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Coitus late in pregnancy: Risk of preterm rupture of

amniotic sac membranes


Edem E. Ekwo, MD, MPH: Carol A. Gosselink, PhD: Robert Woolson, PhD,b
Atef Moawad, MD: and Cynthia R. Long, MSb
Chicago, Illinois, and Iowa City, Iowa

OBJECTIVES: Coitus with or without orgasm in late pregnancy is inconsistently associated with preterm
rupture of amniotic sac membranes. We tested the hypothesis that during late pregnancy sexual
behaviors including sexual positioning relate to the occurrence of premature rupture of membranes.
STUDY DESIGN: Women aged 15 to 45 years having preterm premature rupture of membranes, term
premature rupture of membranes, or preterm delivery without premature rupture of membranes were
matched singly by age, race, and parity to control women delivered of term infants. Information about six
sexual activities, obstetric history, cervical infections, smoking during pregnancy, and sociodemographic
information was obtained by face-to-face interview.
RESULTS: Only the male superior position was significantly associated with preterm premature rupture of
membranes (odds ratio 2.40, 95% confidence interval 1.16 to 4.97) and preterm delivery without
premature rupture of membranes (odds ratio 1.82, confidence interval 1.02 to 3.25) after confounding
variables were controlled for. No sexual positioning or sexual activities related significantly to term
premature rupture of membranes.
CONCLUSION: Most sexual positions and activities during late pregnancy are not associated with
adverse pregnancy outcomes. (AM J QBSTET GYNECOI. 1993;168:22-31.)

Key words: Coitus, late pregnancy, premature rupture of membranes

Investigation of risk factors associated with prema- membranes. 12• 14 Moreover, some of these studies have
ture rupture of membranes is important because of the small sample sizes, use inappropriate control groups, or
relationship of premature rupture of membranes to do not adjust for confounding variables relating sexual
preterm deliveryl.3 and perinatal infections!-6 A possi- behavior to premature rupture of membranes.
ble risk factor for premature rupture of membranes is Different positions used by partners during sexual
sexual intercourse during pregnancy. However, results intercourse and their role in causing premature rupture
from previous studies relating sexual behaviors during of membranes have not been examined. For example,
pregnancy to premature rupture of membranes are do couples who use the male superior position late in
inconsistent. Sexual intercourse during pregnancy has pregnancy have increased risk of premature rupture of
been associated with preterm delivery7. 8 and amniotic membranes as compared with those using the female
fluid infections. 9, 10 Orgasm with or without sexual in- superior position? Does achieving organism late in
tercourse also has been reported to relate to prematu~e pregnancy increase the risk for premature rupture of
rupture of membranes, especially during late pregnan- membranes? The current report is from a matched-pair
cy7, 8 and with a slow fetal heart rate." Yet other studies case-control study examining factors potentially associ-
have failed to find a relationship between sexual inter- ated with premature rupture of membranes, exploring
course and the occurrence of premature rupture of the hypothesis that sexual behaviors during pregnancy
and use of various positions during coitus relate to the
From the Department of Obstetrics and Gynecology and La Rabida occurrence of premature rupture of membranes.
Children's Hospital and Research Center, University of Chicago
PritzAer School of Medicine,· and the DIViSIOn of Biostatistics, De- Material and methods
partment of Preventive Medicine, University of Iowa School of Med-
icine.b Subjects. Those eligible for participation in the study
Supported fry the United States Public Health Service, Natwnal were female subjects aged 15 to 45 years and giving
Institute of ChIld Health and Human Development grant No.5 R01 birth to infants in the Departments of Obstetrics and
HD20361-02.
Received for publicatwn January 28, 1992; revised May 26, 1992; Gynecology at the University of Iowa Hospital and
accepted June 2, 1992. Clinics (1985 to 1986) and the Pritzker School of
Reprint requests: Edem E. Ekwo, MD, MPH, La Rabida ChIldren's Medicine, University of Chicago (1987 to 1990). Writ-
Hospital and Research Center, E. 65th St. and Lake MIChIgan,
Chicago, IL 60649. ten informed consent was obtained from each subject
6/1/39935 after the study'S purpose was explained. The study was

