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Romero R, Conde‐Agudelo A, El‐Refaie W, Rode L, Brizot ML, Cetingoz E, Serra V, Da Fonseca E, Abdelhafez MS, Tabor A, Perales A, Hassan SS, Nicolaides KH. Vaginal progesterone decreases preterm birth and neonatal morbidity and mortality in women with a twin gestation and a short cervix: an updated meta-analysis of individual patient data. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:303-314. [PMID: 28067007 PMCID: PMC5396280 DOI: 10.1002/uog.17397] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 12/23/2016] [Accepted: 12/29/2016] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To assess the efficacy of vaginal progesterone for the prevention of preterm birth and neonatal morbidity and mortality in asymptomatic women with a twin gestation and a sonographic short cervix (cervical length ≤ 25 mm) in the mid-trimester. METHODS This was an updated systematic review and meta-analysis of individual patient data (IPD) from randomized controlled trials comparing vaginal progesterone with placebo/no treatment in women with a twin gestation and a mid-trimester sonographic cervical length ≤ 25 mm. MEDLINE, EMBASE, POPLINE, CINAHL and LILACS (all from inception to 31 December 2016), the Cochrane Central Register of Controlled Trials, Research Registers of ongoing trials, Google Scholar, conference proceedings and reference lists of identified studies were searched. The primary outcome measure was preterm birth < 33 weeks' gestation. Two reviewers independently selected studies, assessed the risk of bias and extracted the data. Pooled relative risks (RRs) with 95% confidence intervals (CI) were calculated. RESULTS IPD were available for 303 women (159 assigned to vaginal progesterone and 144 assigned to placebo/no treatment) and their 606 fetuses/infants from six randomized controlled trials. One study, which included women with a cervical length between 20 and 25 mm, provided 74% of the total sample size of the IPD meta-analysis. Vaginal progesterone, compared with placebo/no treatment, was associated with a statistically significant reduction in the risk of preterm birth < 33 weeks' gestation (31.4% vs 43.1%; RR, 0.69 (95% CI, 0.51-0.93); moderate-quality evidence). Moreover, vaginal progesterone administration was associated with a significant decrease in the risk of preterm birth < 35, < 34, < 32 and < 30 weeks' gestation (RRs ranging from 0.47 to 0.83), neonatal death (RR, 0.53 (95% CI, 0.35-0.81)), respiratory distress syndrome (RR, 0.70 (95% CI, 0.56-0.89)), composite neonatal morbidity and mortality (RR, 0.61 (95% CI, 0.34-0.98)), use of mechanical ventilation (RR, 0.54 (95% CI, 0.36-0.81)) and birth weight < 1500 g (RR, 0.53 (95% CI, 0.35-0.80)) (all moderate-quality evidence). There were no significant differences in neurodevelopmental outcomes at 4-5 years of age between the vaginal progesterone and placebo groups. CONCLUSION Administration of vaginal progesterone to asymptomatic women with a twin gestation and a sonographic short cervix in the mid-trimester reduces the risk of preterm birth occurring at < 30 to < 35 gestational weeks, neonatal mortality and some measures of neonatal morbidity, without any demonstrable deleterious effects on childhood neurodevelopment. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- R. Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of Health, Department of Health and Human ServicesBethesda, MD and DetroitMIUSA
- Department of Obstetrics and GynecologyUniversity of MichiganAnn ArborMIUSA
- Department of Epidemiology and BiostatisticsMichigan State UniversityEast LansingMIUSA
- Center for Molecular Medicine and GeneticsWayne State UniversityDetroitMIUSA
| | - A. Conde‐Agudelo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of Health, Department of Health and Human ServicesBethesda, MD and DetroitMIUSA
- Department of Obstetrics and GynecologyWayne State University School of MedicineDetroitMIUSA
| | - W. El‐Refaie
- Department of Obstetrics and Gynecology, Mansoura University HospitalsMansoura UniversityMansouraEgypt
| | - L. Rode
- Center of Fetal Medicine and Pregnancy, Department of ObstetricsCopenhagen University HospitalRigshospitaletCopenhagenDenmark
- Department of Clinical BiochemistryHerlev and Gentofte HospitalHerlevDenmark
| | - M. L. Brizot
- Department of Obstetrics and GynecologySão Paulo University Medical SchoolSão PauloBrazil
| | - E. Cetingoz
- Department of Obstetrics and GynecologyZeynep Kamil Women and Children Diseases Education and Research HospitalUskudarIstanbulTurkey
| | - V. Serra
- Maternal‐Fetal Medicine Unit, Instituto Valenciano de InfertilidadUniversity of ValenciaValenciaSpain
- Department of Pediatrics, Obstetrics and GynecologyUniversity of ValenciaValenciaSpain
| | - E. Da Fonseca
- Departamento de Obstetrícia e Ginecologia, Hospital do Servidor Publico Estadual ‘Francisco Morato de Oliveira’ and School of MedicineUniversity of São PauloSão PauloBrazil
| | - M. S. Abdelhafez
- Department of Obstetrics and Gynecology, Mansoura University HospitalsMansoura UniversityMansouraEgypt
| | - A. Tabor
- Center of Fetal Medicine and Pregnancy, Department of ObstetricsCopenhagen University HospitalRigshospitaletCopenhagenDenmark
- University of CopenhagenFaculty of Health SciencesCopenhagenDenmark
| | - A. Perales
- Department of Pediatrics, Obstetrics and GynecologyUniversity of ValenciaValenciaSpain
- Department of ObstetricsUniversity Hospital La FeValenciaSpain
| | - S. S. Hassan
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of Health, Department of Health and Human ServicesBethesda, MD and DetroitMIUSA
- Department of Obstetrics and GynecologyWayne State University School of MedicineDetroitMIUSA
| | - K. H. Nicolaides
- Harris Birthright Research Centre for Fetal MedicineKing's College HospitalLondonUK
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Vintzileos AM, Visser GHA. Interventions for women with mid-trimester short cervix: which ones work? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:295-300. [PMID: 28266160 DOI: 10.1002/uog.17357] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 11/07/2016] [Indexed: 06/06/2023]
Affiliation(s)
- A M Vintzileos
- Department of Obstetrics and Gynecology, Winthrop University Hospital, Clinical Campus of Stony Brook University School of Medicine, Mineola, NY, USA
- Department of Obstetrics, Gynecology and Reproductive Medicine, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - G H A Visser
- University Medical Center, Utrecht, The Netherlands
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Jarde A, Lutsiv O, Park CK, Barrett J, Beyene J, Saito S, Dodd JM, Shah PS, Cook JL, Biringer AB, Giglia L, Han Z, Staub K, Mundle W, Vera C, Sabatino L, Liyanage SK, McDonald SD. Preterm birth prevention in twin pregnancies with progesterone, pessary, or cerclage: a systematic review and meta-analysis. BJOG 2017; 124:1163-1173. [DOI: 10.1111/1471-0528.14513] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2016] [Indexed: 12/14/2022]
Affiliation(s)
- A Jarde
- Department of Obstetrics and Gynecology; McMaster University; Hamilton ON Canada
| | - O Lutsiv
- Department of Obstetrics and Gynecology; McMaster University; Hamilton ON Canada
| | - CK Park
- Department of Clinical Epidemiology and Biostatistics; McMaster University Hamilton, ON Canada
| | - J Barrett
- Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - J Beyene
- Department of Clinical Epidemiology and Biostatistics; McMaster University Hamilton, ON Canada
| | - S Saito
- Department of Obstetrics and Gynecology; University of Toyama; Toyama Japan
| | - JM Dodd
- Department of Obstetrics and Gynecology; University of Adelaide; Adelaide Australia
| | - PS Shah
- Department of Paediatrics; University of Toronto; Toronto ON Canada
| | - JL Cook
- The Society of Obstetricians and Gynaecologists of Canada; Ottawa ON Canada
| | - AB Biringer
- Department of Family and Community Medicine; University of Toronto; Toronto ON Canada
| | - L Giglia
- Department of Pediatrics; McMaster University; Hamilton ON Canada
| | - Z Han
- The First Affiliated Hospital of Xi'an Jiaotong University; Xi'an Shaanxi Province China
| | - K Staub
- Canadian Premature Babies Foundation; Sherwood Park AB Canada
| | - W Mundle
- Maternal Fetal Medicine Clinic; Windsor Regional Hospital; Windsor ON Canada
| | - C Vera
- Division of Obstetrics and Gynecology; Escuela de Medicina; Pontificia Universidad Católica de Chile; Santiago Chile
| | - L Sabatino
- Midwifery Education Program; McMaster University; Hamilton ON Canada
| | - SK Liyanage
- Department of Obstetrics and Gynecology; McMaster University; Hamilton ON Canada
| | - SD McDonald
- Department of Obstetrics and Gynecology; McMaster University; Hamilton ON Canada
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Ahn KH, Bae NY, Hong SC, Lee JS, Lee EH, Jee HJ, Cho GJ, Oh MJ, Kim HJ. The safety of progestogen in the prevention of preterm birth: meta-analysis of neonatal mortality. J Perinat Med 2017; 45:11-20. [PMID: 27124668 DOI: 10.1515/jpm-2015-0317] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 03/16/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND The safety of preventive progestogen therapy for preterm birth remains to be established. This meta-analysis aimed to evaluate the effects of preventive progestogen therapy on neonatal mortality. METHODS Randomized controlled trials (RCTs) on the preventive use of progestogen therapy, published between October 1971 and November 2015, were identified by searching MEDLINE/PubMed, EMBASE, Scopus, ClinicalTrials.gov, Cochrane Library databases, CINAHL, POPLINE, and LILACS using "progesterone" and "preterm birth" as key terms. We conducted separate analyses according to the type of progestogen administered and plurality of the pregnancy. RESULTS Twenty-two RCTs provided data on 11,188 neonates. Preventive progestogen treatment in women with a history of preterm birth or short cervical length was not associated with increased risk of neonatal death compared to placebo in all analyzed progestogen types and pregnancy conditions. The pooled relative risks (95% confidence interval) of neonatal mortality were 0.69 (0.31-1.54) for vaginal progestogen in singleton pregnancies, 0.6 (0.33-1.09) for intramuscular progestogen in singleton pregnancies, 0.96 (0.51-1.8) for vaginal progestogen in multiple pregnancies, and 0.96 (0.49-1.9) for intramuscular progestogen in multiple pregnancies. CONCLUSIONS The results of this meta-analysis suggest that administration of preventive progestogen treatment to women at risk for preterm birth does not appear to negatively affect neonatal mortality in single or multiple pregnancies regardless of the route of administration.
