201
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Effects of a Multi-site Expansion of Group Prenatal Care on Birth Outcomes. Matern Child Health J 2019; 23:1424-1433. [DOI: 10.1007/s10995-019-02795-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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202
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Kanninen TT, Moretti ML, Lakhi NA. Autoimmune progesterone dermatitis following vaginal progesterone exposure in pregnancy. Obstet Med 2019; 12:100-102. [PMID: 31217816 DOI: 10.1177/1753495x18771255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In the non-pregnant state, exogenous as well as endogenous fluctuations of progesterone have been demonstrated to cause a rare delayed hypersensitivity reaction known as autoimmune progesterone dermatitis. We describe the case of a 20-year-old woman in her second pregnancy who presented to our delivery unit at 31 weeks and 3 days gestation for a cutaneous breakout with pruritic pustules, blisters, and crusts across her chest back and extremities 23 days after the initiation of vaginal progesterone. After suspension of the vaginal progesterone, the patient's cutaneous lesions resolved. Differential diagnosis and management strategies are discussed. With the increased use of progesterone during pregnancy, complications arising from their use will rise. Clinicians should be aware of their potential adverse effects and consider autoimmune progesterone dermatitis in the differential diagnosis of patients presenting with pruritic lesion in pregnancy.
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Affiliation(s)
- Tomi T Kanninen
- Department of Obstetrics and Gynecology, Richmond University Medical Center, Staten Island, USA.,Department of Obstetrics and Gynecology, New York Medical College, Valhalla, USA
| | - Michael L Moretti
- Department of Obstetrics and Gynecology, Richmond University Medical Center, Staten Island, USA.,Department of Obstetrics and Gynecology, New York Medical College, Valhalla, USA
| | - Nisha A Lakhi
- Department of Obstetrics and Gynecology, Richmond University Medical Center, Staten Island, USA.,Department of Obstetrics and Gynecology, New York Medical College, Valhalla, USA
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203
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Nelson DB, McIntire DD, Leveno KJ. Defining 17OHP-C responsiveness. Am J Obstet Gynecol 2019; 220:608. [PMID: 30790571 DOI: 10.1016/j.ajog.2019.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 02/14/2019] [Indexed: 11/18/2022]
Affiliation(s)
- David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX.
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
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204
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Abstract
Preterm birth can be medically-indicated or spontaneous. Almost half of spontaneous preterm deliveries are preceded by preterm labor. Preterm labor is a clinical diagnosis characterized by regular uterine contractions (painful or painless) with concomitant cervical change. This article discusses the prevention and treatment of spontaneous preterm labor utilizing progesterone and tocolytic agents and provides management recommendations in patients with and without a history of prior spontaneous preterm birth.
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Affiliation(s)
- Soha S Patel
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, B-1100 Medical Center North, Nashville, TN 37232-2519, USA.
| | - Jack Ludmir
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Thomas Jefferson University, 1020 Walnut Street, Philadelphia, PA 19107, USA
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205
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Hauspurg A, Lemon L, Venkataramanan R, Caritis SN. Reply. Am J Obstet Gynecol 2019; 220:608-609. [PMID: 30790567 DOI: 10.1016/j.ajog.2019.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/14/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Alisse Hauspurg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, Magee-Womens Hospital of the University of Pittsburgh, Pittsburgh, PA.
| | - Lara Lemon
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pitsburgh, PA
| | - Steve N Caritis
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, Magee-Womens Hospital of the University of Pittsburgh, Pittsburgh, PA
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206
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Abstract
Pregnancy profoundly alters a woman's physiology. These changes alter drug absorption, distribution, metabolism, and elimination and emphasize the pharmacologic complexity of pregnancy. They also emphasize the dangers of extrapolating pharmacologic expectations from nonpregnant populations to pregnant women and their fetuses. Although concerns about fetal safety have historically limited pharmacokinetic studies during pregnancy, it is important to recognize that many medications are clinically indicated for various maternal or fetal conditions, and it is particularly important that these therapies be evidence-based with appropriate study, including short-term and long-term outcomes data.
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Affiliation(s)
- Robert M Ward
- Pediatrics, Pediatric Clinical Pharmacology, University of Utah, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108, USA.
