: So that's an arcuate uterus. Then next is a septate uterus and patients with a septate uterus and septate is when there's a septum in the middle of the uterus. Okay. And just to back up a little bit, the way the uterus forms is actually pretty cool, the uterus starts out actually our whole bodies when we're growing inside of our own mothers starts out as two sides that come together and meet in the midline. So the uterus starts out as two separate pieces. And then during those early weeks of development, those two separate pieces fuse, actually the vagina does the same thing. They do it in separate processes, but they come together, um, at, as, as you develop in inside of your mother and the very early stages of pregnancy. So septate uterus is when there's the last little part didn't quite come together and there's a septum in the middle of the uterus. Typically on the inside, the outside can look normal, but inside there's a little septum and that can increase the risk of preterm birth to about increases the risk of preterm birth to 12 to 33%. For those who have a septate uterus, depending on how big the septum is. Now, the next stage, if the uterus doesn't come quite together, it's called a bicornate uterus. So that is when the uterus has two horns. You can see, it looks really kind of like a heart shape is the best way to describe it.

Nicole: And in those who have a bicornate, bicornate uterus, there are a lot of words in this episode that are causing me to be tongue tied, but bicornate uterus, the risk of preterm birth is about 21 to 23%. Keeping in mind that the background rate is roughly around 10% also incidentally, um, growth restriction can be an issue and bicornate uterus, as well as the baby being breach. Now uterine didelphis is, and this is very rare is when the uterus is like the two sides are completely separate. So it's called double uterus. They did not come together at all. In that case, the pregnancy is gonna settle in one side of the uterus or one horn of the uterus or the other. Pre-term birth rates in that anomaly are about 28%. And then the final one is unicornuate uterus, where the uterus is just one side. So the other side didn't form. And so only one side developed. So you only have what's called a unicornuate or one horn of the uterus. In that instance, the preterm birth rate is about 20%. So something that may be acquired that can affect the shape of the uterus is fibroids and fibroids, slightly increase the risk of preterm birth. It's going to be higher if the fibroid is large.

Nicole: Also, if you have multiple fibroids, as well as if it's a sub mucosal fibroid, meaning it's on the side of the uterus, that's closest to the inside. So the cavity of the uterus, those fibroids are going to put you at an increased risk of preterm birth.

Nicole: Okay? So moving right along, I'm going to lump all of these together and just say, chronic medical conditions can increase the risk of preterm birth. The numbers vary slightly, but having conditions like hypertension, diabetes, autoimmune diseases like lupus, if you have kidney problems, those are things that can increase the risk of preterm birth. Um, these are all conditions where we would watch your pregnancy closer. These are also all conditions that may increase your risk of indicated preterm birth. You actually have an increased risk of both indicated preterm birth, as well as spontaneous preterm birth with these chronic medical conditions.

Nicole: Okay. So next let's talk about vaginal bleeding in early pregnancy. This is actually something that surprised me. I don't think that I knew these numbers, this, um, this association until I really went to research this episode, but actually early bleeding in pregnancy can increase the risk of preterm pre-labor rupture of membranes. So premature rupture of membranes, and that can increase your risk of preterm birth. The association is strongest for preterm birth that happened before 34 weeks. Also, if you have persistent vaginal bleeding, not just in the first trimester, but also in the second trimester, then that's going to increase your risk as well. Unfortunately, there's not anything that we know that can change that, but it is something to be on the lookout for. There's no evidence that bedrest is going to help. Bedrest can actually be harmful. And sometimes we also say to avoid sexual intercourse when people are bleeding.

Nicole: But to be honest with you, there's not evidence that that's going to harm things either. You know, it, it seems to make intuitive sense not to do that, just to help, not stir up any further bleeding, but there's not evidence that it actually makes a difference. Other anatomical things. We talked about the uterus, we talked about vaginal bleeding, the cervix, having a short cervix, we do know increases the risk of preterm birth, the shorter the cervix, the higher the risk of preterm birth. This is another instance though, where bedrest is not helpful. There's no incidence that it decreases the incidence of preterm birth. Even if you have a really short cervix, it can also increase the risk of blood clots. I mean, bedrest can in increase the risk of blood clots. Bedrest can lead to deconditioning. So again, bedrest is not helpful in pregnancy. And then a dilated cervix. So not a short cervix, but a dilated cervix. If it's dilated more than one centimeter before 24 weeks, that is also associated with an increased risk of preterm birth and the more you're dilated the higher the risk.

