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Okay, so you guys can tell I'm a big fan of holistic medicine. Now I'm a believer. But I gotta pay for these probiotics. You know what that is? Like probiotics, there's a war in my stomach between good bacteria and bad bacteria. And I'm sure you've heard wars cost money. You know, like, and my good bacteria costs 100 bucks a bottle. But here's the good news. Like, I. I read the bottle. Each pill on the bottle contains 360 billion colony forming units. So per colony, very affordable.
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I'm getting a deal.
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I'm getting a deal.
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If you count the number of colony forming units per pill, it's a good deal for the wicked high cash that per people pay for these, you know, live colony probiotics. And I just think he's clever. It's true. I love that there's a war in my stomach between the good and the bad bacteria, but the truth is, that's actually medically accurate. I mean, 70% of all of our immune system and or the origin of its function is in the GI tract. Guys, we don't have to debate the fact that there's a link between gut health and overall health, overall inflammation, even some mental health, mental aspects, and mood disorders. I'm not saying that depression is all caused by your gut, but there's definitely some association between gut health and overall health, including some influences on mood and mental health aspects. Now, we've covered probiotic stuff on this show in the past, mainly regarding bacterial vaginosis and the difference between vaginal application and oral use of probiotic agents. And you got to go back to the archives because I know that we covered that not too long ago, but anyway, I don't want to divert into that, but I was at a store and I saw there's these. You know, I'm in a university town, and there's these. All these college students, these young women, and they're hovering and kind of whispering to each other something. I hear the word vagina as I'm walking by. Oh, my God. Don't stop. Just keep going. Just And I couldn't help it. I'm like, I'm sorry, y'. All. I'm not. Promise. I'm not trying to hit on you because my wife would kill me. But if you're talking about something about probiotics, let me give you some info. And they were super thankful. They thought it was kind of funny, but nonetheless, I pointed them in the right direction. All to say, probiotics is kind of a thing and it's a very popular thing. And some of that has to do with marketing, right? They've been marketed to be the end all and be all for our health. And if you take probiotics, you'll never get sick. Well, that's kind of a stretch. I made that up. The point is, yes, sicknesses still do happen, but probiotics and gut health are a big deal. Nobody can doubt that. However. However, when it comes to the area of obstetrics, which of course, is my little comfort zone, my little home, it gets kind of weird and it gets a little gray. And we're going to cover this. Let me be very clear right off the bat, nobody recommends, oh, hey, you're entering prenatal care. Don't forget your prebiotic or your probiotic. And that's not a general recommendation. However, if somebody asks you as a patient, hey, I take probiotics, is that okay? During pregnancy, you need to be armed with the data for that, especially if they have a high risk factor like previous preterm birth. So here's where I'm going. On February 19, 2026, a new publication out of JAP was just accepted for print and hasn't even come out yet officially. It's an epub, right? It's accepted ahead of print. Now, this took a look at 31 hospitals, so 31 different sites. It's multicenter, but it was single arm, non blinded. Thankfully, it was prospective. But you see the catches here, guys, right? So right off the bat, even in its description, single arm, well, wait a minute. There's no control. That's kind of a flag. It's non blinded. Oh, that's. That's another flag. But it is prospective and multi sender. All right, so it's got some kinks to it. It's got some limitations, right, in its design, but nonetheless, what were they trying to do? Well, out of Japan, they were looking to see if women with a history of preterm birth. So these are all high risk women who took oral antibiotics of a specific strain, which we'll get into here in a minute. If that could reduce the risk of preterm birth as a recurrent factor. Fascinating, isn't it? Now you're thinking, well, how would probiotics even help that inflammation? There is some data that good bacteria can help with the placental uterine interface and the modulation of the inflammatory immune cells there. It is a thing. So this is a fascinating study that needs more study. So I just want to put this out here. I am not advocating for patients with previous preterm births to go knock them out and every day start popping in the bacteria. Okay, I'm not. But if a patient asks, we need to be armed with data, not opinion data to say, look, if you're interested, here's the pros, cons and unknowns of this. The good news is that nowhere in the data has shown that taking probiotics either alone or with prebiotics. In other words, is a food that feeds probiotics, which is basically. Prebiotics