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B 200, Salt Lake City, UT 84132, USA
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207
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Salim R, Hakim M, Zafran N, Nachum Z, Romano S, Garmi G. Double-blind randomized trial of progesterone to prevent preterm birth in second-trimester bleeding. Acta Obstet Gynecol Scand 2019; 98:1318-1325. [PMID: 31087325 DOI: 10.1111/aogs.13641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 04/13/2019] [Accepted: 04/28/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Second-trimester vaginal bleeding increases the risk of spontaneous preterm birth. We aimed to examine the efficacy of vaginal progesterone to reduce preterm birth rate in women with second-trimester vaginal bleeding. MATERIAL AND METHODS Two-center, double-blind, placebo-controlled trial involving pregnant women with second-trimester vaginal bleeding. Women with documented uterine bleeding were randomly assigned in a 1:1 ratio to receive 200 mg of micronized vaginal progesterone or placebo once daily at 16-26 weeks until 36 weeks of gestation. Women who had prior preterm birth or short cervix diagnosed before recruitment were not eligible. The primary outcome was spontaneous delivery <37 weeks. CLINICAL TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01269450. RESULTS Between March 2011 and January 2017, 128 women gave consent and were randomized; 16 withdrew consent and 3 had a second-trimester termination of pregnancy. The final analysis included 109 women: 60 in the progesterone group and 49 in the placebo group. Demographic and obstetric characteristics did not differ between the groups. Primary outcome occurred in 19 (31.7%) and 12 (24.5%) in the progesterone and placebo groups, respectively (odds ratio [OR] 1.32; 95% confidence interval [CI] 0.55-3.16; P = 0.53). The proportion of births <34 weeks was similar between the groups (OR 1.19; 95% CI 0.47-3.02; P = 0.72), as were the survival curves from randomization to delivery (hazard ratio, 1.24; 95% CI, 0.60-2.56; P = 0.57). There were no significant differences in neonatal morbidities between the groups. The study was ended prematurely because of slow recruitment. CONCLUSIONS Antepartum vaginal progesterone does not seem to reduce the incidence of preterm birth in women with second-trimester bleeding.
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Affiliation(s)
- Raed Salim
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Marwan Hakim
- Nazareth Hospital EMMS, Nazareth, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Noah Zafran
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Zohar Nachum
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Shabtai Romano
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Gali Garmi
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
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208
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Ma'ayeh M, Rood KM, Walker HC, Oliver EA, Gee SE, Iams JD. Vaginal progesterone is associated with decreased group B streptococcus colonisation at term: a retrospective cohort study. BJOG 2019; 126:1141-1147. [DOI: 10.1111/1471-0528.15801] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2019] [Indexed: 11/28/2022]
Affiliation(s)
- M Ma'ayeh
- Department of Obstetrics and Gynecology The Ohio State University College of Medicine Columbus OH USA
| | - KM Rood
- Department of Obstetrics and Gynecology The Ohio State University College of Medicine Columbus OH USA
| | - HC Walker
- Department of Obstetrics and Gynecology The Ohio State University College of Medicine Columbus OH USA
| | - EA Oliver
- Department of Obstetrics and Gynecology The Ohio State University College of Medicine Columbus OH USA
| | - SE Gee
- Department of Obstetrics and Gynecology The Ohio State University College of Medicine Columbus OH USA
| | - JD Iams
- Department of Obstetrics and Gynecology The Ohio State University College of Medicine Columbus OH USA
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209