Nicole: Okay, next big category of things is infection. So one of the things that we know may be associated with preterm birth is what's called asymptomatic bacteriuria. So that is when you don't have any symptoms, but you have bacteria in your urine. This is one of the reasons why we check for a urine culture in the first trimester for all pregnant folks, because when we detect it, then we treat it and it may slightly decrease your chances for preterm birth. The association with asymptomatic bacteriuria and preterm is not very strong, but it's a pretty low risk intervention. And one that may help it also may help reduce the risk of developing a kidney infection, which we know can definitely increase the risk of preterm. Another infectious process that is associated with preterm birth is gum disease. There is a slight association with periodontal disease, which is an inflammatory infectious process and preterm birth . Unfortunately, however, although treating any gum disease or, you know, teeth disease is going to help improve your overall health, it has not been shown to improve pregnancy outcomes. Now on the other end of the body genital tract infection is associated with preterm birth. So infection with chlamydia, gonorrhea, trichomonas, bacterial vaginosis, something called ureaplasma have all been associated with an increased risk of preterm birth. One thing that has not been associated with the increased risk of preterm birth is yeast infection. So know that a yeast infection in pregnancy does not increase your risk of preterm birth.

Nicole: Unfortunately, this is another instance where treating does not make a difference in terms of reducing the risk of preterm birth. So we treat chlamydia, we treat gonorrhea, we treat syphilis in pregnancy, not because it reduces the risk of preterm birth. We treat it because it prevents issues from hap other issues from happening in mom, like, uh, syphilis that gets all throughout the body, or it prevents issues happening in baby like gonorrhea or chlamydia of the eye.

Nicole: Treating bacterial vaginosis has never been shown to improve, uh, preterm birth rates. Also treating trichomonas trichomonas is a, a little parasite that also has not been shown to reduce the risk of preterm birth. Now, an interesting area that is emerging is research that looks at the vaginal microbiome and how that affects your risk of preterm birth. The microbiome is the collection of bacteria that live on and in us, we actually have 10 times as many, um, uh, species, uh, bacteria, fungus that live on and in us, then we do human cells. I think that's pretty cool. And we know that some of these things are beneficial, but if that balance of the microbiome is off, there is some evidence that it can lead to preterm birth. This is an emerging area and something that is being studied. Um, so we'll know more as people do more research.

Nicole: So let's get into some behavioral things. One thing that comes up a lot is whether or not physical activity can increase your risk of preterm birth. And there hasn't been a strong association between working in pregnancy and, and pre-term birth. There are some things on the extreme spectrum that may increase your risk. So if you stand a lot, if you walk a lot at work for more than four hours a day, if you do a lot of lifting and carrying of more than five kilograms at a time, and that's a little more than 10 pounds, if you lift and carry a lot in the third trimester, if you have a job that requires a lot of physical effort or exertion, if you work more than 40 hours a week, if you have night shifts, if you have, uh, rotating shifts where you bounce back and forth, the timing of work, all of those things show a slightly increased risk of preterm birth.

Nicole: And by slight, I mean, very slight increased risk. We've never, um, said that because of work or that we need to, let's see, what's the best way to put this. We've always said to be use common sense about the type of work that you do and how it increases your chances of preterm birth. We have to take it on a case by case individual basis. There are some people where yes, we have to say, you need to reduce your work hours because you are at an increase risk of having issues during your pregnancy because of the type of work you do. But that's very, very rare. We do often do things like give people notes that say, Hey, you need to be able to take a break. You don't have to be on your feet all day, those type of things. Um, this is an area that can cause a lot of tension. It's an area that can cause a lot of discrimination actually. So again, we take it on a case by case basis, but the data does show that there may be a slightly increased risk. If you have more physical activity, slightly increased risk of preterm birth.

Nicole: And I will say that that may differ. If you are someone who has a baseline known higher increased risk, like for example, you had a prior spontaneous preterm birth, then maybe the discussion might be a little bit different. Now another physical activity exercise in uncomplicated pregnancies does not increase the risk of preterm birth and it can in fact be helpful. So exercise is always a good thing in pregnancy. Sex also does not increase the risk of preterm birth. Even though we say that towards the end of pregnancy, maybe sex may help bring on labor, but in general, sex during pregnancy does not increase the risk of preterm birth. So you don't have to stop that.