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Intérêt des progestatifs dans la prévention de la prématurité spontanée. ACTA ACUST UNITED AC 2016; 45:1280-1298. [DOI: 10.1016/j.jgyn.2016.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 11/24/2022]
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Melamed N, Pittini A, Hiersch L, Yogev Y, Korzeniewski SJ, Romero R, Barrett J. Do serial measurements of cervical length improve the prediction of preterm birth in asymptomatic women with twin gestations? Am J Obstet Gynecol 2016; 215:616.e1-616.e14. [PMID: 27365003 PMCID: PMC5086275 DOI: 10.1016/j.ajog.2016.06.034] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/14/2016] [Accepted: 06/19/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cervical length at midtrimester is a powerful predictor of preterm birth in twin gestations. However, given the fact that, in some cases, cervical shortening may become evident only later during the second trimester, it seems reasonable that serial monitoring of cervical length may improve the detection of preterm birth in women with twins. However, data in support of such a practice are limited and conflicting. The contradictory results may be related to the fact that in most of these studies, the analysis of the predictive value of serial measurements of cervical length was limited to data derived from only two sequential measurements of cervical length, while data on the predictive value of multiple (>2) measurements are scarce. OBJECTIVE We sought to determine whether serial measurements of cervical length can improve the prediction of preterm birth in asymptomatic women with twin gestations compared with a single measurement of cervical length at midgestation. STUDY DESIGN This was a retrospective cohort study of women with twin pregnancies followed up in a tertiary medical center from 2012 through 2014. All participants underwent routine measurement of cervical length at midgestation and every 2-3 weeks thereafter until 28-32 weeks. For each patient, cervical length was determined at the following time periods: 18+0 to 21+6 weeks (period 1, routine exam), 22+0 to 24+6 weeks (period 2), 25+0 to 27+6 weeks (period 3), and 28+0 to 32+0 weeks (period 4). Measurements of cervical length at periods 2-4 were analyzed in the form of either absolute length (in millimeters) or percent shortening relative to cervical length at period 1. The performance of a stepwise algorithm that incorporated serial measurements of cervical length for the prediction of preterm birth was compared to that achieved with a single measurement of cervical length at period 1. RESULTS Overall, 441 women with twin pregnancies who were eligible for the study underwent a total of 2374 cervical length measurements. The association of a short cervix (<10th percentile) with preterm birth at <32 weeks persisted in each of the 4 periods of gestation [odds ratio (95% confidence interval): 7.2 (3.1-16.5), 15.3 (6.4-36.7), 10.3 (4.4-24.3), and 23.1(8.3-64.1), respectively]. Compared with a single measurement of cervical length at midgestation (period 1), a stepwise algorithm integrating serial cervical length measurements from all 4 successive gestational age periods resulted in a significant increase in the area under the receiver operating characteristic curve (0.917 vs 0.613, P < .001). Similarly, when a target false-positive rate of 5% was used, the same stepwise algorithm was associated with a higher detection rate (69% vs 28%, P < .001), higher positive likelihood ratio (14.54 vs 5.12), and lower negative likelihood ratio (0.32 vs 0.76) for preterm birth at <32 weeks compared with a single measurement of cervical length at period 1. CONCLUSION Integration of serial measurements of cervical length using a stepwise algorithm in asymptomatic women with twin gestations can improve the detection of women at risk of preterm birth. Prospective studies are needed to validate these findings, and to investigate whether improved risk assessment performance is sufficient to offset the additional costs associated with serial cervical length measurements.
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Affiliation(s)
- Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
| | - Alex Pittini
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Liran Hiersch
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yariv Yogev
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Steven J Korzeniewski
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Jon Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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Romero R, Nicolaides KH, Conde-Agudelo A, O'Brien JM, Cetingoz E, Da Fonseca E, Creasy GW, Hassan SS. Vaginal progesterone decreases preterm birth ≤ 34 weeks of gestation in women with a singleton pregnancy and a short cervix: an updated meta-analysis including data from the OPPTIMUM study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:308-17. [PMID: 27444208 PMCID: PMC5053235 DOI: 10.1002/uog.15953] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/19/2016] [Accepted: 04/25/2016] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To evaluate the efficacy of vaginal progesterone administration for preventing preterm birth and perinatal morbidity and mortality in asymptomatic women with a singleton gestation and a mid-trimester sonographic cervical length (CL) ≤ 25 mm. METHODS This was an updated systematic review and meta-analysis of randomized controlled trials comparing the use of vaginal progesterone to placebo/no treatment in women with a singleton gestation and a mid-trimester sonographic CL ≤ 25 mm. Electronic databases, from their inception to May 2016, bibliographies and conference proceedings were searched. The primary outcome measure was preterm birth ≤ 34 weeks of gestation or fetal death. Two reviewers independently selected studies, assessed the risk of bias and extracted the data. Pooled relative risks (RRs) with 95% confidence intervals (CI) were calculated. RESULTS Five trials involving 974 women were included. A meta-analysis, including data from the OPPTIMUM study, showed that vaginal progesterone significantly decreased the risk of preterm birth ≤ 34 weeks of gestation or fetal death compared to placebo (18.1% vs 27.5%; RR, 0.66 (95% CI, 0.52-0.83); P = 0.0005; five studies; 974 women). Meta-analyses of data from four trials (723 women) showed that vaginal progesterone administration was associated with a statistically significant reduction in the risk of preterm birth occurring at < 28 to < 36 gestational weeks (RRs from 0.51 to 0.79), respiratory distress syndrome (RR, 0.47 (95% CI, 0.27-0.81)), composite neonatal morbidity and mortality (RR, 0.59 (95% CI, 0.38-0.91)), birth weight < 1500 g (RR, 0.52 (95% CI, 0.34-0.81)) and admission to the neonatal intensive care unit (RR, 0.67 (95% CI, 0.50-0.91)). There were no significant differences in neurodevelopmental outcomes at 2 years of age between the vaginal progesterone and placebo groups. CONCLUSION This updated systematic review and meta-analysis reaffirms that vaginal progesterone reduces the risk of preterm birth and neonatal morbidity and mortality in women with a singleton gestation and a mid-trimester CL ≤ 25 mm, without any deleterious effects on neurodevelopmental outcome. Clinicians should continue to perform universal transvaginal CL screening at 18-24 weeks of gestation in women with a singleton gestation and to offer vaginal progesterone to those with a CL ≤ 25 mm. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- R Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD and Detroit, MI, USA.
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA.
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA.
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Conde-Agudelo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD and Detroit, MI, USA
| | - J M O'Brien
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY, USA
| | - E Cetingoz
- Department of Obstetrics and Gynecology, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Uskudar, Istanbul, Turkey
| | - E Da Fonseca
- Departamento de Obstetrícia e Ginecologia, Hospital do Servidor Publico Estadual 'Francisco Morato de Oliveira' and School of Medicine, University of São Paulo, São Paulo, Brazil
| | - G W Creasy
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - S S Hassan
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
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Vedel C, Larsen H, Holmskov A, Andreasen KR, Uldbjerg N, Ramb J, Bødker B, Skibsted L, Sperling L, Krebs L, Zingenberg H, Laursen L, Christensen JT, Tabor A, Rode L. Long-term effects of prenatal progesterone exposure: neurophysiological development and hospital admissions in twins up to 8 years of age. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:382-389. [PMID: 27106105 DOI: 10.1002/uog.15948] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 04/13/2016] [Accepted: 04/18/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To perform a neurophysiological follow-up at 48 or 60 months of age in children exposed prenatally to progesterone compared with a placebo and evaluate their medical histories up to 8 years of age. METHODS In this study, Danish participants of the PREDICT study, including 989 surviving children from 498 twin pregnancies, were followed-up. PREDICT was a placebo-controlled randomized clinical trial examining the effect of progesterone for prevention of preterm delivery in unselected twin pregnancies. Medical histories of the children were reviewed and neurophysiological development was evaluated by the parent-completed Ages and Stages Questionnaire (ASQ) at either 48 or 60 months after the estimated date of delivery. We used the method of generalized estimating equation to account for the correlation within twins. RESULTS A total of 492 children had been exposed prenatally to progesterone and 497 to placebo. There was no difference in the number of admissions to or length of stay in hospital between the treatment groups, and we found no overall difference in the rates of diagnoses made. However, the odds ratios (ORs) for a diagnosis concerning the heart was 1.66 (95% CI, 0.81-3.37), favoring placebo, among all children, 2.38 (95% CI, 1.07-5.30) in dichorionic twins and 8.19 (95% CI, 1.02-65.6) in all children when excluding diagnoses made at outpatient clinic visits. ASQ scores were available for 437 children (progesterone, n = 225; placebo, n = 212). Mean ASQ score was slightly higher in the progesterone group compared with the placebo group (P = 0.03). In dichorionic twins, the risk of having a low ASQ score (< 10(th) centile) was decreased in the progesterone group (OR, 0.34 (95% CI, 0.14-0.86)). CONCLUSION Second- and third-trimester exposure of the fetus to progesterone does not seem to have long-term harmful effects during childhood, but future studies should focus on cardiac disease in the child. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C Vedel
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- University of Copenhagen, Faculty of Health Sciences, Copenhagen, Denmark
| | - H Larsen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark
| | - A Holmskov
- Department of Obstetrics and Gynecology, Viborg Hospital, Viborg, Denmark
| | - K R Andreasen
- Department of Obstetrics and Gynecology, Hvidovre Hospital, Hvidovre, Denmark
| | - N Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Skejby, Denmark
| | - J Ramb
- Department of Obstetrics and Gynecology, Sønderborg Hospital, Sønderborg, Denmark
| | - B Bødker
- Department of Obstetrics and Gynecology, Nordsjaellands Hospital, Hillerød, Denmark
| | - L Skibsted
- University of Copenhagen, Faculty of Health Sciences, Copenhagen, Denmark
- Department of Obstetrics and Gynecology, University Hospital Roskilde, Roskilde, Denmark
| | - L Sperling
- University of Copenhagen, Faculty of Health Sciences, Copenhagen, Denmark
- Department of Obstetrics and Gynecology, Herlev Hospital, Herlev, Denmark
| | - L Krebs
- Department of Obstetrics and Gynecology, Holbaek Hospital, Holbaek, Denmark
| | - H Zingenberg
- Department of Obstetrics and Gynecology, Glostrup Hospital, Glostrup, Denmark
| | - L Laursen
- Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - J T Christensen
- Department of Obstetrics and Gynecology, Gentofte Hospital, Hellerup, Denmark
| | - A Tabor
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- University of Copenhagen, Faculty of Health Sciences, Copenhagen, Denmark
| | - L Rode
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Herlev, Denmark
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Azargoon A, Ghorbani R, Aslebahar F. Vaginal progesterone on the prevention of preterm birth and neonatal complications in high risk women: A randomized placebo-controlled double-blind study. Int J Reprod Biomed 2016. [DOI: 10.29252/ijrm.14.5.309] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Abstract
Preterm birth is a major concern in modern obstetrics, and an important source of morbidity and mortality in newborns. Among twin pregnancies, especially, preterm birth is highly prevalent, and it accounts for almost 50% of the complications observed in this obstetrical population. In this article, we review the existing literature regarding the prediction and prevention of preterm birth in both symptomatic and asymptomatic twin pregnancies. In asymptomatic twin pregnancies, the best two predictive tests were cervical length (CL) measurement and cervicovaginal fetal fibronectin (fFN) testing. A single measurement of transvaginal CL at 20-24 weeks of gestation <20 mm or <25 mm is a good predictor of spontaneous preterm birth at <28, <32, and <34 weeks of gestation. A CL beyond 25 mm is associated with a 2% risk for birth before 28 weeks and with a 65% chance for a term pregnancy. Cervicovaginal fFN may be slightly less accurate than CL; however, it has a high negative predictive value in women presenting with threatened preterm labor, as <2% of these women will deliver within one week if the fFN is negative. In symptomatic twin pregnancies, no tests have proven accurate in predicting the risk of preterm birth. For the prevention of preterm birth in asymptomatic twins, regardless of CL, no treatment including bed rest, limitation of home activities, prophylactic tocolysis, progesterone, or cerclage has been shown to reduce the rate of preterm birth. Cervical pessaries might be of interest in cases where there is a short cervix (<25 mm and <38 mm, respectively) but these results need to confirmed in future trials.