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Kalata M, Teter K, Wagner L, Swarr V, Witzeman K. Understanding barriers to uptake of 17 alpha-hydroxyprogesterone caproate (17-OHP) in women with history of preterm birth. J Matern Fetal Neonatal Med 2019; 34:541-546. [PMID: 31006296 DOI: 10.1080/14767058.2019.1610736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Premature birth is responsible for approximately 38% of infant deaths as well as a host of complications, including abnormal lung development, infection, and long-term disabilities. For women with a history of spontaneous preterm birth in a singleton pregnancy, use of 17 alpha-hydroxyprogesterone caproate (17-OHP) can reduce the risk of a recurrent preterm birth by up to 42%. However, less than half of eligible women currently receive 17-OHP.Objectives: The purpose of this study was to understand the barriers to access and acceptability of 17-OHP use from the patient perspective.Study design: A qualitative study was conducted of women with a history of a prior spontaneous, singleton preterm birth who were eligible for 17-OHP during a subsequent singleton pregnancy. Researchers recruited 118 eligible women during the Spring and Summer of 2018 from a safety-net hospital in Denver, CO, USA, a hospital that provides healthcare for individuals regardless of their insurance status or ability to pay. Responses from 35 participants were analyzed, looking at themes surrounding knowledge of and counseling received regarding 17-OHP, hesitations, and barriers toward receiving the treatment.Results: Among respondents (34.0% response rate), the mean age was 31.5 years and mean gestational age at delivery was 32.1 weeks. Major themes from interviews included reasons that encouraged women to use 17-OHP, such as the desire to do anything for the health of their baby and reasons that women felt discouraged from using 17-OHP, including unknown complications and lack of information. Other barriers to this treatment method included the time commitment, specifically the length of clinic appointments and concerns about the safety of the 17-OHP injection.Conclusions: One of the strongest reasons for women choosing to use 17-OHP was a desire to do anything possible to support their babies. Somewhat surprisingly, there was not a significant relationship with the participants between gestational age of prior preterm deliveries and subsequent use of 17-OHP. There were two important reasons women cited most frequently for choosing not to use 17-OHP. One was feeling that they lacked information or knowledge about 17-OHP to make an informed decision, which is crucial because the study also showed that all eligible women are not being appropriately counseled on the option of 17-OHP. In terms of time commitment, it was the length of individual appointments, rather than frequency that was a barrier to receiving weekly injections.
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Affiliation(s)
- Megan Kalata
- School of Medicine, University of Colorado Denver, Denver, CO, USA
| | | | - Lisa Wagner
- Denver Health and Hospital Authority, Montbello Family Health Center, Denver, CO, USA
| | - Vicki Swarr
- Tri-County Health Department, Greenwood Village, CO, USA
| | - Kathryn Witzeman
- Denver Health and Hospital Authority, Women's Care Clinic, Denver, CO, USA
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210
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Miller ES, Sakowicz A, Roy A, Liu LY, Yee LM. The association between 17-hydroxyprogesterone caproate use and postpartum hemorrhage. Am J Obstet Gynecol MFM 2019; 1:144-147. [PMID: 32914089 DOI: 10.1016/j.ajogmf.2019.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate whether receipt of 17α-hydroxyprogesterone caproate within seven days of delivery is associated with increased risk of postpartum hemorrhage. STUDY DESIGN This was a retrospective cohort study of women who were receiving 17α-hydroxyprogesterone caproate for preterm birth prevention and delivered between 2010 and 2014. Women were dichotomized by whether a dose of 17α-hydroxyprogesterone caproate was administered within seven days of delivery. Demographic and clinical characteristics were examined, including obstetric history and details of 17α-hydroxyprogesterone caproate receipt. Bivariable analyses were used to compare the frequency of postpartum hemorrhage in women stratified by 17α-hydroxyprogesterone caproate receipt within seven days of delivery. Multivariable analysis was used to adjust for potential confounders. RESULTS Of 221 women who met inclusion criteria, 93 (42%) received 17α-hydroxyprogesterone caproate within seven days of delivery and 18 (7.8%) experienced a postpartum hemorrhage. No differences were observed in the frequency of postpartum hemorrhage between women who did and did not deliver within seven days of 17α-hydroxyprogesterone caproate injection (9.7% vs 7.0%, p=0.478). These findings persisted after adjusting for potential confounders (aOR for PPH 2.9, 95% CI, 0.5-15.8). CONCLUSION Recent receipt of 17α-hydroxyprogesterone caproate for prevention of recurrent preterm birth is not associated with risk of postpartum hemorrhage.