22 0002-9378/93 $1.00 + 0.20


Volume 168 Coitus late in pregnancy 23
Number I . Part 1

approved by the institutional review boards for human and alcohol or drug use, (4) complications occurring
experimentation at both study sites. during the index pregnancy, and (5) sexual history. The
Because risk factors for preterm premature rupture current report focuses on sexual history. Twenty-four
of membranes may differ from those for term prema- sexual experiences were selected initially, but after ex-
ture rupture of membranes, two study groups were tensive pretesting six of these sexual activity questions
defined. Also, prematurity itself may constitute a risk were retained because they were practiced most consis-
factor for premature rupture of membranes; therefore a tently and frequently by the study population.
third study group consisting of women who were deliv- The following instructions were read to the subjects
ered preterm without premature rupture of membranes from the questionnaire about their sexual behaviors.
was included. On the basis of study eligibility criteria, "In this section we are going to ask some questions
women were classified within 72 hours of delivery into about sexual experiences you mayor may not have had.
three study groups: (1) pre term premature rupture of This is a list of sexual experiences that some people
membranes if the amniotic sac membranes ruptured at have. (Subjects were then handed a card listing the
least 3 hours before the onset of sustained labor at =:; 36 sexual experiences and the response options.) We
weeks of gestation; (2) preterm delivery without prema- would like to know which of these experiences you had.
ture rupture of membranes if delivery occurred at =:; 36 We are particularly interested in the 6 months before
weeks of gestation after the onset of sustained sponta- you were pregnant, the whole time you were pregnant
neous labor and before rupture of amniotic sac mem- except for the last month of pregnancy, and during the
branes, and (3) term premature rupture of membranes last 4 weeks before the membranes ruptured (or you
if delivery occurred at ~ 37 weeks of gestation and the had your baby). For those you experienced, please
amniotic sac membranes spontaneously ruptured at tell me the letter that describes how often this hap-
least 3 hours before onset of sustained labor. Control pened."
women were delivered ~ 39 weeks of gestation after The interviewer then read each sexual experience.
onset of sustained labor before spontaneous or artificial Subjects stated the frequencies of their experiences for
rupture of amniotic sac membranes occurred. The def- periods corresponding to the 6 months before concep-
inition of controls avoided serious selection bias that tion and the time of pregnancy except for the last
would result from including women whose gestational month and the last 4 weeks before membrane rupture
age was actually =:; 36 weeks but was wrongly classified or delivery. The six sexual experiences listed on the
as 37 to 38 weeks. Excluding women at 37 to 38 weeks response cards were: (1) sexual intercourse with you
of gestation could potentially result in selection bias, lying on top of your partner (female superior), (2)
but such a selection bias is not as serious as the former sexual intercourse with your partner lying on top of you
bias. Control women were matched singly to cases by (male superior), (3) sexual intercourse with both of you
age (± 1 year), race, and parity (0, 1, 2 to 5, ~ 6). The lying side by side, (4) sexual intercourse with vaginal
diagnosis of premature rupture of membranes was entry from the rear, (5) orgasm (coming) with or with-
made by direct observation of discharged fluid from the out sexual intercourse, and (6) kissing on the mouth.
vagina on careful speculum examination, a positive The frequences of individual experiences were catego-
Nitrazine paper test, and positive fernings . Gestational rized as follows: never, one or two times a month, three
age was estimated from last menstrual cycle, by ultra- or four times a month, two or three times a week, four
sonography, or by physical examination of the infact to six times a week, and daily.
with the criteria of Dubowitz et al. 15 Eligible mothers The interviewer recorded responses to each question .
were enrolled only once in the study, irrespective of If a subject did not understand a question, the inter-
whether they had more than one delivery during the viewer again read it aloud without further elaboration.
study period. Subjects were excluded from the study for Subjects were informed they could refuse to answer any
these reasons: (1) a chronic debilitating disease (e.g., part or all of the questions if they felt uncomfortable
cystic fibrosis or chronic heart failure), (2) exposure to with the intimate details of their sexual experiences.
chemotherapy or radiation therapy during pregnancy, Medical information. Medical data abstracted from
(3) inability to respond to the interview survey, or (4) mothers' and infants' charts were used to cross-check
multiple births at the index pregnancy. the accuracy of responses obtained during the inter-
Interviews. All subjects were interviewed within 72 view. Information on medical matters from the chart
hours of delivery. Interviews were conducted by an was always assumed to be more accurate than that
extensively trained interviewer with 6 years' experience obtained from the mother; the reverse was assumed for
in interviewing techniques. A structured standardized sociodemographic and life-style information.
questionnaire was used to obtain information in five Abstracted data included obstetric history, medica-
primary categories: (1) sociodemographic variables, (2) tions taken during pregnancy, complications of preg-
gynecologic history, (3) smoking, caffeine consumption, nancy, culture results, and history of infections during
24 Ekwo et al. January 1993
Am J Obstet Gynecol