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Affiliation(s)
- F Fuchs
- Departement de Gynécologie-Obstétrique, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris (APHP), Le Kremlin Bicêtre, France; INSERM, CESP Centre de recherche en Epidémiologie et Santé des Populations, U1018, Reproduction et Développement de l'enfant, Villejuif, France; Université Paris-Sud, UMRS 1018, Villejuif, France
| | - M-V Senat
- Departement de Gynécologie-Obstétrique, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris (APHP), Le Kremlin Bicêtre, France; INSERM, CESP Centre de recherche en Epidémiologie et Santé des Populations, U1018, Reproduction et Développement de l'enfant, Villejuif, France; Université Paris-Sud, UMRS 1018, Villejuif, France.
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Conde-Agudelo A, Romero R. Vaginal progesterone to prevent preterm birth in pregnant women with a sonographic short cervix: clinical and public health implications. Am J Obstet Gynecol 2016; 214:235-242. [PMID: 26450404 PMCID: PMC5703061 DOI: 10.1016/j.ajog.2015.09.102] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/18/2015] [Accepted: 09/23/2015] [Indexed: 12/20/2022]
Abstract
Vaginal progesterone administration to women with a sonographic short cervix is an efficacious and safe intervention used to prevent preterm birth and neonatal morbidity and mortality. The clinical and public health implications of this approach in the United States have been critically appraised and compared to other therapeutic interventions in obstetrics. Vaginal progesterone administration to women with a transvaginal sonographic cervical length (CL) ≤25 mm before 25 weeks of gestation is associated with a significant and substantial reduction of the risk for preterm birth from <28 to <35 weeks of gestation, respiratory distress syndrome, composite neonatal morbidity and mortality, admission to the neonatal intensive care unit, and mechanical ventilation. These beneficial effects have been achieved in women with a singleton gestation, with or without a history of spontaneous preterm birth, and did not differ significantly as a function of CL (<10 mm, 10-20 mm, or 21-25 mm). The number of patients required for treatment to prevent 1 case of preterm birth or adverse neonatal outcomes ranges from 10-19 women. The number needed to screen for the prevention of 1 case of preterm birth before 34 weeks of gestation is 125 women, and 225 for the prevention of 1 case of major neonatal morbidity or neonatal mortality. Several cost-effectiveness and decision analyses have shown that the combination of universal transvaginal CL screening and vaginal progesterone administration to women with a short cervix is a cost-effective intervention that prevents preterm birth and associated perinatal morbidity and mortality. Universal assessment of CL and treatment with vaginal progesterone for singleton gestations in the United States would result in an annual reduction of approximately 30,000 preterm births before 34 weeks of gestation and of 17,500 cases of major neonatal morbidity or neonatal mortality. In summary, there is compelling evidence to recommend universal transvaginal CL screening at 18-24 weeks of gestation in women with a singleton gestation and to offer vaginal progesterone to those with a CL ≤25 mm, regardless of the history of spontaneous preterm birth, with the goal of preventing preterm birth and neonatal morbidity and mortality.
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Affiliation(s)
- Agustin Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI.
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62
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Kim YJ. Progesterone treatment for the prevention of preterm birth. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2016. [DOI: 10.5124/jkma.2016.59.4.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Young Ju Kim
- Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Korea
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Combs CA, Schuit E, Caritis SN, Lim AC, Garite TJ, Maurel K, Rouse D, Thom E, Tita AT, Mol B. 17-Hydroxyprogesterone caproate in triplet pregnancy: an individual patient data meta-analysis. BJOG 2015; 123:682-90. [PMID: 26663620 DOI: 10.1111/1471-0528.13779] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Preterm birth complicates almost all triplet pregnancies and no preventive strategy has proven effective. OBJECTIVE To determine, using individual patient data (IPD) meta-analysis, whether the outcome of triplet pregnancy is affected by prophylactic administration of 17-hydroxyprogesterone caproate (17OHPc). SEARCH STRATEGY We searched literature databases, trial registries and references in published articles. SELECTION CRITERIA Randomised controlled trials (RCTs) of progestogens versus control that included women with triplet pregnancies. DATA COLLECTION AND ANALYSIS Investigators from identified RCTs collaborated on the protocol and contributed their IPD. The primary outcome was a composite measure of adverse perinatal outcome. The secondary outcome was the rate of birth before 32 weeks of gestation. Other pre-specified outcomes included randomisation-to-delivery interval and rates of birth at <24, <28 and <34 weeks of gestation. MAIN RESULTS Three RCTs of 17OHPc versus placebo included 232 mothers with triplet pregnancies and their 696 offspring. Risk-of-bias scores and between-study heterogeneity were low. Baseline characteristics were comparable between 17OHPc and placebo groups. The rate of the composite adverse perinatal outcome was similar among those treated with 17OHPc and those treated with placebo (34 and 35%, respectively; risk ratio [RR] 0.98, 95% confidence interval [95% CI] 0.79-1.2). The rate of birth at <32 weeks was also similar in the two groups (35 and 38%, respectively; RR 0.92, 95% CI 0.55-1.56). There were no significant between-group differences in perinatal mortality rate, randomisation-to-delivery interval, or other specified outcomes. CONCLUSION Prophylactic 17OHPc given to mothers with triplet pregnancies had no significant impact on perinatal outcome or pregnancy duration. TWEETABLE ABSTRACT 17-Hydroxyprogesterone caproate had no significant impact on the outcome or duration of triplet pregnancy.
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Affiliation(s)
- C A Combs
- Obstetrix Collaborative Research Network, the Center for Research, Education, and Quality, Mednax National Medical Group, Sunrise, FL, USA
| | - E Schuit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands.,Stanford Prevention Research Center, Stanford University, Stanford, CA, USA
| | - S N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA, USA
| | - A C Lim
- Department of Obstetrics and Gynaecology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - T J Garite
- Obstetrix Collaborative Research Network, the Center for Research, Education, and Quality, Mednax National Medical Group, Sunrise, FL, USA.,Department of Obstetrics and Gynecology, University of California Irvine, Irvine, CA, USA
| | - K Maurel
- Obstetrix Collaborative Research Network, the Center for Research, Education, and Quality, Mednax National Medical Group, Sunrise, FL, USA
| | - D Rouse
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Maternal-Fetal Medicine Units Network (MFMU), Bethesda, MD, USA.,Department of Obstetrics and Gynecology, Alpert Medical School, Women & Infants Hospital, Brown University, Providence, RI, USA.,Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA
| | - E Thom
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Maternal-Fetal Medicine Units Network (MFMU), Bethesda, MD, USA.,The Biostatistics Center, George Washington University, Washington, DC, USA
| | - A T Tita
- Department of Obstetrics and Gynecology, Alpert Medical School, Women & Infants Hospital, Brown University, Providence, RI, USA.,Department of Obstetrics and Gynecology and Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bwj Mol
- Department of Obstetrics and Gynaecology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands.,The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, and The South Australian Health and Medical Research Institute, Adelaide, SA, Australia
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Ragab A, Mesbah Y. To do or not to do emergency cervical cerclage (a rescue stitch) at 24-28 weeks gestation in addition to progesterone for patients coming early in labor? A prospective randomized trial for efficacy and safety. Arch Gynecol Obstet 2015; 292:1255-60. [PMID: 26041325 DOI: 10.1007/s00404-015-3772-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 05/27/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE To measure the outcome of emergency cervical cerclage (ECC) combined with progesterone vs. progesterone alone in pregnancy prolongation for preterm labor at 24-28 weeks. METHODS One hundred patients in early labor were allocated randomly into two equal groups. Group A were treated by ECC and progesterone, and group B were on the same progesterone dose only treatment. RESULTS No significant differences were observed in both groups as regard demographic data, fetal gestational age or cervical state on admission. However, a significant pregnancy prolongation was observed in group A (28.44 ± 12.73 days vs. 9.96 ± 3.27 in group B, p < 0.001) with subsequent increase in fetal gestational age (32.04 ± 3.2 vs. 27.86 ± 3.213, p < 0.001), heavier weight, higher Apgar score at 1 and 5 min, and lower rate of cesarean delivery (1033.1 ± 170.83 vs. 715.1 ± 138.73, p < 0.001) (2.68 ± 1.132 vs. 2.14 ± 0.93, p < 0.001), (5.48 ± 2.6 vs. 2.38 ± 1.59, p = 0.01) and (16 vs. 62 %, p = 0.01), respectively. Also neonatal outcomes in terms of early neonatal deaths were lower in this group (18 vs. 46 %, p = 0.049). CONCLUSIONS ECC is effective in pregnancy prolongation when judiciously used in combination with progesterone compared to progesterone alone.