Nicole: Some other things, diet has never been shown to definitively affect the rates of preterm birth. We all know that having a healthier, more balanced diet is going to improve your health. And we believe pregnancy outcomes in general, but there's not like a strong association between your diet and preterm birth. There is however, a strong association between smoking and preterm birth. So you definitely want to stop smoking to reduce your risk of preterm birth. Substance use all, and that's, uh, marijuana, you know, heroin, cocaine, any of those type of, um, drugs can increase the risk of preterm birth cocaine having the highest risk. And we think that's related to the vascular changes that happen with cocaine use. Extremes of weight may also be associated with a slightly increased risk of preterm birth. So if you're very thin or if you're obese, then that may increase your risk of preterm birth. When folks are obese, it's most often related to preterm birth resulting from needing to be induced from a medical complication of pregnancy, whereas with low weight gain or lower weight, it's, um, more likely to be spontaneous preterm birth. Interestingly women who have a shorter stature. So shorter height also are at a slightly increased risk of preterm birth compared to taller women.

Nicole: And then let's talk for a moment about stress. Um, stress is common. It's really common. Most women report having some stressful life events. So it's really hard to pinpoint stress as a cause of preterm birth. We know that it's a contributing factor, meaning that people who report higher levels of stress do have an increased risk of preterm birth. But that it's something that's really hard to quantify. I find this a lot that people often beat themselves up because they were, they had a preterm birth and they were like, well, I was under so much stress and I, and I caused this because I was stressed and do your best to control your stress, but know that it's not necessarily like a direct slam dunk. If you have X amount of stress, you are causing this preterm labor, preterm birth for your baby, do your best to try to stay in the best sort of mental health that you can, um, and not focus too much or not beat yourself up because of your stress levels. And there are a few studies that have shown that things like meditation, massage, yoga, breathing, exercises, music, aromatherapy, all of those things are things that can help decrease your stress.

Nicole: Okay. And the last couple things I will talk about the environment can have an effect on your risk of preterm birth. Particularly if you were in an area that has a lot of fine particulate matter and ozone in the air, also a very high environmental temperature, all of those things can increase your risk of preterm birth. The effects are small, but they are there. And then finally having a male baby will slightly increase your risk of preterm birth. Okay. Whew. That is it. Just to recap, there are a lot of risk factors for preterm birth. Unfortunately, most of the things we can't do much about, we also don't have any good strategies or ways to put those risk factors together, no blood test or things that can predict the risk of preterm birth. Oh, one thing I forgot to talk about is something called fetal fibronectin.

Nicole: Fetal fibronectin is a test that is done. It's like a cervical swab that's done, and it can be useful to predict preterm birth within seven to 14 days, if you have contractions and cervical dilation. So that is one test that can be helpful in predicting preterm birth. But other than that, we have no great strategies to prevent preterm birth or predict who's going to be at risk for preterm birth. Some things that we know are strong risk factors, or if you have a prior preterm birth, although that doesn't necessarily mean you're going to have another one. I personally am an example of that. My first baby was born at 32 weeks. The next one was born full term. Having a short cervix will also increase your, your risk of preterm birth. And both of those instances, progesterone supplementation may be helpful in order to prolong pregnancy.

Nicole: It can reduce the risk of preterm birth by about 20%. Some of the things that we know that we can change are smoking cessation, um, treating any drug use disorders, treating asymptomatic urine, asymptomatic bacteria in the urine, doing our best to get a normal body mass index, also spacing out pregnancies so that it's longer than six months, even 12 months would be ideal. Singleton gestations are less likely to be preterm than multiple. So if you're undergoing fertility treatments, then making sure that you try to have just one baby and not two or three. And one final thing I'll say that I also thought was interesting for women who have a preterm birth. We do actually. And I say, we, because I am included in this, we do actually have a slightly increased risk of heart issues. So cardiovascular, um, problems later down the line. So I think it's even more important for us to maintain our overall health and to make sure we stay on top of all of the things like low, low cholesterol blood pressure to reduce our cardiovascular risk.

Nicole: Um, side note preeclampsia does the same thing. It can increase your risk of long term cardiovascular conditions. So just be mindful of that. All right. So there you have it. That is the first episode. The next ones that are coming are gonna be preterm labor and preterm premature rupture of membranes. Do me a favor. If you like the podcast, if you like this episode, then share it with a friend. Sharing is caring and it helps the show to grow, helps me to reach and serve more pregnant folks. Also subscribe to the podcast wherever you are listening to me right now. And if you want more information from me, then hop on my email list. It's drnicolerankins.com/email. I send a great weekly email with tips and information and inspirational quotes. It's a great way for you to get more information from me, but not have to be on social media. So you can sign up for that at drnicolerankins.com/email. Okay. So that's it for this episode do come on back next week and remember that you deserve a beautiful pregnancy and birth.