pregnancy and the immediate postpartum period (48 branes served as the referent group. Women having
hours) for mothers and infants. both previous preterm and term premature rupture of
Clinical chorioamnionitis was defined by the criteria membranes were too few (n = 13) to form a separate
of Gibbs et al. 16 and consisted of two or more of the group and were classified as having preterm premature
following: fever ;:: 38° C, maternal and fetal tachycardia, rupture of membranes since we hypothesized that a
uterine tenderness, foul odor, and peripheral leukocy- history of preterm rather than term premature rupture
tosis. Urinary tract infection was documented from of membranes would be a more predictive variable in
urine culture ;:: 100,000 single species of organisms per relation to preterm premature rupture of membranes
milliliter anytime during the pregnancy. Cervical in subsequent pregnancy outcome. Previous cervical
Chlamydia trachomatis infection was evidenced by cervical surgery, history of urinary tract infection during the
culture by the standard culture technique. I7 Endocervi- index pregnancy, and presence of chorioamnionitis in
cal calcium-alginated swabs were placed in sucrose- the index pregnancy were each dichotomized. Cervical
phosphate buffer glutamate transport media and im- infection with chlamydia was coded as positive cul-
mediately kept on wet ice until inoculated within 4 ture = 1 and negative culture = O. However, to prevent
hours of collection on cycloheximide-treated McCoy women who had no culture or whose results could not
cells for recovery of C. trachomatis. A separate endocer- be traced from being eliminated from the analysis, a
vical swab was directly inoculated onto a Thayer-Martin dummy variable was constructed to reflect situations in
medium for recovery of Neisseria gonorrhoeae. which no culture was performed (coded as 1) versus
Data analysis. Sociodemographic variables were an- negative culture (coded as 0). When either one of these
alyzed univariately; the p values for the matched-pair X2 two chlamydia variables showed a significant relation-
test are reported. I8 Sexual experiences were recoded as ship to the outcome, both were retained in the final
dichotomous variables (no = 0, if the woman did not model.
have the particular experience; yes = 1, if she had the
experience). Conditional logistic regression analyses Results
with the use of maximum likelihood parameter esti- During the 4 1/2-year catchment period 1353 mothers
mates were used to determine whether sexual experi- who met the criteria for enrollment as either case or
ences for matched case and control pairs differed. control were approached. Ninety-nine of these women
Separate logistic regressions were performed for each refused to participate primarily because they did not
study group on every sexual behavior; the unadjusted want to take the time to be interviewed. Appropriate
odds ratio and 95% confidence intervals are reported. matches could not be found for 78 cases generally
The independent effects of variables potentially con- involving older women with high parity or from racial-
founding the relationship of sexual intercourse to preg- ethnic groups that could not be matched. Thus a total
nancy outcome, such as marital status, history of having of 588 cases and their matched controls, or 1176
premature rupture of membranes and delivery in a participants, completed the study. Of these, 19 women
previous pregnancy, smoking history, history of any refused to answer any of the sexual questions. They and
operation on the cervix, or urinary tract, cervical, or their respective matches were eliminated from all fur-
intraamniotic infection during index pregnancy, were ther analysis. These women did not differ from the
analyzed in the same manner. Multiple conditional participants by mean age, years of education, or parity.
logistic regression analyses were performed to examine The distribution of the three variables (age, parity,
the independent effects of risk factors and to adjust and race) used for matching cases to controls in each
simultaneously for such possible confounding effects. 18 study group shows that cases and controls were appro-
The independent variables controlled for in the anal- priately matched (Table I). In the preterm premature
ysis were coded as follows: Three levels of household rupture of membranes group the mean maternal age
exposure of the subject to cigarette smoke were created, for cases was 25.1 ± 5.4 compared with 25.2 ± 5.2
the referent group being the household where no one years for controls and parity was 1.3 ± 1.4 versus
smoked. These three levels of exposure included house- 1.2 ± 1.3 for cases compared with controls. The mean
holds in which other individuals but not the study of the differences between case-control pairs in either
subject smoked, households where the study subject age (- 0.06 ± 0.07, P = 0.44) or parity (0.07 ± 0.05,
alone smoked, and those where both the subject and P = 0.14) was not statistically different from O. For
other household members smoked. Previous experi- preterm delivery without premature rupture of mem-
ence with premature rupture of membranes was coded branes and term premature rupture of membranes
to two levels indicating whether the women had any groups, the mean of the differences between case-
previous pregnancies complicated by either preterm or control pair's age and parity was similarly not statisti-
term premature rupture of membranes. Women having cally different from 0, indicating an appropriate match
no previous experience of premature rupture of mem- on these variables. The percentage of nonwhite moth-
Volume 168 Coitus late in pregnancy 25
l\ umber I. Part I

ers was higher for the preterm delivery without prema- Table I. Distribution of matched variables for
ture rupture of membranes group than for the other cases and controls by study group
two groups.
Cases Controls
The percent distribution of sociodemographic vari-
ables for preterm premature rupture of membranes Preterm delzvery WIth premature rupture of membranes
Age (yr)
and preterm delivery without premature rupture of :519 29 (16.2) 23 (12.9)
membranes groups is shown in Table II. Controls were 20-24 57 (31.8) 60 (33.5)
significantly more educated than cases among the pre- 25-29 51 (28.5) 56 (31.3)
~30 42 (23.5) 40 (22.3)
term premature rupture of membranes group, with Parity
31.4% of controls versus 21.8% of controls having some o 63 (35.2) 63 (35.2)
college or more education. A significantly higher per- 1 53 (29.6) 53 (29.6)
2-3 47 (26.3) 52 (29.9)
centage of preterm premature rupture of membranes 4-5 15 (8.4) 10 (5.6)
cases (53.3%) than controls (46.4%) relied on Medicaid ~6 1 (0.5) 1 (0.5)
to cover their pregnancy-related health-care costs. Sig- Race
White 73 (40.8) 73 (40.8)
nificantly more term premature rupture of membranes Nonwhite 106 (59.2) 106 (59.2)
cases than controls were employed outside the home Term deltvery with premature rupture of membranes
(Table III). However, the percentage distribution of Age (yr)
:5 19 43 (20.5) 43 (20.5)
most of the sociodemographic variables for controls 20-24 77 (36.7) 76 (36.2)
and cases was not statistically different. 25-29 50 (23.8) 51 (24.3)
Sexual experiences of cases and controls during the 4 ~30 40 (19.0) 40 (19.0)
Parity
weeks before delivery were examined (Table IV). The 0 108 (51.4) 107 (51.0)
male superior position was reported most frequently by 1 59 (28.1) 59 (28.1)
all case groups and was used by 13% to 31% of the 2-3 38 (18.1) 38 (18.1)
4-5 5 (2.4) 6 (2.8)
women during sexual intercourse. Control subjects ~6 0(0.0) 0(0.0)
most often used either the male superior or side-by-side Race
position during intercourse. From 22% to 33% of case White 88 (41.9) 88 (41.9)
Nonwhite 122 (58.1) 122 (58.1)
and control women achieved orgasm during inter- Preterm delzvery WIthout premature rupture of membranes
course. Age (yr)
The frequencies of sexual experiences throughout :5 19 60 (33.3) 60 (33.3)
20-24 57 (31.7) 58 (32.3)
pregnancy were lower than during the 6 months before 25-29 41 (22.8) 42 (23.4)
conception and continued to decline in the last 4 weeks ~30 22 (12.2) 20 (1Ll)
of gestation. The average number of times per week Parity
o 80 (44.4) 80 (44.4)
cases and controls reported using the male superior 1 49 (27.2) 49 (27.2)
position during sexual intercourse is shown in Table V. 2-3 42 (23.3) 46 (25.6)
The frequency of this most common position declines 4-5 9 (5.1) 5 (2.8)
~6 0(0.0) 0(0.0)
as gestation progresses. Repeated-measures analysis of Race
variance showed no significant differences in frequen- White 41 (22.8) 41 (22.8)
cies between cases and controls in the preterm without Nonwhite 139 (77.2) 139 (77.2)
premature rupture of membranes and term premature
rupture of membranes groups. Significant differences
in average frequency of engaging in coitus with the
male superior position did occur between preterm pre- univariate conditional logistic regression analysis of the
mature rupture of membranes cases and controls relationship between sexual activities and pregnancy
(P = 0.002); however, the frequencies declined in the outcome in the 4 weeks preceding delivery showed that
same manner for cases and controls from 6 months the male superior position (odds ratio 1.84, confidence
before pregnancy to the duration of pregnancy except interval 1.05 to 3.22) and orgasm with or without sexual
for the last month (p = 0.66), and from the duration of intercourse (odds ratio 1. 91, confidence interval 1.12 to
pregnancy except for the last month to the last 4 weeks 3.23) were associated with statistically significant risk of
of pregnancy (p = 0.23). The frequency of couples pre term rupture of amniotic sac membranes (Table VI).
kissing each other should not be affected appreciably by Vaginal entry from the rear and female superior posi-
pregnancy. Indeed, the percentage of women report- tions showed a slight but not statistically significant
ing kissing remained high among case and control trend toward increased risk. The male superior position
groups. was not associated with a statistically increased risk of
Examination of unadjusted odds ratios and 95% term premature rupture of membranes (odds ratio
confidence intervals for each variable by means of 1.59, confidence interval 0.93 to 2.71), although there
26 Ekwo at al. January 1993
Am J Obstet Gynecol