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Affiliation(s)
- Emily S Miller
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Allie Sakowicz
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Archana Roy
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lilly Y Liu
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lynn M Yee
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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211
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Norman JE, Marlow N, Messow CM, Shennan A, Bennett PR, Thornton S, Robson SC, McConnachie A, Petrou S, Sebire NJ, Lavender T, Whyte S, Norrie J. Does progesterone prophylaxis to prevent preterm labour improve outcome? A randomised double-blind placebo-controlled trial (OPPTIMUM). Health Technol Assess 2019; 22:1-304. [PMID: 29945711 DOI: 10.3310/hta22350] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Progesterone prophylaxis is widely used to prevent preterm birth but is not licensed and there is little information on long-term outcome. OBJECTIVE To determine the effect of progesterone prophylaxis in women at high risk of preterm birth on obstetric, neonatal and childhood outcomes. DESIGN Double-blind, randomised placebo-controlled trial. SETTING Obstetric units in the UK and Europe between February 2009 and April 2013. PARTICIPANTS Women with a singleton pregnancy who are at high risk of preterm birth because of either a positive fibronectin test or a negative fibronectin test, and either previous spontaneous birth at ≤ 34 weeks+0 of gestation or a cervical length of ≤ 25 mm. INTERVENTIONS Fibronectin test at 18+0 to 23+0 weeks of pregnancy to determine risk of preterm birth. Eligible women were allocated (using a web-based randomisation portal) to 200 mg of progesterone or placebo, taken vaginally daily from 22+0 to 24+0 until 34+0 weeks' gestation. Participants, caregivers and those assessing the outcomes were blinded to group assignment until data collection was complete. MAIN OUTCOME MEASURES There were three primary outcomes, as follows: (1) obstetric - fetal death or delivery before 34+0 weeks' gestation; (2) neonatal - a composite of death, brain injury on ultrasound scan (according to specific criteria in the protocol) and bronchopulmonary dysplasia; and (3) childhood - the Bayley-III cognitive composite score at 22-26 months of age. RESULTS In total, 96 out of 600 (16%) women in the progesterone group and 108 out of 597 (18%) women in the placebo group had the primary obstetric outcome [odds ratio (OR) 0.86, 95% confidence interval (CI) 0.61 to 1.22]. Forty-six out of 589 (8%) babies of women in the progesterone group and 62 out of 587 (11%) babies of
women in the placebo group experienced the primary neonatal outcome [OR 0.72, 95% CI 0.44 to 1.17]. The mean Bayley-III cognitive composite score of the children at 2 years of age was 97.3 points [standard deviation (SD) 17.9 points; n = 430] in the progesterone group and 97.7 points (SD 17.5 points; n = 439) in the placebo group (difference in means -0.48, 95% CI -2.77 to 1.81). LIMITATIONS Overall compliance with the intervention was 69%. HARMS There were no major harms, although there was a trend of more deaths from trial entry to 2 years in the progesterone group (20/600) than in the placebo group (16/598) (OR 1.26, 95% CI 0.65 to 2.42). CONCLUSIONS In this study, progesterone had no significant beneficial or harmful effects on the primary obstetric, neonatal or childhood outcomes.The OPPTIMUM trial is now complete. We intend to participate in a comprehensive individual patient-level data meta-analysis examining women with a singleton pregnancy with a variety of risk factors for preterm birth. TRIAL REGISTRATION Current Controlled Trials ISRCTN14568373. FUNDING This trial was funded by the Medical Research Council (MRC) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership.
