Role of prenatal probiotics in preterm birth

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Reviewed by:
Dr. Norendro Molhotro
MBBS, MD, FIAJAGO, FICMU,
FICOG, FICMCH, FRCOG,
FICS, FMAS, AFIAP
Monoging Director Globol
Roinbow Heolthcore
Director ART Roinbow lVF, Agro
Director MHMH (P) Ltd. Agro
Director MTTBC, Agro
Director IAN Donold School
President InSARG (2020)
Vice President SAFOG
(2O2Ol & WAPM (2018)
Post President ISAR/ISPAI/tFUMB
/FOGSI/AOGS/ICMU (Deon)
Founder Editor SAFOG Journol
Director SMRITI Monyoto CSE
Choirmon SMRITI (NGO)
- New Level of Core
Presideni Rotory Club
Agro Toj City
preierm birth insteod of prolonging gestotion. A mojor couse of preterm
birth ond lobor is bocteriol voginosis & nutritionol deficiencies. correction
of voginol floro with probiotics & nutrition is very importont for fovoroble
pregnoncy outcomes. Evidences hove shown thot probiotics contoining
Loctobocilli ore effective in reducing the risk of preterm birth ond com-
plicotions ossocioted with it. I would prefer to prescribe probiotics to my
pregnont potients olong with iron, colcium, Vit D3 ond Micronutrients.
What is a pieterm birth?
Any birth that occurs before 37 weeks of gestation is termed as preterm birth (pB).
It is classified in two categories: 1) indicated- are those deliveries which initiated
by the clinician for the benefit of either the fetus or the mother and (2) spontaneous
PB-those that follow either spontaneous preterm labor or spontaneous rupture of
the membranes.1,2
It has been estimated that 15 million infants are born preterm globally,
disproportionately affecting low and middle income countries. India accounts for
the most preterm births in the world (3.5 million).l3
hildren born preterm ore ot increosed risks of heolth ond develop-
mentol problems. This underscores the importonce of preventing
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Children who are born at preterm are at higher risk for
mortality and a variety of health and developmental prob-
lems than infants born at full term. Various complications
such as acute respiratory, gastrointestinal, immunologic,
central nervous system, hearing, and vision problems, as
well as longer-term motor, cognitive, visual, hearing, be-
havioral, social-emotional, health, and growth problems
can be experienced by these children.a
Moreover, birth of a preterm infant can also bring
considerable emotional disturbances and economic burden
to families and have negative implications for public-sector
services, such as health insurance, educational, and other
social support systems.a
Etiological factors
Etiology of PB is complex in nature and its pathophysiology
that triggers PB is largely unknown. However, few factors
have been identified and reported in the literature include
maternal, fetal and placental predisposing factors.'
The most common of these factors are:
. Antepartum hemorrhage or abruption
o Mechanical factors such as uterine over-distention
and cervical incompetence
o Hormonal changes
o Bacterial infection and inflammation
Pathogenesis of preterm birth
Alteration in endogenous vaginal micrbiome is a charac-
teristic feature of bacterial vaginosis (BV). This polymi-
crobial dysbiosis characterized by reduction of beneficial
Lactobacilli and healy colonization of anaerobic bacteria.
Presence ofpathogenic bacteria in BV causes localized
inflammation in the endometrium and make the intrauter-
ine environment incompatible for embryo implantation
and placental development (Figure 1).s
Ways to prevent preterm birth
Management of preterm labor should be directed towards
establishing the cause, ensuring delivery under optimal
conditions, and consideration of the pros and cons of
delaying delivery to increase gestational age.6
Role of probiotics
Probiotics are defined as living microorganisms that
confer a health benefit'to the host. Typical probiotic
bacteria administered are Bifidobacteria, Lactobacillus or
Saccharomyces.'
Figure 1: Pathogenesis ofpreterm birth
Initiation of inflammatory cascade
tps sA rps
LTA
Premature labor
Adapted from! Prenatal Probioticsr The Way Forward in Prevention of Preterm Birth'
foumal of Clinical Gynecology md Obstetrics, Nortl America' 8, seP. 2019'
Consequences of BV include increased risk of sexually
transmitted diseases including human immunodeficiency
virus and elevated risk of PB. Medical interventions, such
as antibiotics, have been suboptimally effective and have
failed to reduce the incidence of PB. The absence of Lac-
tobacilli in the vagina, a specific feature of BV raises the
question as to whether restoration of Lactobacilll, by probi-
otic therapy, can restore the normal flora and improve the
chances ofhaving a healthy term pregnancy.8
Various studies have been reported the use ofprobiotics
in pregnant women to Prevent and manage complications
arise from preterm birth and same has been listed in
Table 1.