Table II. Percent distribution of sociodemographic variables for cases and controls at index pregnancy:
Preterm premature rupture of membranes and preterm delivery without premature rupture
of membranes
Preterm premature Preterm delivery without
rupture of membranes premature rupture of membranes

Cases Controls Cases Controls


(n = 179) (n = 179) (n = 180) (n = 180)
Variable (%) (%) Significance * (%) (%) Significance*
Education
< High school 30.7 25.1 P = 0.002 44.4 39.4 P = 0.36
High school 47.5 37.4 32.8 32.8
> High school 21.8 37.4 22.8 27.8
Marital status
Not married 49.2 50.8 P = 0.69 62.8 60.6 P = 0.62
Married 50.8 49.2 37.2 39.4
Household income
~$25,OOO 17.9 18.4 P = 0.63 10.6 13.9 P = 0.44
Refused or do 5.6 3.9 7.2 10.6
not know
$10,000-$24,999 21.2 25.7 21.7 21.1
<$10,000 55.3 51.9 60.6 54.4
Insurance
Self-pay 11.7 19.5 P = 0.03 10.0 11.1 P = 0.70
Medicaid 53.6 46.4 62.8 59.4
Third-party 34.6 43.1 27.2 29.4
Employment
Unemployed 73.2 72.6 P = 0.89 81.7 80.0 P = 0.64
Employed 26.8 27.4 18.3 20.0

*p Value of matched X2 calculated by k x k contingency tables, where k is number of levels of the variable.

Table III. Percent distribution of the pre term delivery without premature rupture of
sociodemographic variables for cases membranes group, however, the male superior position
and controls at index pregnancy: Term proved to be significantly associated with the risk of
premature rupture of membranes pereterm delivery without premature rupture of mem-
branes (odds ratio 2.05, confidence interval 1.20 to
Cases Controls
(n = 210) (n = 210) 3.50). Orgasm was not associated with increased risk for
Variable (%) (%) Significance preterm delivery without premature rupture of mem-
Education branes.
< High school 25.2 24.3 P = 0.84 Univariate analyses of the confounding variables
High school 35.7 34.8 likely to modifY the association of sexual activities with
> High school 39.1 40.9
Marital status pregnancy outcome consisting of preterm premature
Not married 44.3 43.8 P = 0.90 rupture of membranes or preterm delivery without
Married 55.7 56.2 premature rupture of membranes are shown in Table
Household income
VII. Among women with preterm premature rupture of
~$25,OOO 19.5 20.5 P = 0.73
Refused or do 6.2 5.2 membranes, variables with signficant unadjusted odds
not know ratios included previous history of pre term premature
$10,000-$24,999 21.9 25.2
<$10,000 52.4 49.1 rupture of membranes (odds ratio 4.64, confidence
Insurance interval 2.02 to 10.70) or term premature rupture of
Self-pay 19.5 21.9 P = 0.19 membranes (odds ratio 2.58, confidence interval 1.29
Medicaid 47.2 41.9
Third-party 33.3 36.2 to 5.16), urinary tract infection during index pregnancy
Employment (odds ratio 3.08, confidence interval 1.65 to 5.75),
Unemployed 65.2 73.8 P = 0.04 history of cervical surgery (odds ratio 1.83, confidence
Employed 34.8 26.2
interval 1.03 to 3.26), subject alone smoked (odds ratio
*p Value of matched X· calculated by k x k contingency 4.24, confidence interval 1.79 to lO.03), or she and
tables, where k is number of levels of the variable. others in the household smoked (odds ratio 2.06, con-
fidence interval 1.20 to 3.54), or chorioamnionitis dur-
was a trend in that direction. None of the other five ing index pregnancy (odds ratio 8.5, confidence inter-
sexual positions was associated with increased risk of val 1.96 to 36.79). The odds for preterm premature
term premature rupture of membranes, and therefore rupture of membranes of 4.24 when the mother alone
no further analysis of this group was undertaken. For smoked were less than the odds of 2.06 when she and
Volume 168 Coitus late in pregnancy 27
Number 1, Part I