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Affiliation(s)
- Ahmed Ragab
- Department of Obstetrics and Gynecology, Mansoura College of Medicine, Mansoura University, Mansoura, Egypt.
| | - Yasser Mesbah
- Department of Obstetrics and Gynecology, Mansoura College of Medicine, Mansoura University, Mansoura, Egypt
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Bousleiman SZ, Rice MM, Moss J, Todd A, Rincon M, Mallett G, Milluzzi C, Allard D, Dorman K, Ortiz F, Johnson F, Reed P, Tolivaisa S. Use and attitudes of obstetricians toward 3 high-risk interventions in MFMU Network hospitals. Am J Obstet Gynecol 2015; 213:398.e1-11. [PMID: 25957021 PMCID: PMC4556564 DOI: 10.1016/j.ajog.2015.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 04/08/2015] [Accepted: 05/02/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE We sought to evaluate the frequency of, and factors associated with, the use of 3 evidence-based interventions: antenatal corticosteroids for fetal lung maturity, progesterone for prevention of recurrent preterm birth, and magnesium sulfate for fetal neuroprotection. STUDY DESIGN A self-administered survey was conducted from January through May 2011 among obstetricians from 21 hospitals that included 30 questions regarding their knowledge, attitudes, and practice of the 3 evidence-based interventions and the 14-item short version of the Team Climate for Innovation survey. Frequency of use of each intervention was ascertained from an obstetrical cohort of women between January 2010 and February 2011. RESULTS A total of 329 obstetricians (74% response rate) who managed 16,946 deliveries within the obstetrical cohort participated in the survey. More than 90% of obstetricians reported that they incorporated each intervention into routine practice. Actual frequency of administration in women eligible for the treatments was 93% for corticosteroids, 39% for progesterone, and 71% for magnesium sulfate. Provider satisfaction with quality of treatment evidence was 97% for corticosteroids, 82% for progesterone, and 57% for magnesium sulfate. Obstetricians perceived that barriers to treatment were most frequent for progesterone (76%), 30% for magnesium sulfate, and 17% for corticosteroids. Progesterone use was more frequent among patients whose provider reported the quality of the evidence was above average to excellent compared with poor to average (42% vs 25%, respectively; P < .001), and they were satisfied with their knowledge of the intervention (41% vs 28%; P = .02), and was less common among patients whose provider reported barriers to hospital or pharmacy drug delivery (31% vs 42%; P = .01). Corticosteroid administration was more common among patients who delivered at hospitals with 24 hours a day-7 days a week maternal-fetal medicine specialist coverage (93% vs 84%; P = .046), CONCLUSION: Obstetricians in Maternal-Fetal Medicine Units Network hospitals frequently use these evidence-based interventions; however, progesterone use was found to be related to their assessment of evidence quality. Neither progesterone nor the other interventions were associated with overall climate of innovation within a hospital as measured by the Team Climate for Innovation. National Institutes of Health Consensus Conference Statements may also have an impact on use; there is such a statement for antenatal corticosteroids but not for progesterone for preterm prevention or magnesium sulfate for fetal neuroprotection.
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Affiliation(s)
- Sabine Zoghbi Bousleiman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY.
| | - Madeline Murguia Rice
- Department of Obstetrics and Gynecology, George Washington University Biostatistics Center, Washington, DC
| | - Joan Moss
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Allison Todd
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Monica Rincon
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR
| | - Gail Mallett
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Cynthia Milluzzi
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH
| | - Donna Allard
- Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI
| | - Karen Dorman
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Felecia Ortiz
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, TX
| | - Francee Johnson
- Department of Obstetrics and Gynecology, The Ohio State University School of Medicine, Columbus, OH
| | - Peggy Reed
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | - Susan Tolivaisa
- Department of Obstetrics and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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66
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Fuchs F, Senat MV. [Progesterone and prevention of preterm birth]. ACTA ACUST UNITED AC 2015; 44:760-70. [PMID: 26183175 DOI: 10.1016/j.jgyn.2015.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 06/02/2015] [Accepted: 06/03/2015] [Indexed: 11/20/2022]
Abstract
The literature confirms the interest of progesterone for prevention of preterm delivery in specific indications for patients carrying a singleton pregnancy. In contrast, randomized trials have shown no benefit using progesterone in the prevention of prematurity in twins and even an adverse effect.
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Affiliation(s)
- F Fuchs
- Département de gynécologie-obstétrique, hôpital Bicêtre, AP-HP, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France; Université Paris-Sud, UMRS 1018, 94807 Villejuif, France.
| | - M-V Senat
- Département de gynécologie-obstétrique, hôpital Bicêtre, AP-HP, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France; Université Paris-Sud, UMRS 1018, 94807 Villejuif, France.
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67
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Brizot ML, Hernandez W, Liao AW, Bittar RE, Francisco RP, Krebs VL, Zugaib M. Vaginal progesterone for the prevention of preterm birth in twin gestations: a randomized placebo-controlled double-blind study. Am J Obstet Gynecol 2015; 213:82.e1-82.e9. [PMID: 25731690 DOI: 10.1016/j.ajog.2015.02.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 01/20/2015] [Accepted: 02/19/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the use of vaginal progesterone for the prevention of preterm delivery in twin pregnancies. STUDY DESIGN We conducted a prospective, randomized, double-blind, placebo-controlled trial that involved 390 naturally conceived twin pregnancies among mothers with no history of preterm delivery who were receiving antenatal care at a single center. Women with twin pregnancies between 18 and 21 weeks and 6 days' gestation were assigned randomly to daily vaginal progesterone (200 mg) or placebo ovules until 34 weeks and 6 days' gestation. The primary outcome was the difference in mean gestational age at delivery; the secondary outcomes were the rate of spontaneous delivery at <34 weeks' gestation and the rate of neonatal composite morbidity and mortality in the treatment and nontreatment groups. RESULTS The baseline characteristics were similar in both groups. The final analysis included 189 women in the progesterone group and 191 in the placebo group. No difference (P = .095) in the mean gestational age at delivery was observed between progesterone (35.08 ± 3.19 [SD]) and placebo groups (35.55 ± 2.85). The incidence of spontaneous delivery at <34 weeks' gestation was 18.5% in the progesterone group and 14.6% in the placebo group (odds ratio, 1.32; 95% confidence interval, 0.24-2.37). No difference in the composite neonatal morbidity and mortality was observed between the progesterone (15.5%) and placebo (15.9%) groups (odds ratio, 1.01; 95% confidence interval, 0.58-1.75). CONCLUSION In nonselected twin pregnancies, vaginal progesterone administration does not prevent preterm delivery and does not reduce neonatal morbidity and death.
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68
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Carcopino X, Barde K, Petrovic M, Beucher G, Capmas P, Huchon C, Deffieux X, d’Ercole C, Bretelle F. Menace de fausse couche tardive. Recommandations françaises. ACTA ACUST UNITED AC 2014; 43:842-55. [DOI: 10.1016/j.jgyn.2014.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Awwad J, Usta IM, Ghazeeri G, Yacoub N, Succar J, Hayek S, Saasouh W, Nassar AH. A randomised controlled double-blind clinical trial of 17-hydroxyprogesterone caproate for the prevention of preterm birth in twin gestation (PROGESTWIN): evidence for reduced neonatal morbidity. BJOG 2014; 122:71-9. [PMID: 25163819 DOI: 10.1111/1471-0528.13031] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine whether 17 alpha-hydroxyprogesterone caproate (17OHPC) prolongs gestation beyond 37 weeks of gestation (primary outcome) and reduces neonatal morbidity (secondary outcome) in twin pregnancy. DESIGN Randomised controlled double-blind clinical trial. SETTING Tertiary-care university medical centre. POPULATION Unselected women with twin pregnancies. METHODS Participants received weekly injections of 250 mg 17OHPC (n = 194) or placebo (n = 94), from 16-20 to 36 weeks of gestation. Randomisation was performed using the permuted-block randomisation method. Data were analysed on an intention-to-treat basis. MAIN OUTCOME MEASURE Preterm birth (PTB) rate before 37 weeks of gestation. RESULTS There were no significant differences in the average gestational age at delivery, or in the rates of PTB before 37, 32, and 28 weeks of gestation, between the two groups. The proportion of very-low-birthweight neonates (<1500 g) was significantly lower in the 17OHPC group (7.6%) compared with placebo (14.3%) (relative risk, RR 0.5; 95% confidence interval, 95% CI 0.3-0.9; P = 0.01). Progestogen-treated neonates had a significantly lower composite neonatal morbidity (19.1%) compared with placebo (30.9%) (odds ratio, OR 0.53; 95% CI 0.31-0.90; P = 0.02), with significantly lower odds for respiratory distress syndrome (14.4 versus 23.4%; OR 0.55; 95% CI 0.31-0.98; P = 0.04), retinopathy of prematurity (1.1 versus 4.6%; OR 0.21; 95% CI 0.05-0.96; P = 0.04), and culture-confirmed sepsis (3.4 versus 12.8%; OR 0.24; 95% CI 0.10-0.57; P = 0.00). CONCLUSIONS Intramuscular 17OHPC therapy did not reduce PTB before 37 weeks of gestation in unselected twin pregnancies. Nonetheless, 17OHPC significantly reduced neonatal morbidity parameters and increased birthweight.
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Affiliation(s)
- J Awwad
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
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Schuit E, Stock S, Rode L, Rouse DJ, Lim AC, Norman JE, Nassar AH, Serra V, Combs CA, Vayssiere C, Aboulghar MM, Wood S, Çetingöz E, Briery CM, Fonseca EB, Worda K, Tabor A, Thom EA, Caritis SN, Awwad J, Usta IM, Perales A, Meseguer J, Maurel K, Garite T, Aboulghar MA, Amin YM, Ross S, Cam C, Karateke A, Morrison JC, Magann EF, Nicolaides KH, Zuithoff NPA, Groenwold RHH, Moons KGM, Kwee A, Mol BWJ. Effectiveness of progestogens to improve perinatal outcome in twin pregnancies: an individual participant data meta-analysis. BJOG 2014; 122:27-37. [PMID: 25145491 DOI: 10.1111/1471-0528.13032] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND In twin pregnancies, the rates of adverse perinatal outcome and subsequent long-term morbidity are substantial, and mainly result from preterm birth (PTB). OBJECTIVES To assess the effectiveness of progestogen treatment in the prevention of neonatal morbidity or PTB in twin pregnancies using individual participant data meta-analysis (IPDMA). SEARCH STRATEGY We searched international scientific databases, trial registration websites, and references of identified articles. SELECTION CRITERIA Randomised clinical trials (RCTs) of 17-hydroxyprogesterone caproate (17Pc) or vaginally administered natural progesterone, compared with placebo or no treatment. DATA COLLECTION AND ANALYSIS Investigators of identified RCTs were asked to share their IPD. The primary outcome was a composite of perinatal mortality and severe neonatal morbidity. Prespecified subgroup analyses were performed for chorionicity, cervical length, and prior spontaneous PTB. MAIN RESULTS Thirteen trials included 3768 women and their 7536 babies. Neither 17Pc nor vaginal progesterone reduced the incidence of adverse perinatal outcome (17Pc relative risk, RR 1.1; 95% confidence interval, 95% CI 0.97-1.4, vaginal progesterone RR 0.97; 95% CI 0.77-1.2). In a subgroup of women with a cervical length of ≤25 mm, vaginal progesterone reduced adverse perinatal outcome when cervical length was measured at randomisation (15/56 versus 22/60; RR 0.57; 95% CI 0.47-0.70) or before 24 weeks of gestation (14/52 versus 21/56; RR 0.56; 95% CI 0.42-0.75). AUTHOR'S CONCLUSIONS In unselected women with an uncomplicated twin gestation, treatment with progestogens (intramuscular 17Pc or vaginal natural progesterone) does not improve perinatal outcome. Vaginal progesterone may be effective in the reduction of adverse perinatal outcome in women with a cervical length of ≤25 mm; however, further research is warranted to confirm this finding.