are nothing more than non digestible plant based fiber. No study has shown that that leads to some kind of bacterial sepsis or actual harm in pregnancy. Except, Casey, here's the caveat. And I'm going to get into this after the intro, which is in the intro, except maybe, possibly, notice those words there, those qualifiers, maybe, possibly in association with an increased risk in preeclampsia of. But even that is debated because it may have to do with when the actual probiotic was taken. Okay, sorry, I kind of lost my word there. So if you can't tell, if you notice my, I don't know, maybe you've never heard of the show before, but this is not my normal voice. I have once again caught some kind of allergy slash viral syndrome, whatever. So I'm doing this. I've got two cups of coffee, two cups in front of me. One is my rise coffee because I'm trying to get a little caffeine to do something here. And then the other, I've got my. My hot theraflu Tylenol slash liquid lemon medicine thing, whatever. So, yeah, I'm going back and forth between those. It's weird, it doesn't taste good, but I'm trying to do what I got to do. So, yes, I have two. Two different hot drinks in front of me. Based on what the spirit leads me to, I either take a sip of my rise or of my theraflu knot, a sponsor. So what. What, where am I, what am I doing, Michael? Huh? Oh, yeah, yeah. So there's one study, there's one study that shows that probiotics potentially may Increase preterm labor risk. That was an umbrella meta analysis. I'm gonna get into that minute just from last year, guys. 20, 25. But that's got some limitations, too. So short of it is if a patient wants to take a probiotic and they didn't get it from some guy off the street corner and seems to be legit and. Okay, well, we're gonna give you the data for that. I'm gonna give you the good, the bad, and the unknown as it relates to a brand new study not yet out, officially in print from the gray journal from Japan about recurrent preterm birth and oral, not vaginal, oral probiotics. My goodness, that's. That's a mouthful. I think I've said it up enough. Let me take a double swish of my rise coffee and then my theraflu. We'll be right back. Podcast family. I'm happy to share information from one of our corporate sponsors, Perspective Medical. In a C section, every second counts, especially when managing postpartum hemorrhage. But traditional surgical draping often hides the very signs that we need to see concealed bleeding around or under the patient. Introducing the OB GYN physician designed Hemorrhage View C section Drape. It's designed to provide clear and direct visualization of the patient to allow assessment of any concealed bleeding. Now, you can recognize hemorrhage earlier and monitor bleeding in real time without compromising the sterile field. Whether you're placing a uterine balloon or administering utero tonics, or assisting in a second stage C section, you now have clear visualization. You need to act fast. So let's be proactive, not reactive, in the recognition and management of hemorrhage. Visit perspectivemedical.org to learn more about the Hemorrhage View C section drape or to request a trial option. This is Dr. Chapas, obgyn clinical pearls. No spin podcast. That is not even close to who I am. You tend to make things about yourself. Your gut is off. It's leaky. Take a probiotic. It is a mess. Oh, my goodness. I'm gonna use that next time I'm arguing with somebody. Hey, man, look, just your. Your gut must be off. Just take a probiotic. Oh, that is so stupid. I don't even know what that clip was. Some women arguing. I don't know, like some. Was that the housewives or something that show? Who knows. Oh, not a sponsor. Okay, so probiotics and obstetrics. There's probiotic data for pretty much everything. Mental mood, disorders, of course, Inflammation, that's a big one. Heart health? Yes. Overall immunity? Yes. Autoimmune issues? Yes. Gynecological things like bv? Yes, again, we've covered that. The question is for, for our particular home in obstetrics, if you see a patient and they say, hey, I'm starting prenatal care, I take my daily probiotic, is it okay? This is to arm ourselves with that. Okay. Because we're surrounded by all of these commercials about probiotics versus prebiotics and or both. So very quickly, just as a recap, probiotics typically are live colonies. They are live bacteria that is supposed to help our microbiome reset itself. Okay? Now the best are the kind that are real cultures that you have to keep refrigerated versus the freeze dried capsules that you kind of get off the shelf where the bacteria are supposed to reactivate kind of in the body. You know, who knows if that's true or not. I'm not trying to, you know, knock off the, the freeze dried probiotics, but there's definitely data that the better quality, quality seem to be the ones you have to keep refrigerated like a lab experiment on the second shelf of your refrigerator. Okay, so probiotics, even in neonatology, guys, let me get away from perinatology with the obstetrical world. But in neonatology there's data that when tiny little sick babies get probiotics administered to them, it actually reduces some morbidity like nerve Titan enterocolitis. It can help reduce mortality. And it depends on the, obviously on the kind of