Table IV. Frequency distribution of sexual positions, activities, and orgasm during last 4 weeks
of pregnancy
Study group

Preterm delzvery with Term delivery with Preterm delivery without


premature rupture premature rupture premature rupture
of membranes of membranes of membranes

Cases Controls Cases Controls Cases Controls


(n = 179) (n = 179) (n = 210) (n = 210) (n = 180) (n = 180)
Sexual
actiVity No.
I % No. I % No.
I % No. I % No.
I % No. I %
Male superior
Yes 49 27.4 33 18.4 41 19.5 28 13.3 54 30.0 33 18.3
No 130 72.6 146 81.6 169 80.5 182 86.7 126 70.4 147 81.7
Female superior
Yes 30 16.8 22 12.3 26 12.4 30 14.3 23 12.9 23 12.8
No 149 83.2 157 87.7 184 87.6 180 85.7 157 87.2 157 87.2
Couples lying side by side
Yes 39 21.8 34 19.0 36 17.1 42 20.0 35 19.4 30 16.7
No 140 78.2 145 81.0 174 82.9 168 80.0 145 80.6 150 83.3
Vaginal entry from rear
Yes 25 14.0 19 10.6 20 9.5 23 10.9 20 ILl 19 10.6
No 154 86.0 160 89.4 190 90.5 187 89.1 160 88.9 161 89.4
Orgasm With or without coztus
Yes 58 32.4 39 21.8 52 24.8 49 23.3 52 28.9 55 30.6
No 121 67.6 140 78.2 158 75.2 161 76.7 128 7Ll 125 69.4
Kissing*
Yes 138 77.5 140 78.2 166 79.4 165 78.9 140 77.8 131 72.8
No 40 22.5 39 21.8 43 20.6 44 21.1 40 22.2 49 27.2

*Some responses are missing.

Table V. Distribution of average times per week of male superior position during coitus for 6 months
before pregnancy, throughout pregnancy except for last month, and during last 4 weeks
of pregnancy
Average times per week

Preterm delivery With Preterm delivery Without Term delivery wzth


premature rupture premature rupture premature rupture
Male superior of membranes of membranes of membranes
position
dUring coitus Cases
I Controls Cases I Controls Cases I Controls
During 6 mo before pregnancy 2.24 1.85 2.00 2.16 1.93 1.88
Throughout pregnancy except 1.37 0.88 0.98 1.21 1.05 0.90
for last month
During last 4 wk of pregnancy 0.57 0.30 0.34 0.32 0.18 0.15

others in the household smoked. A majority of the case history of previous preterm premature rupture of mem-
(40/63, 63.5%) and control (27/44, 61.4%) mothers branes (odds ratio, 2.83, confidence interval 1.11 to
living in households where others smoked were them- 7.22) or previous cervical surgery (odds ratio 2.50,
selves light smokers « 10 cigarettes per day). Thus confidence interval 1.35 to 4.65), smoking by the sub-
their total exposure to cigarette smoke could have been ject and other household members (odds ratio 2.35,
less than that for mothers who were the only smokers in confidence interval 1.31 to 4.21), and cervical chlamy-
their households. This no doubt accounts for a lack of dia infection during pregnancy (odds ratio 3.67, confi-
incremental risk for smoking mothers living with other dence interval 1.02 to 13.14). Chorioamnionitis was not
smokers, compared with mothers who alone smoked. a significant risk factor and was excluded from subse-
Preterm premature rupture of membranes cases had quent multivariate analysis.
3.33 odds of cervical chlamydia infection, but this was The relationship of sexual intercourse in the male
not significant at the 0.05 level. superior position to preterm premature rupture of
Variables significantly associated with preterm deliv- membranes was examined by multiple conditional lo-
ery without premature rupture of membranes included gistic regression analysis after confounding variables
28 Ekwo et al. January 1993
Am J Obstet Gynecol

Table VI. Conditional logistic analysis of relationship of sexual activities in last 4 weeks of gestation to
pregnancy outcome
Preterm delivery with Term delivery with Preterm delivery wIthout
premature rupture premature rupture premature rupture
of membranes of membranes of membranes

Sexual activity
Unadjusted
odds ratio
I 95%interval
Confidence Unadjusted
odds ratio
I 95%interval
Confidence Unadjusted
odds ratio
I 95%interval
Confidence