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Affiliation(s)
- E Schuit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Obstetrics and Gynaecology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
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71
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van de Mheen L, Schuit E, Lim AC, Porath MM, Papatsonis D, Erwich JJ, van Eyck J, van Oirschot CM, Hummel P, Duvekot JJ, Hasaart TH, Groenwold RH, Moons KG, de Groot CJ, Bruinse HW, van Pampus MG, Mol BW. Prediction of Preterm Birth in Multiple Pregnancies: Development of a Multivariable Model Including Cervical Length Measurement at 16 to 21 Weeks’ Gestation. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:309-319. [DOI: 10.1016/s1701-2163(15)30606-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Sananès N, Langer B, Gaudineau A, Kutnahorsky R, Aissi G, Fritz G, Boudier E, Viville B, Nisand I, Favre R. Prediction of spontaneous preterm delivery in singleton pregnancies: where are we and where are we going? A review of literature. J OBSTET GYNAECOL 2014; 34:457-61. [PMID: 24661250 DOI: 10.3109/01443615.2014.896325] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Prematurity is the chief cause of neonatal morbidity and mortality. The objective of this study is to review the different methods for predicting preterm delivery in asymptomatic pregnant women and in situations of threatened preterm delivery. A search of the PubMed/Medline database was carried out for the years 1980-2012. We included studies for predicting preterm birth in asymptomatic and symptomatic patients. Models for predicting preterm delivery based on maternal factors, cervical length and obstetric history in first trimester of pregnancy is a valuable avenue of research. Nevertheless, prediction accuracy still needs to be improved. In the second and third trimesters, routine digital vaginal examination is of no value in asymptomatic women. Echography of the cervix is not useful except in patients with a history of late miscarriage or preterm delivery in order to offer them a preventive treatment. In symptomatic women, the combination of digital vaginal examination, cervical echography and fibronectin gives the best predictive results. Electromyography of the uterus and elastography of the cervix are interesting avenues for future research. Identifying patients at risk of preterm delivery should be considered differently at each stage of pregnancy.
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Affiliation(s)
- N Sananès
- Department of Obstetrics and Gynecology, CMCO Hospital , Schiltigheim
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73
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Preterm birth rates in a prematurity prevention clinic after adoption of progestin prophylaxis. Obstet Gynecol 2014; 123:34-39. [PMID: 24463661 DOI: 10.1097/aog.0000000000000048] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether progestin prophylaxis influenced the odds of recurrent spontaneous preterm birth among pregnant women with a previous preterm birth. METHODS A retrospective cohort study was performed evaluating outcomes of pregnant women with one or more previous preterm births who received prenatal care in a single academic prematurity clinic. Care algorithms were determined and revised by a single supervising physician. Progestin prophylaxis was adopted in 2004 with accelerated access to the first clinic visit adopted in 2008. Rates of preterm birth before 37, 35, and 32 weeks of gestation were compared over time. RESULTS One thousand sixty-six women with a history of one or more spontaneous preterm births received care in the prematurity clinic and were delivered between January 1, 1998, and June 30, 2012. The gestational age at initiation of prenatal care declined significantly after adoption of an accelerated appointment process (median of 19.1 weeks before 2003, 16.2 weeks from 2004 to 2007, and 15.2 weeks from 2008 to 2012, P<.01), and progestin use increased from 50.8% in 2004-2007 to 80.3% after 2008 (P<.01). After adjustment for race, smoking, cerclage, and number of prior preterm deliveries, we noted a statistically significant decreased odds of spontaneous preterm birth in years 2008-2012 compared with 1998-2007 before 37 (adjusted odds ratio [OR] 0.75, 95% confidence interval [CI] 0.58-0.97) and 35 (adjusted OR 0.70, 95% CI (.52-0.94) weeks of gestation. CONCLUSION Adoption of prophylactic progestin treatment was associated with a decreased odds of recurrent preterm birth before 37 or 35 weeks of gestation after adoption of an aggressive program to facilitate early initiation of progestin treatment. LEVEL OF EVIDENCE II.
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Romero R, Yeo L, Chaemsaithong P, Chaiworapongsa T, Hassan SS. Progesterone to prevent spontaneous preterm birth. Semin Fetal Neonatal Med 2014; 19:15-26. [PMID: 24315687 PMCID: PMC3934502 DOI: 10.1016/j.siny.2013.10.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Preterm birth is the leading cause of perinatal morbidity and mortality worldwide, and its prevention is an important healthcare priority. Preterm parturition is one of the 'great obstetrical syndromes' and is caused by multiple etiologies. One of the mechanisms of disease is the untimely decline in progesterone action, which can present as a clinically silent sonographic short cervix in the midtrimester. The detection of a short cervix in the midtrimester is a powerful risk factor for preterm delivery. Vaginal progesterone can reduce the rate of preterm delivery by 45% and the rate of neonatal morbidity (admission to the neonatal intensive care unit, respiratory distress syndrome, need for mechanical ventilation, etc.). To prevent one case of spontaneous preterm birth <33 weeks of gestation, 11 patients with a short cervix would need to be treated (based on an individual patient meta-analysis). Vaginal progesterone reduces the rate of spontaneous preterm birth in women with a short cervix, both with and without a prior history of preterm birth. In patients with a prior history of preterm birth, vaginal progesterone is as effective as cervical cerclage to prevent preterm delivery. 17α-Hydroxyprogesterone caproate has not been shown to be effective in reducing the rate of spontaneous preterm birth in women with a short cervix.
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, Detroit, MI, USA; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA.
| | - Lami Yeo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Piya Chaemsaithong
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Sonia S Hassan
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
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Fuchs F, Audibert F, Senat MV. Progestérone et prévention de l’accouchement prématuré : retour vers le futur ? ACTA ACUST UNITED AC 2014; 42:112-122. [DOI: 10.1016/j.gyobfe.2013.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Indexed: 10/25/2022]
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Rode L, Tabor A. Prevention of preterm delivery in twin pregnancy. Best Pract Res Clin Obstet Gynaecol 2013; 28:273-83. [PMID: 24378186 DOI: 10.1016/j.bpobgyn.2013.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 11/24/2013] [Indexed: 10/25/2022]
Abstract
The incidence of twin gestation has increased markedly over the past decades, mostly because of increased use of assisted reproductive technologies. Twin pregnancies are at increased risk of preterm delivery (i.e. birth before 37 weeks of gestation). Multiple gestations therefore account for 2-3% of all pregnancies but constitute at least 10% of cases of preterm delivery. Complications from preterm birth are not limited to the neonatal period, such as in retinopathy of prematurity, intraventricular haemorrhage, necrotising enterocolitis, respiratory disorder and sepsis; they can also constitute sequelae such as abnormal neurophysiological development in early childhood and underachievement in school. Several treatment modalities have been proposed in singleton high-risk pregnancies. The mechanism of initiating labour may, however, be different in singleton and twin gestations. Therefore, it is mandatory to evaluate the proposed treatments in randomised trials of multiple gestations. In this chapter, we describe the results of trials to prevent preterm delivery in twin pregnancies.
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Affiliation(s)
- Line Rode
- Center of Fetal Medicine, Department of Obstetrics, Copenhagen University Hospital, 2100 Rigshospitalet, Denmark
| | - Ann Tabor
- Center of Fetal Medicine, Department of Obstetrics, Copenhagen University Hospital, 2100 Rigshospitalet, Denmark.
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Dodd JM, Jones L, Flenady V, Cincotta R, Crowther CA. Prenatal administration of progesterone for preventing preterm birth in women considered to be at risk of preterm birth. Cochrane Database Syst Rev 2013; 2013:CD004947. [PMID: 23903965 PMCID: PMC11035916 DOI: 10.1002/14651858.cd004947.pub3] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Preterm birth is a major complication of pregnancy associated with perinatal mortality and morbidity. Progesterone for the prevention of preterm labour has been advocated. OBJECTIVES To assess the benefits and harms of progesterone for the prevention of preterm birth for women considered to be at increased risk of preterm birth and their infants. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (14 January 2013) and reviewed the reference list of all articles. SELECTION CRITERIA Randomised controlled trials, in which progesterone was given for preventing preterm birth. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated trials for methodological quality and extracted data. MAIN RESULTS Thirty-six randomised controlled trials (8523 women and 12,515 infants) were included. Progesterone versus placebo for women with a past history of spontaneous preterm birth Progesterone was associated with a statistically significant reduction in the risk of perinatal mortality (six studies; 1453 women; risk ratio (RR) 0.50, 95% confidence interval (CI) 0.33 to 0.75), preterm birth less than 34 weeks (five studies; 602 women; average RR 0.31, 95% CI 0.14 to 0.69), infant birthweight less than 2500 g (four studies; 692 infants; RR 0.58, 95% CI 0.42 to 0.79), use of assisted ventilation (three studies; 633 women; RR 0.40, 95% CI 0.18 to 0.90), necrotising enterocolitis (three studies; 1170 women; RR 0.30, 95% CI 0.10 to 0.89), neonatal death (six studies; 1453 women; RR 0.45, 95% CI 0.27 to 0.76), admission to neonatal intensive care unit (three studies; 389 women; RR 0.24, 95% CI 0.14 to 0.40), preterm birth less than 37 weeks (10 studies; 1750 women; average RR 0.55, 95% CI 0.42 to 0.74) and a statistically significant increase in pregnancy prolongation in weeks (one study; 148 women; mean difference (MD) 4.47, 95% CI 2.15 to 6.79). No differential effects in terms of route of administration, time of commencing therapy and dose of progesterone were observed for the majority of outcomes examined. Progesterone versus placebo for women with a short cervix identified on ultrasound Progesterone was associated with a statistically significant reduction in the risk of preterm birth less than 34 weeks (two studies; 438 women; RR 0.64, 95% CI 0.45 to 0.90), preterm birth at less than 28 weeks' gestation (two studies; 1115 women; RR 0.59, 95% CI 0.37 to 0.93) and increased risk of urticaria in women when compared with placebo (one study; 654 women; RR 5.03, 95% CI 1.11 to 22.78). It was not possible to assess the effect of route of progesterone administration, gestational age at commencing therapy, or total cumulative dose of medication. Progesterone versus placebo for women with a multiple pregnancy Progesterone was associated with no statistically significant differences for the reported outcomes. Progesterone versus no treatment/placebo for women following presentation with threatened preterm labour Progesterone, was associated with a statistically significant reduction in the risk of infant birthweight less than 2500 g (one study; 70 infants; RR 0.52, 95% CI 0.28 to 0.98). Progesterone versus placebo for women with 'other' risk factors for preterm birth Progesterone, was associated with a statistically significant reduction in the risk of infant birthweight less than 2500 g (three studies; 482 infants; RR 0.48, 95% CI 0.25 to 0.91). AUTHORS' CONCLUSIONS The use of progesterone is associated with benefits in infant health following administration in women considered to be at increased risk of preterm birth due either to a prior preterm birth or where a short cervix has been identified on ultrasound examination. However, there is limited information available relating to longer-term infant and childhood outcomes, the assessment of which remains a priority.Further trials are required to assess the optimal timing, mode of administration and dose of administration of progesterone therapy when given to women considered to be at increased risk of early birth.