strain of probiotics that is used. But there's no question that out of the neonatology literature, appropriately given probiotics, typically multiple strain probiotics, have some kind of benefit there to help the child establish his own immunity and microbiome. I'm not making that up, guys. That's a big thing. Because I found that fascinating when I read that starting about five years ago, however, probiotics given to pregnant women, that's a little trickier issue. Then there's the whole debate versus should it be vaginal as a first vaginal pass or oral? Obviously, vaginal probiotics offer some theoretical advantages by directly restoring lactobacilli in the site closest to the uterus and where the child will obviously transverse. There's data for that. There has been a randomized trial in women with vaginal dysbiosis, otherwise known as bv, found that vaginal lactobacilli, specifically a specific one called lactobacillus caseae eromnesus can significantly increase gestational age at delivery and help prevent low birth weight. What, I mean, it's out there now. No one's gonna promote this. This is why. This is. We definitely need a lot more data. And remember that things placed vaginally outside of some minimal absorption into the bloodstream. It's sometimes thought to be better than entering into the GI for a variety of different reasons when it comes to obstetrics. So there, there is data that oral probiotics may not work as well as vaginal probiotics. But, but we need a lot more data. But, but if you're, if somebody asks you, is there any data for vaginal probiotics and obstetrics? Yeah, there is and it was actually a randomized trial. But, but we need much more data before this is advocated for, for everybody. Remember, those patients had vaginal dysbiosis. That's the medical term that, the sciency term for bv. Okay, so we do have some data. The problem is the study populations that have looked at this have been very heterogeneous. Some have included low risk populations. Very few have just high risk populations like this study that we're going to cover. These patients had a previous preterm birth. And then some have kind of a mixture. And then there's the big question here is what kind of probiotic is being used? You can't just do a study, say and call it probiotics because there's different strains, there's different colony counts. Some are mixed strains, some are a single bacteria, some are live cultures that have to be kept refrigerated. Some are freeze dried. You see the difference here? When we try to link all studies in under one umbrella of probiotics, there's just way too much there to try to figure out. Now, is there some data where it could be that it could be beneficial? And the answer is yes. There's actually a very large Norwegian cohort study that had over 70,000 women that found that probiotics in milk, okay, when taken early in pregnancy, can be associated with reduced risks of preterm birth. Now, the odds ratio for that study, again out of no, out of Norway, was 0.79. So it wasn't like half, but I'll take any reduction and that's fine. And the confidence interval was just under 1. It was 0.6 up to 0.97. So it got close to 1, but it didn't include it, meaning maybe there's something there. This was published back in 2018 in BMJ Open. Okay, but here's the catch. This was not an rct, okay? It was a population based prospective cohort study. So that's one of the catches. Again, there is data, but just because you have data doesn't mean it's high quality data. But it's reassuring that this one showed, yeah, for prevention of preterm birth, when taken early, maybe it could do something. Now here's the catch. Probiotic milk intake in late pregnancy. Okay, so here's. Listen to this, guys. This is a clinical pearl. Probiotic milk intake, according to this Norwegian study, again, BMJ Open 2018, taken in late pregnancy was associated with lower preeclampsia risk, but when it was done early on, couldn't really tell what happened. It was very small benefit. Okay, so perhaps it has to do with the initiation of the probiotic and its overall outcome. So again, according to this Norway study, when probiotic milk was taken in early pregnancy, it helped reduce preterm birth, but it wasn't an rct. And when it was taken late in pregnancy, it showed lower preeclampsia risk. So this is why it gets confusing. So you've got this very large population cohort study from Norway showing it has to do with timing. And if you take it late in pregnancy, preeclampsia can go down. But if you just throw in all the data, if you put in a probiotic and preeclampsia risk, regardless of timing, then things get gray. Because here it is, guys. A Cochrane Systematic Review in 2021 showed that oral probiotics, yes, could be potentially be helpful in sugar control and therefore in preventing gestational diabetes, but it found an increased risk of preeclampsia. Thankfully, the relative risk was under 2, but it was 1.85. So it was above 1, but not quite 2 and the confidence interval was 1.04. So it did touch 1 up to 3.29. So they said, I don't know, maybe something of concern there. Remember that was Cochrane 2021. And that was again kind of reinforced by a separate 2025 umbrella Meta analysis that said that probiotics, yes, possibly could increase preeclampsia odds, but they found