Female superior 1.50 0.80-2.82 0.88 0.41-1.67 1.08 0.51-2.29


Male superior 1.84 1.05-3.22 1.59 0.93-2.71 2.05 1.20-3.50
Couples lying side 1.19 0.71-1.98 0.84 0.48-1.36 1.19 0.71-2.01
by side
Vaginal entry from 1.40 0.72-2.72 0.88 0.43-1.79 1.06 0.55-2.01
rear
Orgasm with or 1.91 1.12-3.23 1.12 0.70-1.79 0.93 0.60-1.41
without inter-
course

Table VII. Conditional logistic analysis of potential confounders of relationship of sexual activities in last
4 weeks of gestation to pregnancy outcome
Preterm delivery WIth Preterm delivery WIthout
premature rupture of membranes premature rupture of membranes

Individual 95% Confidence Individual 95% Confidence


Potential confounder odds ratIO I znterval odds ratio I interval
History of premature rupture of membranes
Preterm 4.64 2.02-10.70 2.83 1.11-7.22
Term 2.58 1.29-5.16 0.99 0.46-2.13
Family history of premature 0.72 0.44-1.20 0.79 0.46-1.37
rupture of membranes
Urinary tract infection 3.08 1.65-5.75 1.30 0.78-2.14
History of cervical surgery 1.83 1.03-3.26 2.50 1.35-4.65
Smoking in household
Others alone smoke 1.06 0.60-1.89 1.76 0.99-3.12
Subject alone smokes 4.24 1.79-10.03 1.47 0.58-3.74
Subject and others smoke 2.06 1.20-3.54 2.35 1.31-4.21
Chlamydia infection
Positive 3.33 0.92-12.11 3.67 1.02-13.14
Not available 1.00 0.56-1.78 0.63 0.39-1.22
Chorioamnionitis 8.50 1.96-36.79 1.00 0.25-3.99

were controlled for (Table VIII). Variables having po- The relationship of orgasm with or without sexual
tentially significant confounding effects at the univari- intercourse to preterm premature rupture of mem-
ate level were included in the analysis. However, no branes shows a trend toward significance after con-
other sexual experience variables were included be- founding variables were controlled for (Table IX). The
cause they did not further contribute to the fit of the odds ratio for the association was 1.92 (confidence
model. As a consequence of the large number of po- interval 1.02 to 3.61) when urinary tract infection,
tentially confounding variables, two models were built previous cervical surgery, and household smoking ex-
to explore the effects of controlling for infection in the posure were included (model 1). However, the relation-
analysis. With history of urinary tract infection included ship between orgasm and preterm premature rupture
in the model, the independent association of the male of membranes was strong, although no longer signifi-
superior position to preterm premature rupture of cant (odds ratio 1.93, confidence interval 0.97 to 3.86)
membranes remained statistically significant (odds ratio when chlamydia and chorioamnioftitis were also in-
2.63, confidence interval 1.30 to 5.S1). When chlamydia cluded (model 2). The p values for the relationship of
infection and clinical chorioamnionitis were added to orgasm to preterm premature rupture of membranes
the model, the association between sexual intercourse were 0.04 and 0.06 for models 1 and 2, respectively.
and male superior position was still significant, al- Similarly, a statistically significant association was
though the magnitude of the odds ratio decreased to found between sexual intercourse in the male superior
2.40 (confidence interval 1.16 to 4.97). position and preterm delivery without premature rup-
Volume 168 Coitus late in pregnancy 29
Jl<umber I, Part I

Table VIII. Conditional multiple logistic regression analysis of relationship of male superior sexual
position to preterm delivery with premature rupture of amniotic sac membranes after confounding
variables are controlled for
Modell Model 2

Adjusted 95% Confidence Adjusted 95% Confidence


Vanable odds ratIO I interval odds ratIO
I interval

Male superior position 2.63 1.30-5.31 2.40 1.16-4.97


Previous premature rupture of membranes
Preterm 7.32 2.70-19.84 7.51 2.67-21.12
Term 3.10 1.34-7.14 3.15 1.33-7.45
Urinary tract infection 4.56 2.13-9.77 5.17 2.24-11.97
Previous cervical surgery 2.48 1.15-5.36 2.02 0.92-4.46
Household smoking
Others alone smoke 1.01 0.51-1.97 0.86 0.42-1.77
Subject alone smokes 7.28 2.50-21.24 6.60 2.18-19.99
Subject and others smoke 2.41 1.27-4.57 2.28 1.15-4.55
Chlamydia culture
Positive 7.53 1.18-48.17
Not available 1.42 0.66-3.03
Chorioamnionitis 8.18 1.65-40.51

Table IX. Conditional multiple logistic regression analysis of relationship of orgasm with or without sexual
intercourse to preterm delivery with premature rupture of amniotic sac membranes after
confounding variables are controlled for
Modell Model 2