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Affiliation(s)
- Jodie M Dodd
- School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide,Australia.
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Legardeur H, Mandelbrot L, Kayem G. [What use of progesterone to prevent preterm birth?]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2013; 41:459-464. [PMID: 23876420 DOI: 10.1016/j.gyobfe.2013.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 05/21/2013] [Indexed: 06/02/2023]
Abstract
Widely prescribed in the years 1970-1980 to prolong gestation, progesterone has regained interest after the publication of randomized trials since 10 years. In women at increased risk of preterm birth with a history of preterm delivery or late miscarriage, the use of progesterone, especially intramuscularly may reduce the incidence of spontaneous preterm birth. In contrast, in cases of preterm labor or twin pregnancies, progesterone efficacy to reduce preterm birth has not been demonstrated. In women with asymptomatic midtrimester sonographic short cervix, randomized studies show conflicting results and new studies are necessary before its widespread utilisation.
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Affiliation(s)
- H Legardeur
- Service de gynécologie-obstétrique, université Paris-Diderot, hôpital Louis-Mourier, Colombes, France.
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El-Gharib MN, El-Hawary TM. Matched sample comparison of intramuscular versus vaginal micronized progesterone for prevention of preterm birth. J Matern Fetal Neonatal Med 2013; 26:716-9. [PMID: 23205864 DOI: 10.3109/14767058.2012.755165] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To compare vaginal with intramuscular progesterone administration to prevent preterm labor in women with singleton pregnancies and at increased risk of preterm birth. STUDY DESIGN Prospective comparative clinical trial. POPULATION One hundred and sixty pregnant women at 20-24 weeks gestation at the risk of preterm labor were classified into: 80 women who received micronized progesterone tablets 200 mg vaginally daily (Group A) and 80 women who received 100 mg progesterone in the form of intramuscular every third day (Group B). METHODS Estimation of gestational age, assessment of fetal growth and fetal biophysical profile by trans-abdominal ultrasonographic examination was done every 4 weeks till delivery. Measurement of cervical length was achieved by transvaginal ultrasonography, done every 4 weeks till delivery. MAIN OUTCOME MEASURES Incidence of preterm delivery, mean gestational age and the incidence of adverse events of intramuscular versus vaginal route of progesterone administration. RESULTS The incidence of preterm delivery in Group A was 20% and in Group B was 27.5%. The difference between both groups was statistically insignificant. In addition, the rate of adverse events reported in women received injectable progesterone was significantly higher than the rate of adverse events reported in women who received vaginal progesterone therapy. CONCLUSION Vaginally administrated progesterone was nearly as equally effective as intramuscular progesterone in the prevention of preterm labor in women at risk and in the meantime has less undesirable events.
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Affiliation(s)
- M N El-Gharib
- Department of Obstetrics & Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt.
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Senat MV, Porcher R, Winer N, Vayssière C, Deruelle P, Capelle M, Bretelle F, Perrotin F, Laurent Y, Connan L, Langer B, Mantel A, Azimi S, Rozenberg P. Prevention of preterm delivery by 17 alpha-hydroxyprogesterone caproate in asymptomatic twin pregnancies with a short cervix: a randomized controlled trial. Am J Obstet Gynecol 2013; 208:194.e1-8. [PMID: 23433324 DOI: 10.1016/j.ajog.2013.01.032] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 12/05/2012] [Accepted: 01/15/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate the use of 17 alpha-hydroxyprogesterone caproate (17P) to reduce preterm delivery in women with a twin pregnancy and short cervix. STUDY DESIGN This open-label, multicenter, randomized controlled trial included women with a twin pregnancy between 24(+0) and 31(+6) weeks of gestation who were asymptomatic and had a cervical length of 25 mm or less measured by routine transvaginal ultrasound. Women were randomized to receive (or not) 500 mg of intramuscular 17P, repeated twice weekly until 36 weeks or preterm delivery. The primary outcome was time from randomization to delivery. Analysis was performed according to the intent-to-treat principle. RESULTS The 17P and control groups did not differ significantly for median [interquartile range] time to delivery: 45 (26-62) and 51 (36-66) days, respectively. However, treatment with 17P was associated with a significant increase in the rate of preterm delivery before 32 weeks. CONCLUSION Twice-weekly injections of 17P did not prolong pregnancy significantly in asymptomatic women with a twin pregnancy and short cervix.
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Affiliation(s)
- Marie-Victoire Senat
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Paris, Hopital Bicêtre, Hopital Antoine Béclère, Université Paris Sud, Faculté de Medecine, Paris, France.
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Abstract
OBJECTIVE We systematically reviewed the effectiveness of progestogens for prevention of preterm birth among women with prior spontaneous preterm birth, multiple gestations, preterm labor, short cervix, or other indications. DATA SOURCES We searched MEDLINE and EMBASE databases for English language articles published from January 1966 to October 2011. METHODS OF STUDY SELECTION We excluded publications that were not randomized controlled trials or had fewer than 20 participants, identifying 34 publications, of which 19 contained data for Bayesian meta-analysis. TABULATION, INTEGRATION, AND RESULTS Two reviewers independently extracted data and assigned overall quality ratings based on predetermined criteria. Among women with prior preterm birth and a singleton pregnancy (five randomized controlled trials), progestogen treatment decreased the median risk of preterm birth by 22% (relative risk [RR] 0.78, 95% Bayesian credible interval 0.68-0.88) and neonatal death by 42% (RR 0.58, 95% Bayesian credible interval 0.27-0.98). The evidence suggests progestogen treatment does not prevent prematurity (RR 1.02, 95% Bayesian credible interval 0.87-1.17) or neonatal death (RR 1.44, 95% Bayesian credible interval 0.46-3.18) in multiple gestations. Limited evidence suggests progestogen treatment may prevent prematurity in women with preterm labor (RR 0.62, 95% Bayesian credible interval 0.47-0.79) and short cervix (RR 0.52, 95% Bayesian credible interval 0.36-0.70). Across indications, evidence about maternal, fetal, or neonatal health outcomes, other than reducing preterm birth and neonatal mortality, is inconsistent, insufficient, or absent. CONCLUSION Progestogens prevent preterm birth when used in singleton pregnancies for women with a prior preterm birth. In contrast, evidence suggests lack of effectiveness for multiple gestations. Evidence supporting all other uses is insufficient to guide clinical care. Overall, clinicians and patients lack longer-term information to understand whether intervention has the ultimately desired outcome of preventing morbidity and promoting normal childhood development.
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Conde-Agudelo A, Romero R, Nicolaides K, Chaiworapongsa T, O'Brien JM, Cetingoz E, da Fonseca E, Creasy G, Soma-Pillay P, Fusey S, Cam C, Alfirevic Z, Hassan SS. Vaginal progesterone vs. cervical cerclage for the prevention of preterm birth in women with a sonographic short cervix, previous preterm birth, and singleton gestation: a systematic review and indirect comparison metaanalysis. Am J Obstet Gynecol 2013; 208:42.e1-42.e18. [PMID: 23157855 PMCID: PMC3529767 DOI: 10.1016/j.ajog.2012.10.877] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 10/12/2012] [Accepted: 10/17/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE No randomized controlled trial has compared vaginal progesterone and cervical cerclage directly for the prevention of preterm birth in women with a sonographic short cervix in the mid trimester, singleton gestation, and previous spontaneous preterm birth. We performed an indirect comparison of vaginal progesterone vs cerclage using placebo/no cerclage as the common comparator. STUDY DESIGN Adjusted indirect metaanalysis of randomized controlled trials. RESULTS Four studies that evaluated vaginal progesterone vs placebo (158 patients) and 5 studies that evaluated cerclage vs no cerclage (504 patients) were included. Both interventions were associated with a statistically significant reduction in the risk of preterm birth at <32 weeks of gestation and composite perinatal morbidity and mortality compared with placebo/no cerclage. Adjusted indirect metaanalyses did not show statistically significant differences between vaginal progesterone and cerclage in the reduction of preterm birth or adverse perinatal outcomes. CONCLUSION Based on state-of-the-art methods for indirect comparisons, either vaginal progesterone or cerclage are equally efficacious in the prevention of preterm birth in women with a sonographic short cervix in the mid trimester, singleton gestation, and previous preterm birth. Selection of the optimal treatment needs to consider adverse events, cost and patient/clinician preferences.
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Romero R, Yeo L, Miranda J, Hassan S, Conde-Agudelo A, Chaiworapongsa T. A blueprint for the prevention of preterm birth: vaginal progesterone in women with a short cervix. J Perinat Med 2013; 41:27-44. [PMID: 23314512 PMCID: PMC4151573 DOI: 10.1515/jpm-2012-0272] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 12/07/2012] [Indexed: 12/11/2022]
Abstract
Preterm birth is the leading cause of perinatal morbidity and mortality worldwide, and is the most important challenge to modern obstetrics. A major obstacle has been that preterm birth is treated (implicitly or explicitly) as a single condition. Two thirds of preterm births occur after the spontaneous onset of labor, and the remaining one third after "indicated" preterm birth; however, the causes of spontaneous preterm labor and "indicated" preterm birth are different. Spontaneous preterm birth is a syndrome caused by multiple etiologies, one of which is a decline in progesterone action, which induces cervical ripening. A sonographic short cervix (identified in the midtrimester) is a powerful predictor of spontaneous preterm delivery. Randomized clinical trials and individual patient meta-analyses have shown that vaginal progesterone reduces the rate of preterm delivery at <33 weeks of gestation by 44%, along with the rate of admission to the neonatal intensive care unit, respiratory distress syndrome, requirement for mechanical ventilation, and composite neonatal morbidity/mortality score. There is no evidence that 17-α-hydroxyprogesterone caproate can reduce the rate of preterm delivery in women with a short cervix, and therefore, the compound of choice is natural progesterone (not the synthetic progestin). Routine assessment of the risk of preterm birth with cervical ultrasound coupled with vaginal progesterone for women with a short cervix is cost-effective, and the implementation of such a policy is urgently needed. Vaginal progesterone is as effective as cervical cerclage in reducing the rate of preterm delivery in women with a singleton gestation, history of preterm birth, and a short cervix (<25 mm).