a lower relative risk as opposed to the first Cochrane review. So Cochrane Review 2021 found an increased risk of preeclampsia with a relative risk of 1.85, but the 2025 umbrella meta analysis found a relative risk of 1.23. So confusing. You see that? So this, this is why things get very Very gray. So what's my take home? It maybe can help when you take it in late pregnancy according to the Norwegian study. But if it's taken without regard to to gestational age, potentially could lead to like a 12% increase in preeclampsia risk. Now let me pause here for a minute. So it is kind of unknown. Let me just say very clearly it's kind of contradictory whether oral probiotics increase preeclampsia or not. There is data that it does, but the percent is kind of small. This is why if we're talking about preeclampsia and you listen to my aspirin podcast and even the one with my friend Alex who had his, I think it was called Alex's input about aspirin and preeclampsia risk. I'm all for universal, let's not risk stratify, just give everybody aspirin whether it's 81 milligrams or. Like me, I favor the 162 milligrams. And you can get a kind of a handle a suppression effect on baseline risk of preeclampsia in the general population as well as those that are at higher risk. So just throwing that out there. So there is some gray stuff guys, gray stuff about oral probiotics and preeclampsia. However, the good news is is that the variety of studies, both as single studies and multiple systematic reviews and meta analyses, haven't really shown any excess harm outside of that small little blip of uncertainty for preeclampsia regarding other prenatal or perinatal issues. Okay, the question is that we're supposed to answer and we're about to do here, and we're gonna do this quick now cause we're. I just wanna start speeding this up is what do we do with this with preterm birth? Okay, now be very clear. Preterm birth, I'm not talking as an incident, we're talking about recurrence. So it's already happened to a patient, she says, hey, well probiotics, because of my gut health, can that help reduce the risk of recurrent preterm birth? Well, right now there's what's existing in the data and then there's brand new data. Right now what's existing in the data is that that doesn't seem to be the case. Okay, so we don't have high quality evidence from well designed RCTs that oral antibiotics or vaginal for that reason caused a significant reduction in preterm birth. We have population Based studies. We have retrospective studies. We have some based on questionnaires, which obviously have issues, but we don't have a lot of high evidence that oral or vaginal probiotics can significantly. That's the catch. Significantly reduce preterm birth. This is why, guys, this is why I found this new publication out of Japan in the gray journal. Very intriguing because it at least opens the door to discussion. So. And it shuts down the naysayers. Like, that's not gonna help. Wait a minute. Just because you don't know about it or hasn't been studied yet doesn't mean it doesn't help. This study had some beneficial outcomes. It actually worked. Spoiler. But it was single arm, non blinded, non randomized, so there's some issues. Okay. But I think it's a fascinating discussion. Now, before we get into this study, let me just tell you that they used Clostridium bacteria as their probiotic of choice here. Now that freaks people out because we're so used to hearing things like C. Diff, Clostridium perfringes, Clostridium tetani, all of which nobody wants, right? You know, you don't want to get C. Diff, you don't want to get C. Perfringes, that's gas gangrene. You don't want to get Clostridium tetani. That's tetanus. So Clostridium kind of freaks people out. However, yet another clinical pearl. Don't forget that Clostridium species are varied and they are a big part of the normal gastrointestinal flora in healthy individuals across all age groups and whether you're a man or a woman. So Clostridium lives in us. It's just certain players, certain cousins of in the Clostridium family that are really bad, but some are actually very helpful. So I found that so, so interesting. So this single arm, prospective, not randomized study, use Clostridium species, the good kind, specifically Clostridium budaricum. Yeah, I'm not saying I should say that again. Clostridium butterecum as their main probiotic strain, even though there was others included in there. Okay, so that's where we're going. That's just the setup. I just wanted to let you know what exists out there. Is it harmful to take a probiotic? Probably not. It's a little gray on the preeclampsia thing, but maybe it has to do with when you take it with the Norwegian study saying maybe could reduce preeclampsia if you take it late in pregnancy and it could maybe increase gestational age. In other words, reduce preterm birth. If you take it early in pregnancy. I mean, Wow. I mean, you see how confusing this is? That leads us to Japan.
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My day kicks off with a refreshing Celsius energy drink, then straight to the gym, pre K pickup back home to meal prep. Time for my fire station shift. One more Celsius. Gotta keep the lights on when the three alarm hits.
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I'm ready.