1
Adjusted 95% Confidence Adjusted 95% Confidence
Vanable odds ratio I tnterval odds ratIO interval

Orgasm 1.92 1.02-3.61 1.93 0.97-3.86


Previous premature rupture of membranes
Preterm 5.62 2.16-14.64 5.82 2.16-15.69
Term 2.98 1.32-6.79 3.01 1.29-7.03
Urinary tract infection 4.49 2.12-9.51 5.01 2.20-11.44
Previous cervical surgery 2.09 1.00-4.30 1.72 0.79-3.70
Household smoking
Others alone smoke 1.16 0.59-2.27 0.99 0.48-2.06
Subject alone smokes 6.78 2.42-19.02 6.38 2.16-18.86
Subject and others smoke 2.37 1.27-4.46 2.32 1.17-4.60
Chlamydia culture
Positive 8.16 1.29-51.49
Not available 1.43 0.67-3.02
Chorioamnionitis 8.59 1.75-42.05

ture of membranes (Table X). The odds ratio was 1.84 branes and delivery more often used the male superior
(confidence interval 1.05 to 3.26) without chlamydia position than did their matched controls but the differ-
infection (model I) and was 1.82 (confidence interval ences were not statistically significant. Only women
1.02 to 3.25) when chlamydia infection was included delivered of preterm infants after premature rupture of
(model 2). Hence the relationship remains in both membranes experienced more frequent orgasm with or
models. without sexual intercourse as compared with control
women during the last 4 weeks of pregnancy.
Comment Even after adjustment for important confounding
Women delivered preterm after premature rupture covariates such as presence of urinary tract infection
of membranes and with preterm delivery without pre- during pregnancy, previous history of premature rup-
mature rupture of membranes had a statistically signif- ture of membranes, household exposure to cigarette
icant exposure rate as compared with that of their smoke during pregnancy, chlamydia infection, and
matched controls for the male superior position during chorioamnionitis, the increased risk of exposure to the
sexual intercourse in the last 4 weeks of pregnancy. male superior position among women with preterm
Women who had term premature rupture of mem- premature rupture of membranes and delivery still
30 Ekwo et al. January 1993
Am J Obstet Gynecol

Table X. Conditional multiple logistic regression analysis of relationship of male superior sexual position
to preterm delivery without premature rupture of amniotic sac membranes after confounding
variables are controlled for
Modell Model 2

I I
Adjusted 95% Confidroce Adjusted 95% Confidroce
Variable odds ratio interval odds ratio internal

Male superior position 1.84 1.05-3.26 1.82 1.02-3.25


Previous premature rupture of membranes
Pre~~ 2.M 1.04-7.92 2.60 0.91-7.40
Te~ 0.95 0.41-2.19 0.93 0.40-2.18
Previous cervical surgery 2.76 1.39-5.48 2.93 1.45-5.90
Household smoking
Others alone smoke 1. 70 0.93-3.08 1.57 0.85-2.85
Subject alone smokes 1.35 0.50-3.66 1.43 0.53-3.89
Subject and others smoke 2.23 1.20-4.14 2.27 1.20-4.28
Chlamydia culture
Positive 4.12 1.08-15.76
Not available 0.79 0.42-1.49

remained significant. The association between orgasm sexual activity with term premature rupture of mem-
and pre term premature rupture of membranes with branes and delivery and may explain part of the incon-
delivery was no longer statistically significant, although sistencies found in previous studies where preterm
the trend remained strong, after these same confound- premature rupture of membranes was not always differ-
ing variables were controlled for. entiated from that at term.
Both case and control women reported declines in Findings in the current study suggest that several
their sexual experiences from before pregnancy to 4 sexual positions during pregnancy are not associated
weeks before delivery. This decline in sexual experi- with increased risk for premature rupture of mem-
ences during pregnancy is consistent with past re- branes. However, the frequently used sexual position
search,19-21 although some have reported an increase in with the male partner in the superior position increases
sexual activity during pregnancy.22 The importance of the risk for preterm rupture of amniotic sac mem-
sexual positioning during intercourse in pregnancy and branes. Because the male superior position is also
its relationship to pregnancy outcome have not been associated with increased risk of premature delivery
previously explored. Prior studies have indicated incon- without premature rupture of membranes, however,
sistent statistical association between sexual intercourse trauma during sexual intercourse alone cannot be in-
and premature rupture of membranes. In a study of voked as a major etiologic factor for preterm premature
500 women, Pugh and Fernandez2' found an average rupture of membranes.
time between coitus and admission for delivery to be 52 Some researchers have found that orgasm with or
days but the average time for patients with premature without sexual intercourse is associated with premature
rupture of membranes was 42 days. They found no rupture of membranes. 25 • 26 Orgasms resulting from
statistical association between premature rupture of masturbation have been reported to be stronger than
membranes and coitus. Perkins 24 also failed to show orgasms resulting from sexual intercourse.22 Goodlin et
association of coitus with premature rupture of mem- al. B implied that toward the latter stages of pregnancy
branes after controlling for the interval between coitus orgasm may produce uterine contractions strong
and labor onset. Naeye and Peters 5 showed no increase enough to induce labor, although other researchers
in risk for premature rupture of membranes among have thought this unlikely. Wagner et al.,' who studied
women who had sexual intercourse one or two times 19 women delivered prematurely matched to control
during the month of delivery . In a study from Israel" mothers delivered at term, found that the frequency of
no association was found between coitus in the last 3 orgasm with or without sexual intercourse was higher
months of pregnancy and either premature rupture of for the premature group than the control group. In the
membranes or low birth weight. In none of these current study women in the preterm premature rupture
studies were sexual positions investigated. Further, of membranes group more frequently had orgasms
most studies have not differentiated between premature during the last 4 weeks of pregnancy than did controls.
rupture of membranes at term and in association with This was not true for either the women giving birth to
premature delivery. The current study shows no asso- preterm infants without premature rupture of mem-
ciation between sexual position or the frequency of branes or mothers delivered at term after premature
Volume 168 Coitus late in pregnancy 31
Number 1, Part 1