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, MD, USA.
| | - Lami Yeo
- Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, Maryland, and Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Jezid Miranda
- Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Sonia Hassan
- Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, Maryland, and Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Agustin Conde-Agudelo
- Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, NICHD, NIH, DHHS, Bethesda, Maryland, and Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
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Di Renzo GC, Giardina I, Clerici G, Mattei A, Alajmi AH, Gerli S. The role of progesterone in maternal and fetal medicine. Gynecol Endocrinol 2012; 28:925-32. [PMID: 23057618 DOI: 10.3109/09513590.2012.730576] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Progesterone is an essential hormone in the process of reproduction. It has been extensively studied in the treatment of different gynecological pathologies, as a contraceptive and in assisted reproductive technologies. However, the use of progesterone in the pathophysiology of pregnancy remains controversial. Progesterone, and its synthetic form 17 α-hydroxyprogesterone caproate (17 OHP-C), offer an effective intervention when the continuation of pregnancy is at risk from immunological factors, luteinic and neuroendocrine deficiencies, and myometrial hypercontractility. Progesterone has been successfully used as prophylaxis in the prevention of spontaneous miscarriage, with treatment beginning from the first trimester of pregnancy. There is substantial evidence, too, to indicate that women with idiopathic recurrent miscarriage may benefit from the immunomodulatory properties of progesterone in early pregnancy. The use of progesterone and 17 OHP-C has been extensively studied in the prevention of preterm birth in a variety of settings. Transvaginal ultrasound measurement of cervical length in singleton pregnancies between 19 and 24 weeks' gestation has been deemed the best way to identify women (approximately 2% of the pregnant population) who would benefit from prophylactic progesterone treatment for the prevention of spontaneous preterm birth. This paper reviews the evidence for the safety and efficacy of the use of progesterone in each of these indications.
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Affiliation(s)
- Gian Carlo Di Renzo
- Department of Gynecology and Obstetrics, Centre for Reproductive and Perinatal Medicine, University of Perugia, Perugia, Italy.
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Khandelwal M. Vaginal progesterone in risk reduction of preterm birth in women with short cervix in the midtrimester of pregnancy. Int J Womens Health 2012; 4:481-90. [PMID: 23071418 PMCID: PMC3469232 DOI: 10.2147/ijwh.s28944] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Preterm birth is a major health problem for the neonate, family, country, and society in general. Despite many risk factors being identified for women destined to deliver preterm, short cervical length detected on transvaginal ultrasound is the most plausible, practical and sensitive risk factor for prediction of spontaneous preterm birth. The definition of short cervix has varied in various studies, but most commonly accepted is ≤2.5 cm in the midtrimester of pregnancy, though risk of spontaneous preterm birth (sPTB) increases as the cervical length decreases. Vaginal progesterone, a naturally occurring steroid hormone, is the most bioavailable form of progesterone for uterine and cervical effects with the fewest side effects. Multiple prospective studies have consistently shown its benefits in decreasing sPTB rate in women with asymptomatic midtrimester short cervix. The safety for mother and fetus, and tolerability of vaginal progesterone, particularly the gel form, is also well established. Vaginal progesterone is a minimally invasive intervention that is not painful and is very safe, with reasonable cost where the benefits (even if argued to be small) clearly outweigh the risks. Thus there should be little hesitation for implementation of universal transvaginal cervical length screening and preventive vaginal progesterone treatment for women with short cervix.
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Affiliation(s)
- Meena Khandelwal
- Department of Obstetrics and Gynecology, Cooper University Hospital, Camden, NJ, USA
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Abd El Hameed AA. Vaginal versus intramuscular progesterone in the prevention of preterm labor and their effect on uterine and fetal blood flow. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2012. [DOI: 10.1016/j.mefs.2011.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Sotiriadis A, Papatheodorou S, Makrydimas G. Perinatal outcome in women treated with progesterone for the prevention of preterm birth: a meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:257-266. [PMID: 22611023 DOI: 10.1002/uog.11178] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/05/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To quantify the effect on perinatal outcome in women treated with progesterone for the prevention of preterm birth. METHODS MEDLINE and SCOPUS searches, including references of the retrieved articles and additional automated search using the 'search for related articles' PubMed function, were used. Randomized controlled trials assigning women at risk for preterm birth to progesterone or placebo were included (both singleton and multiple pregnancies). Outcomes were neonatal and perinatal death, respiratory distress syndrome (RDS), retinopathy, necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH) Grade 3-4, sepsis, admission to the neonatal intensive care unit (NICU) and composite adverse outcome. RESULTS Sixteen studies (singletons, n = 7; twins, n = 7; triplets, n = 2) were included in the meta-analysis. For singleton pregnancies, progesterone reduced the rates of neonatal death (risk ratio (RR) 0.487 (95% CI, 0.290-0.818)), RDS (RR 0.677 (95% CI, 0.490-0.935)), NICU admission (RR 0.410 (95% CI, 0.204-0.823)) and composite adverse outcome (RR 0.576 (95% CI, 0.373-0.891)). No favorable effect was observed in twins; in fact, progesterone was associated with increased rates of perinatal death (RR 1.551 (95% CI, 1.014-2.372)), RDS (RR 1.218 (95% CI, 1.038-1.428)) and composite adverse outcome (RR 1.211 (95% CI, 1.029-1.425)). No significant effect was observed in triplet pregnancies. CONCLUSION Progesterone administration in singleton pregnancies at risk for preterm birth improves perinatal outcomes, but may actually have adverse effects in multiple pregnancies.
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Affiliation(s)
- A Sotiriadis
- Second Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
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90
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Hernandez-Andrade E, Romero R, Ahn H, Hussein Y, Yeo L, Korzeniewski SJ, Chaiworapongsa T, Hassan SS. Transabdominal evaluation of uterine cervical length during pregnancy fails to identify a substantial number of women with a short cervix. J Matern Fetal Neonatal Med 2012; 25:1682-9. [PMID: 22273078 PMCID: PMC3422449 DOI: 10.3109/14767058.2012.657278] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the diagnostic performance of transabdominal sonographic measurement of cervical length in identifying patients with a short cervix. METHODS Cervical length was measured in 220 pregnant women using transabdominal and transvaginal ultrasound (US). Reproducibility and agreement between and within both methods were assessed. The diagnostic accuracy of transabdominal US for identifying cases with a cervical length <25 mm was evaluated. RESULTS Twenty-one out of 220 cases (9.5%) had a cervical length <25 mm by transvaginal US. Only 43% (n = 9) of patients with a short cervix were correctly identified by transabdominal US. In patients with a cervical length of <25 mm by transvaginal US, transabdominal measurement of the cervix overestimated this parameter by an average of 8 mm (95% LOAs, -26.4 to 10.5 mm). Among women without a short cervix, transabdominal US underestimated cervical length on average (LOA) by 1.1 mm (95% LOAs, -11.0 to 13.2 mm). Transvaginal US was also more reproducible (intraclass correlation coefficient: (ICC) (0.96; 95% CI, 0.94 to 0.97) based on comparisons between 2D images and immediately acquired 3D volume datasets relative to transabdominal US (ICC: 0.71; 95% CI, 0.57 to 0.84). Transvaginal US detected 13 cases with funneling and six cases with sludge whereas only three cases of funneling and one of sludge were detected by transabdominal US. CONCLUSION Transabdominal measurement overestimated cervical LOA by 8 mm among women with a short cervix and resulted in the underdiagnosis of 57% of cases.
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Affiliation(s)
- Edgar Hernandez-Andrade
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Roberto Romero
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, MI, USA
| | - Hyunyoung Ahn
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, MI, USA
| | - Youssef Hussein
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, MI, USA
| | - Lami Yeo
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Steven J. Korzeniewski
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Sonia S Hassan
- Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
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91
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Serra V, Perales A, Meseguer J, Parrilla JJ, Lara C, Bellver J, Grifol R, Alcover I, Sala M, Martínez-Escoriza JC, Pellicer A. Increased doses of vaginal progesterone for the prevention of preterm birth in twin pregnancies: a randomised controlled double-blind multicentre trial. BJOG 2012; 120:50-7. [DOI: 10.1111/j.1471-0528.2012.03448.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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92
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Parry S, Simhan H, Elovitz M, Iams J. Universal maternal cervical length screening during the second trimester: pros and cons of a strategy to identify women at risk of spontaneous preterm delivery. Am J Obstet Gynecol 2012; 207:101-6. [PMID: 22633270 DOI: 10.1016/j.ajog.2012.04.021] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 03/20/2012] [Accepted: 04/18/2012] [Indexed: 11/26/2022]
Abstract
Three large randomized controlled trials investigating the efficacy of universal cervical length screening and treatment with vaginal progesterone or cervical cerclage to prevent preterm delivery have been published over the past several years. None of these trials demonstrate proven efficacy for universal cervical length screening and cerclage placement in women with short cervical length. However, universal cervical length screening and treatment with daily vaginal progesterone in women with short cervical length reduces the risk of preterm birth, but large numbers of women must be screened to prevent a relatively small number of preterm deliveries. Issues that should be considered while implementing universal cervical length screening include: (1) standards of quality and reproducibility for transvaginal ultrasound cervical length ascertainment; (2) implications of screening on the application of therapeutic strategies to populations not known to benefit (so-called "indication creep"); and (3) willingness of obstetricians to prescribe vaginal progesterone formulations that are not approved by the US Food and Drug Administration for preterm birth prevention. Optimal strategies to employ cervical ultrasound and progesterone treatment might be revealed by additional studies investigating cervical length cutoffs, frequency of screening, selective screening in higher-risk groups, and the use of transabdominal cervical length screening as a surrogate for transvaginal cervical length screening.
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93
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Abstract
Preterm birth is a significant problem in the United States, contributing to neonatal morbidity and mortality. Progesterone is a hormone naturally produced by the corpus luteum and the placenta in early pregnancy and is essential for maintaining pregnancy. Clinicians and researchers have used this hormone in later gestation to try to prevent preterm birth. However, mechanisms of action, indications for use, dosing and administration have varied and are not fully understood. This article revisits two recent randomized controlled trials in which researchers investigated the effectiveness of vaginal progesterone suppositories and gel in the prevention of preterm birth among women who were at high risk for delivering prematurely.
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Affiliation(s)
- Holly B Fontenot
- William F. Connell School of Nursing, Boston College, Chestnut Hill, MA, USA.
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94
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Progesterone and preterm birth prevention: translating clinical trials data into clinical practice. Am J Obstet Gynecol 2012; 206:376-86. [PMID: 22542113 DOI: 10.1016/j.ajog.2012.03.010] [Citation(s) in RCA: 231] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 03/13/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We sought to provide evidence-based guidelines for using progestogens for the prevention of preterm birth (PTB). METHODS Relevant documents, in particular randomized trials, were identified using PubMed (US National Library of Medicine, 1983 through February 2012) publications, written in English, which evaluate the effectiveness of progestogens for prevention of PTB. Progestogens evaluated were, in particular, vaginal progesterone and 17-alpha-hydroxy-progesterone caproate. Additionally, the Cochrane Library, organizational guidelines, and studies identified through review of the above were utilized to identify relevant articles. Data were evaluated according to population studied, with separate analyses for singleton vs multiple gestations, prior PTB, or short transvaginal ultrasound cervical length (CL), and combinations of these factors. Consistent with US Preventive Task Force suggestions, references were evaluated for quality based on the highest level of evidence, and recommendations were graded. RESULTS AND RECOMMENDATIONS Summary of randomized studies indicates that in women with singleton gestations, no prior PTB, and short CL ≤ 20 mm at ≤ 24 weeks, vaginal progesterone, either 90-mg gel or 200-mg suppository, is associated with reduction in PTB and perinatal morbidity and mortality, and can be offered in these cases. The issue of universal CL screening of singleton gestations without prior PTB for the prevention of PTB remains an object of debate. CL screening in singleton gestations without prior PTB cannot yet be universally mandated. Nonetheless, implementation of such a screening strategy can be viewed as reasonable, and can be considered by individual practitioners, following strict guidelines. In singleton gestations with prior PTB 20-36 6/7 weeks, 17-alpha-hydroxy-progesterone caproate 250 mg intramuscularly weekly, preferably starting at 16-20 weeks until 36 weeks, is recommended. In these women with prior PTB, if the transvaginal ultrasound CL shortens to < 25 mm at < 24 weeks, cervical cerclage may be offered. Progestogens have not been associated with prevention of PTB in women who have in the current pregnancy multiple gestations, preterm labor, or preterm premature rupture of membranes. There is insufficient evidence to recommend the use of progestogens in women with any of these risk factors, with or without a short CL.