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Celsius Live fit. Go grab a cold refreshing Celsius at your local retailer or locate now@celsius.com
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prevention of recurrent spontaneous preterm birth using probiotics results from a prospective single arm multi center trial. Now I love that the authors put that into their title. So it's not giving off any false errors, right? It's not an rct. It doesn't have a control group. So again, just take it for what it is. This does have some issues, but it needs to open up the door to this discussion. So here's what they did again. Using a chief strain of Clostridium, but Recrum. They wanted to see if the use of oral probiotics with that strain helped prevent recurrent spontaneous preterm birth in a subsequent pregnancy. No problem. Right? So this spanned 2021 to 2024 as the year range. This included pregnant women that were between 18 and 43 age with a history of spontaneous preterm birth. And then they were given oral probiotics and say take it as early as 10 to 14 weeks and they go all the way to 36 weeks and six days, which is the end of preterm labor spectrum. Okay, so we're trying to get to them to get to 37 and 0. The primary endpoint was a rate of recurrent spontaneous preterm birth under 37 weeks compared to to the historical rate of preterm birth in Japan's national database, which was 22.3%. Let me stop there for a minute. That's high, guys. Now again, that's pretty. That's pretty high, right? So according to the authors, the historical rate in Japan's national perinatal database for Preterm birth is 22.3%. Fine. I didn't know that. I don't know if you knew that. Just throwing that out there. The short of it is they also looked at the rate of spontaneous preterm birth before 34 weeks and some neonatal outcomes. So I just want to do this very quickly. Remember, there's got issues I Already told you the limitations. And I'm not advocating this for everybody because we definitely need better trials, which is what these authors say, as they should. But the short of it is, it was kind of impressive. Short answer is, yeah, it did something. It. It kind of worked. So among 343 enrolled patients, remember, not an RCT. Right. 343 said, I'll play along. 315. So that was 92% of the actual cohort actually went into the analysis. So very quickly, the recurrence rate of spontaneous Preterm birth under 37 weeks was 14.9%. Remember, the baseline was supposed to be 22. So this was 14.9% or, which is an obvious improvement compared to the historical control. Now, the secondary endpoint showed that the rate of spontaneous preterm birth before 34 weeks was 3.5%. Wow. So, yeah, it seems to be going in the right direction. Now, they also looked at patients whose preterm birth was at an extreme preterm ega. Remember, that's defined as less than 28 weeks. Among those patients with a history of extreme preterm Delivery, again, under 28 weeks, the rate of recurrent spontaneous preterm birth, that was extremely early, again, less than 28, was 1.5%. No stillbirths occurred, which is good. There was no serious adverse events. There was no real complications or side effects from taking these probiotics. So the authors are like, hey, maybe this thing works. So drastic improvement compared to a historical control benchmark. It's. I'm like, if you just read this, you're like, I'm in. However, however, with the limitations we've already discussed. Plus, remember, this was from 21 up to about 24. And there was no real obstetrical change during that time of management. But they say, I don't know. I mean, we don't really change the way that we took care of patients at that time. But we can't account for some clinician, you know, differences in care, some protocol changes for obstetrics that got us to a lower number. But just taken by itself without any kind of univariate or multivariate analysis, it seems intriguing. This was eye opening enough for the editors of the gray journal to go, yeah, we'll take it. Remember this gray. Not the pink journal, the gray journal. I would have said, man, you need to do some, at least a multivariable or univariable analysis. I don't know. It's got no control group. You know, go back to work on it. But it was accepted and it went into print. So it'll be out officially later on. This is just ahead of print. But yes, in this non controlled, single arm, non blinded study, those are all the limitations. Oral probiotics with clostridium specific strain of clostridium actually had wonderful reduction in not just overall preterm birth, but extreme early preterm birth under 28 weeks. Are we ready for this to be mainstream? No. Are major professional societies going to adopt this? No. But if a patient asks you, not for you necessarily to promote, but if a patient asks you what is the data for this, you go, well, we know no one gets sepsis. We know it can possibly help reduce gestational diabetes or help control gestational diabetes. Those are good. Not real sure if it helps with preterm birth, but maybe. Depends on which strain you take. And the risk of preeclampsia is gray. But maybe if you take it later on and not early on, then maybe it can help. While some studies say it can hurt slightly, increased the rate to 12%. So fascinating, fascinating that these authors said, well, let's try probiotics. Progesterone kind of went out the door. I am. Progesterone kind of went out the window. There's still a place for vaginal progesterone and I'm not going to get into that now. We've covered that many times on this show for prevention of recurrent preterm birth. But my goodness, in 2026, I mean this is where we're at. We're looking at probiotics for preterm birth because nothing else has really done what it's supposed to do. And it's fascinating. My our second child is a product of IAM progesterone. 250 milligrams of 17 hydroxyprogesterone. Weekly injections. We did those and then the data was like, well, never mind. Actually we can't replicate that. It probably is not that big of a deal. So that's gone. But again, there is still a place for a vaginal progesterone in the select patient based on cervical length and even that is controversial. If you want to go listen to all of that data, go back into our archive and you can find that. So in brief, we have covered a brand new, not yet released publication from the Gray Journal, which is prevention of recurrent spontaneous preterm birth using probiotics, results from a prospective single arm multi center trial. Is that fascinating or what? So, podcast family, I am going to leave you now because I have dropped now consumed all of my rice coffee, and my other little cup of theraflu is nice and cold. Maybe I'll go get some probiotics. What about that? All right, let's just stop there. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. Oh, geez, Michael. I only have one nostril. I feel terrible. All right, now that we've done all that, let's take it home. Foreign. This is Dr. Chapas, obgyn clinical pearls no spin podcast.