Bacterial vaginosis/Vaginal dysbiosis
Pathogens ascend to the uterus
Amniotic fluid

3. 759 pregnant
women in their
first trimester
8.5% of women with abnormal vaginal flora
and,4.6o/o of women with BV had severe pB
(25 to 34 weeks)
84 pregnant
women with BV in
their first trimester
At fourth and eighth weeks post treatment, the
probiotic group had a significant reduction of
BV
Out oftotal 241
enrolled pregnant
mothers,205
motherlinfant pairs
completed the
follow-up
. Eczema was reported to be more in placebo
group (71%) than infants in probiotic
group(29%)
. Chronically persistent eczema was $eea
in26o/o in placebo group and only 10?o in
probiotic group
70 149 singleton
pregnancies were
included
. Probiotic milk intake in late pregnancy was
significantly associated with io*"r pr.-
eclampsia risk
. Probiotic intake during early pregnancy was
significantly associated with lower risk of
preterm delivery
Donders et al
Neri et al
Rautava ef al
Nordqvist ef al
Conclusion
Probiotics have a proven role in preventing or minimis-
ing the risk of Urogenital Tract Infections such as Bacte-
rial vaginitis, Yeast vaginitis and UTI. Studies have shown
that preventing vaginal infections helps to prevent preterm
birth. Evidences have shown that probiotics containing
Lactobacillus rhamnosus GR1 and Lactobacillus reuteri
RC14 play a potential protective role in reducing the recur-
rence ofvaginal infections and incidence of preterm birth.
References
1. Quinn fA, Munoz FM, Gonik B, et al. pretermbirth: Case definition
& guidelines for data collection, analysis, and presentation of
immunisation safety data. Vaccine. 2016;34(49):6047 -6056.
2. Institute of Medicine (US) Roundtable on Environmental Health
Sciences, Research, and Medicinei Mattison DR, Wilson S, Coussens
C, et al., editors. The Role of Environmental Hazards in prema&fre
Birth: Workshop Summary. Washington (DC): National Academies
. Press (US);2003. 1, Preterm Birth and Its Consequences. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK2l622l. Accessed
on:231312021.
Women with BV and abnormal
vaginal flora are at a risk of
preterm delivery and late
mlscarrrage
Continuous correction of both
the vaginal pH and Lactobacillus
spp flora was crucial for normal
vaginal ecology
It was observed that risk ofatopic
disease in infants can be reduced
with the supplementation of
probiotics to pregnant mothers
Consumption of probiotics is
found to be effective in reducing
incidence of PB and pre-eclampiia
North Araerica' 8, eep. 2019. Amilable atr <htFs://ww1,v,jcgo.org/ind€x.php/icgo/eti€le/viedi71/37t>. Accesed aat t9!312o2r.
Honavar SG. Do we need India-specific retinopathy of prematurity
screening guidelines?. Indian I Ophthalmol. 2019 ;67 (6):7 tt -7 16.
Institute of Medicine (US) Committee on Understanding premature
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Washington (DC): National Academies Press (US); 2007. Available
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The Way Forward in Prevention ofPreterm Birth. lournal ofClinical
Gynecology and Obstetrics, North America, 8, sep. 2019. Available
at: <https://www.j cgo.org/index.php/j cgoI afiicleI viewI 57 I I 37 I >.
Accessed on: 191312021.
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of preterm labow. Arch Dis Child Fetal Neonatal Ed.
2007;92(2):F88-F93.
Grev f, Berg M, Soll R. Maternal probiotic supplementation for
prevention ofmorbidity and mortality in preterm infants. Cochrane
Database Syst Rev. 2018;72(12) :CDO125 19.
Reid G, Bocking A. The potential for probiotics to prevent
bacterial vaginosis and preterm labor. Am I Obstet Gynecol.2003
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