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95
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Schuit E, Stock S, Groenwold RHH, Maurel K, Combs CA, Garite T, Spong CY, Thom EA, Rouse DJ, Caritis SN, Saade GR, Zachary JM, Norman JE, Rode L, Klein K, Tabor A, Cetingöz E, Morrison JC, Magann EF, Briery CM, Serra V, Perales A, Meseguer J, Nassar AH, Lim AC, Moons KGM, Kwee A, Mol BWJ. Progestogens to prevent preterm birth in twin pregnancies: an individual participant data meta-analysis of randomized trials. BMC Pregnancy Childbirth 2012; 12:13. [PMID: 22420582 PMCID: PMC3315727 DOI: 10.1186/1471-2393-12-13] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 03/15/2012] [Indexed: 12/02/2022] Open
Abstract
Background Preterm birth is the principal factor contributing to adverse outcomes in multiple pregnancies. Randomized controlled trials of progestogens to prevent preterm birth in twin pregnancies have shown no clear benefits. However, individual studies have not had sufficient power to evaluate potential benefits in women at particular high risk of early delivery (for example, women with a previous preterm birth or short cervix) or to determine adverse effects for rare outcomes such as intrauterine death. Methods/design We propose an individual participant data meta-analysis of high quality randomized, double-blind, placebo-controlled trials of progestogen treatment in women with a twin pregnancy. The primary outcome will be adverse perinatal outcome (a composite measure of perinatal mortality and significant neonatal morbidity). Missing data will be imputed within each original study, before data of the individual studies are pooled. The effects of 17-hydroxyprogesterone caproate or vaginal progesterone treatment in women with twin pregnancies will be estimated by means of a random effects log-binomial model. Analyses will be adjusted for variables used in stratified randomization as appropriate. Pre-specified subgroup analysis will be performed to explore the effect of progestogen treatment in high-risk groups. Discussion Combining individual patient data from different randomized trials has potential to provide valuable, clinically useful information regarding the benefits and potential harms of progestogens in women with twin pregnancy overall and in relevant subgroups.
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Affiliation(s)
- Ewoud Schuit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands.
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96
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Obstetric interventions beneficial to prematurely delivering newborn babies: antenatal corticostetroids, progesterone, magnesium sulfate. Clin Perinatol 2012; 39:33-45. [PMID: 22341535 DOI: 10.1016/j.clp.2011.12.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Although improvements in neonatal care have continued to result in reduced mortality and morbidity of prematurely delivering newborns for decades, the results of a myriad of obstetric efforts and interventions have failed to reduce the overall rate of prematurity or prolong pregnancy at any gestational age. A few new developments or refinements of established interventions give increased hope for an improved obstetric contribution to the problem of prematurity. These include a better understanding of how best to use antenatal corticosteroids, and the newer options of magnesium sulfate to ameliorate or avoid cerebral palsy associated with prematurity and maternal progesterone administration to selected at-risk populations to decrease the likelihood of premature delivery.
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97
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Romero R, Nicolaides K, Conde-Agudelo A, Tabor A, O'Brien JM, Cetingoz E, Da Fonseca E, Creasy GW, Klein K, Rode L, Soma-Pillay P, Fusey S, Cam C, Alfirevic Z, Hassan SS. Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and metaanalysis of individual patient data. Am J Obstet Gynecol 2012; 206:124.e1-19. [PMID: 22284156 PMCID: PMC3437773 DOI: 10.1016/j.ajog.2011.12.003] [Citation(s) in RCA: 337] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To determine whether the use of vaginal progesterone in asymptomatic women with a sonographic short cervix (≤ 25 mm) in the midtrimester reduces the risk of preterm birth and improves neonatal morbidity and mortality. STUDY DESIGN Individual patient data metaanalysis of randomized controlled trials. RESULTS Five trials of high quality were included with a total of 775 women and 827 infants. Treatment with vaginal progesterone was associated with a significant reduction in the rate of preterm birth <33 weeks (relative risk [RR], 0.58; 95% confidence interval [CI], 0.42-0.80), <35 weeks (RR, 0.69; 95% CI, 0.55-0.88), and <28 weeks (RR, 0.50; 95% CI, 0.30-0.81); respiratory distress syndrome (RR, 0.48; 95% CI, 0.30-0.76); composite neonatal morbidity and mortality (RR, 0.57; 95% CI, 0.40-0.81); birthweight <1500 g (RR, 0.55; 95% CI, 0.38-0.80); admission to neonatal intensive care unit (RR, 0.75; 95% CI, 0.59-0.94); and requirement for mechanical ventilation (RR, 0.66; 95% CI, 0.44-0.98). There were no significant differences between the vaginal progesterone and placebo groups in the rate of adverse maternal events or congenital anomalies. CONCLUSION Vaginal progesterone administration to asymptomatic women with a sonographic short cervix reduces the risk of preterm birth and neonatal morbidity and mortality.
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
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98
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Vaginal micronized natural progesterone treatment and reduced risk of recurrent preterm birth. ACTA ACUST UNITED AC 2012. [DOI: 10.5468/kjog.2012.55.10.699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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99
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Ierullo AM, Fernandez S, Palacio M, Gratacos E, Hernandez-Andrade E. Cervical blood perfusion assessed using power Doppler-derived estimation of fractional moving blood volume: a reproducibility study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:57-61. [PMID: 21584885 DOI: 10.1002/uog.8974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/11/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To evaluate the reproducibility of estimation of power Doppler-derived fractional moving blood volume (FMBV) in the uterine cervix of women with uncomplicated pregnancies. METHODS Two experienced operators evaluated 30 uncomplicated singleton pregnancies at 20-24 weeks of gestation. The PDU box was positioned in a mid-sagittal view of the cervix, including the internal os and external os, in the same plane as that in which cervical length is measured. Two consecutive examinations were performed by each operator, in each of which the cervical length was measured and five consecutive good-quality images with PDU information were obtained. The region of interest (ROI) (cervix) was delineated offline and FMBV, which expresses the percentage of blood occupying the ROI, was calculated with purpose-designed software. Intra- and interobserver intraclass correlation coefficients (ICCs) and mean differences with 95% limits of agreement (LOA) were calculated. RESULTS The median gestational age at examination was 22 + 0 weeks. Measurements (median ± SD) obtained for cervical length and FMBV were as follows: Operator A: 37 ± 7.4 mm and 8.11 ± 2.9%; Operator B: 37.5 ± 9.3 mm and 7.9 ± 3.3%, respectively. The intra- and interobserver ICCs for FMBV were 0.88 (95% CI, 0.75-0.94) and 0.82 (95% CI, 0.64-0.94), respectively. There was a mean difference in FMBV measurement between operators of - 0.2 ± 1.75% (95% LOA, - 3.7 to 3.2%). CONCLUSIONS Reproducible assessment of cervical blood perfusion through estimation of FMBV can be achieved while cervical length is being measured.
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Affiliation(s)
- A M Ierullo
- Department of Maternal-Fetal Medicine, ICGON, Hospital Clinic-IDIBAPS, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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100
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Hassan SS, Romero R, Vidyadhari D, Fusey S, Baxter JK, Khandelwal M, Vijayaraghavan J, Trivedi Y, Soma-Pillay P, Sambarey P, Dayal A, Potapov V, O'Brien J, Astakhov V, Yuzko O, Kinzler W, Dattel B, Sehdev H, Mazheika L, Manchulenko D, Gervasi MT, Sullivan L, Conde-Agudelo A, Phillips JA, Creasy GW. Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:18-31. [PMID: 21472815 PMCID: PMC3482512 DOI: 10.1002/uog.9017] [Citation(s) in RCA: 590] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/05/2011] [Indexed: 05/13/2023]
Abstract
OBJECTIVES Women with a sonographic short cervix in the mid-trimester are at increased risk for preterm delivery. This study was undertaken to determine the efficacy and safety of using micronized vaginal progesterone gel to reduce the risk of preterm birth and associated neonatal complications in women with a sonographic short cervix. METHODS This was a multicenter, randomized, double-blind, placebo-controlled trial that enrolled asymptomatic women with a singleton pregnancy and a sonographic short cervix (10-20 mm) at 19 + 0 to 23 + 6 weeks of gestation. Women were allocated randomly to receive vaginal progesterone gel or placebo daily starting from 20 to 23 + 6 weeks until 36 + 6 weeks, rupture of membranes or delivery, whichever occurred first. Randomization sequence was stratified by center and history of a previous preterm birth. The primary endpoint was preterm birth before 33 weeks of gestation. Analysis was by intention to treat. RESULTS Of 465 women randomized, seven were lost to follow-up and 458 (vaginal progesterone gel, n=235; placebo, n=223) were included in the analysis. Women allocated to receive vaginal progesterone had a lower rate of preterm birth before 33 weeks than did those allocated to placebo (8.9% (n=21) vs 16.1% (n=36); relative risk (RR), 0.55; 95% CI, 0.33-0.92; P=0.02). The effect remained significant after adjustment for covariables (adjusted RR, 0.52; 95% CI, 0.31-0.91; P=0.02). Vaginal progesterone was also associated with a significant reduction in the rate of preterm birth before 28 weeks (5.1% vs 10.3%; RR, 0.50; 95% CI, 0.25-0.97; P=0.04) and 35 weeks (14.5% vs 23.3%; RR, 0.62; 95% CI, 0.42-0.92; P=0.02), respiratory distress syndrome (3.0% vs 7.6%; RR, 0.39; 95% CI, 0.17-0.92; P=0.03), any neonatal morbidity or mortality event (7.7% vs 13.5%; RR, 0.57; 95% CI, 0.33-0.99; P=0.04) and birth weight < 1500 g (6.4% (15/234) vs 13.6% (30/220); RR, 0.47; 95% CI, 0.26-0.85; P=0.01). There were no differences in the incidence of treatment-related adverse events between the groups. CONCLUSIONS The administration of vaginal progesterone gel to women with a sonographic short cervix in the mid-trimester is associated with a 45% reduction in the rate of preterm birth before 33 weeks of gestation and with improved neonatal outcome.
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Affiliation(s)
- S S Hassan
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, USA
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