rupture of membranes. This would indicate that orgasm 3. Garite TJ. Premature rupture of the membranes: the
may have an indirect relationship to preterm prema- enigma for the obstetrician. AM] OBSTET GYNECOL 1985;
151:1001-5.
ture rupture of membranes by propagating nascent 4. Romero R, Quintero R, Oyarzun E, et al. Intraamniotic
intraamniotic infection, disseminating existing ascend- infection and the onset of labor in pre term premature
ing cervical infections or infectious products. Orgasm rupture of the membranes. AM ] OBSTET GYNECOL 1988;
159:661-6.
and the resultant uterine contraction are inconsistently 5. Naeye RL, Peters EC. Causes and consequences ofprema-
associated with deceleration in fetal heart rate, but their ture rupture of fetal membranes. Lancet 1980; 1: 192-4.
relationship to onset of labor is enigmatic. II 6. Garite T], Freeman RK. Chorioamnionitis in the preterm
gestation. Obstet Gynecol 1982;59:539-45.
Why the male superior position should be associated 7. Wagner NN, Butler ]C, Sanders ]P. Prematurity and or-
with an increased risk of premature rupture of mem- gasmic coitus during pregnancy: data on a small sample.
branes and preterm delivery is uncertain. The observed Fertil Steril 1976;27:911-5.
8. Goodlin RC, Keller DW, Raffin M. Orgasm during late
relationship may not be causal but may reflect the pregnancy: possible deleterious effects. Obstet Gynecol
indirect effects of other, yet unknown factors. A possible 1971 ;38:916-20.
explanation is that the pressure placed on the woman 9. Naeye RL. Coitus and associated amniotic fluid infections.
N Engl] Med 1979;301:1198-200.
and the resultant trauma caused by movements may 10. Naeye RL, Ross S. Coitus and chorioamnionitis: a pro-
make this position unsuitable during the later months spective study. Early Hum Dev 1982;6:91-7.
of pregnancy. Various cervical infections may play a II. Goodlin RC, Schmidt W, Creevy DC. Uterine tension and
fetal heart rate during orgasm. Obstet Gynecol 1972;39:
role. This is supported by recent studies showing that 129-7.
vaginal colonization with bacterial flora and the occur- 12. Rayburn WF, Wilson EA. Coital activity and premature
rence of chorioamnionitis are associated with prema- delivery. AM] OBSTET GYNECOL 1980;137:972-4.
13. Mills ]L, Harlap S, Harley EE. Should coitus late in
ture rupture of membranes and premature delivery.4. 27 pregnancy be dhcouraged? Lancet 1981; 1: 136-8.
Whether bacterial infection of fetal membranes and 14. Georgakopoulos PA, Dodos D, Mechleris D. Sexuality in
chorioamnionitis precede or follow fetal membrane pregnancy and premature labor. Br ] Obstet Gynaecol
1984;91:891-3.
rupture is uncertain. Amniotic fluid from women with 15. Dubowitz LMS, Dubowitz V, Goldberg C. Clinical assess-
intact fetal membranes but in premature labor has ment of gestational age in the newborn infants. ] Pediatr
been shown to grow vaginal flora, indicating that pri- 1970;77: 1-10.
16. Gibbs RS, Castillo MS, Rodgers PJ. Management of acute
mary ascending infection does occur!8 Whether these chorioamnionitis. AM] OBSTET GYNECOL 1980;136:709-13.
events relate to sexual intercourse and the frequency of 17. Yoder BL, Stamm WE, Koester CM, Alexander ER. A
sexual experiences is debatable. However, these and microtest procedure for isolating of C. trachomatts. ] Clin
MicrobioI1981;13:1036-9.
other data indicate that most sexual experiences and 18. Breslow NE, Day NE. Volume 1: statistical methods in
positioning with the exception of the male superior cancer research-the analysis of case-control studies.
position are not harmful during pregnancy. Lyon, France: International Agency on Cancer, 1980.
19. Morris NM. The frequency of sexual intercourse during
We should also point out that no combinations of pregnancy. Arch Sex Behav 1975;4:501-7.
sexual experiences were examined. Therefore it is pos- 20. Perkins RP. Sexuality in pregnancy: what determines be-
sible that some relationships among the sexual posi- havior? Obstet Gynecol 1982;59:189-98.
21. Solberg DA, Butler ], Wagner NN. Sexual behavior in
tions used during gestation may influence pregnancy pregnancy. N Engl] Med 1973;288:1098-103.
outcome. We hope to explore these relationships in 22. Masters WH, Johnson VE. Human sexual response.
future analyses. Boston: Little Brown, 1966.
23. Pugh WE, Fernandez FL. Coitus in late pregnancy. Obstet
In conclusion, there is no consistent evidence that Gynecol 1953;2:636-42.
most sexual positions and activities other than the male 24. Perkins RP. Sexual behavior and response in relation to
superior position during pregnancy may be harmful. complications of pregnancy. AM] OBSTET GYNECOL 1979;
134:498-505.
Our results should be confirmed by subsequent studies 25. Pugh WE. Coitus and late pregnancy, delivery, and the
before broad-based recommendations for sexual prac- puerperium. AM] OBSTET GYNECOL 1952;64:333-9.
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2:646.
27. Gravett MG, Nelson HP, DeRouen T, Critchlow C, Eschen-
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