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Affiliation(s)
- Jane E Norman
- Tommy's Centre for Maternal and Fetal Health, MRC Centre for Maternal and Fetal Health, University of Edinburgh, Edinburgh, UK
| | - Neil Marlow
- Institute of Women's Health, University College London, London, UK
| | - Claudia-Martina Messow
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Andrew Shennan
- Women's Health Academic Centre, King's College London, London, UK
| | - Philip R Bennett
- Obstetrics and Gynaecology, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Steven Thornton
- Obstetrics and Gynaecology (Barts), Queen Mary University of London, London, UK
| | | | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Stavros Petrou
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Neil J Sebire
- Institute of Women's Health, University College London, London, UK
| | - Tina Lavender
- School of Nursing, University of Manchester, Manchester, UK
| | - Sonia Whyte
- Tommy's Centre for Maternal and Fetal Health, MRC Centre for Maternal and Fetal Health, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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212
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Mesiano SA, Peters GA, Amini P, Wilson RA, Tochtrop GP, van Den Akker F. Progestin therapy to prevent preterm birth: History and effectiveness of current strategies and development of novel approaches. Placenta 2019; 79:46-52. [PMID: 30745115 PMCID: PMC6766339 DOI: 10.1016/j.placenta.2019.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 01/11/2019] [Accepted: 01/19/2019] [Indexed: 10/27/2022]
Abstract
In the 1930s the "progestin" hormone produced by the corpus luteum was isolated and found to be a Δ4-keto-steroid. It was aptly named progesterone (P4) and in the following 30 years the capacity of P4 and derivatives to prevent preterm birth (PTB) was examined. Outcomes of multiple small studies suggested that progestin prophylaxis beginning at mid-gestation decreases the risk for PTB. Subsequent larger trials found that prophylaxis with weekly intramuscular injections of 17α-hydroxyprogesterone caproate (17HPC) beginning at mid-gestation decreased PTB risk in women with a history of PTB. Other trials found that daily vaginal P4 prophylaxis, also beginning at mid-gestation decreased PTB risk in women with a short cervix. Currently, prophylaxis with 17HPC (in women with a history of PTB) or vaginal P4 (in women with a short cervix) are used to prevent PTB. Recent advances in understanding the molecular biology of P4 signaling in uterine cells is revealing novel progestin-based targets for PTB prevention. One possibility is to use selective P4 receptor (PR) modulators (SPRMs) to boost PR anti-inflammatory activity that blocks labor, while simultaneously preventing PR phosphorylation that causes loss of P4/PR anti-inflammatory activity. This may be achieved by SPRMs that induce a specific PR conformation that prevents site-specific serine phosphorylation that inhibits anti-inflammatory activity. Further advances in understanding how P4 promotes uterine quiescence and how its labor blocking actions are withdrawn to trigger parturition will reveal novel therapeutic targets to more effectively prevent PTB.
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Affiliation(s)
- Sam A Mesiano
- Department of Reproductive Biology, Case Western Reserve University, Cleveland, OH, USA; Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| | - Gregory A Peters
- Department of Reproductive Biology, Case Western Reserve University, Cleveland, OH, USA
| | - Peyvand Amini
- Department of Reproductive Biology, Case Western Reserve University, Cleveland, OH, USA
| | - Rachel A Wilson
- Department of Reproductive Biology, Case Western Reserve University, Cleveland, OH, USA
| | - Gregory P Tochtrop
- Department of Chemistry, Case Western Reserve University, Cleveland, OH, USA
| | - Focco van Den Akker
- Department of Biochemistry, Case Western Reserve University, Cleveland, OH, USA
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213
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Arenas-Hernandez M, Romero R, Xu Y, Panaitescu B, Garcia-Flores V, Miller D, Ahn H, Done B, Hassan SS, Hsu CD, Tarca AL, Sanchez-Torres C, Gomez-Lopez N. Effector and Activated T Cells Induce Preterm Labor and Birth That Is Prevented by Treatment with Progesterone. THE JOURNAL OF IMMUNOLOGY 2019; 202:2585-2608. [PMID: 30918041 DOI: 10.4049/jimmunol.1801350] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 02/26/2019] [Indexed: 12/21/2022]
Abstract
Preterm labor commonly precedes preterm birth, the leading cause of perinatal morbidity and mortality worldwide. Most research has focused on establishing a causal link between innate immune activation and pathological inflammation leading to preterm labor and birth. However, the role of maternal effector/activated T cells in the pathogenesis of preterm labor/birth is poorly understood. In this study, we first demonstrated that effector memory and activated maternal T cells expressing granzyme B and perforin are enriched at the maternal-fetal interface (decidua) of women with spontaneous preterm labor. Next, using a murine model, we reported that prior to inducing preterm birth, in vivo T cell activation caused maternal hypothermia, bradycardia, systemic inflammation, cervical dilation, intra-amniotic inflammation, and fetal growth restriction, all of which are clinical signs associated with preterm labor. In vivo T cell activation also induced B cell cytokine responses, a proinflammatory macrophage polarization, and other inflammatory responses at the maternal-fetal interface and myometrium in the absence of an increased influx of neutrophils. Finally, we showed that treatment with progesterone can serve as a strategy to prevent preterm labor/birth and adverse neonatal outcomes by attenuating the proinflammatory responses at the maternal-fetal interface and cervix induced by T cell activation. Collectively, these findings provide mechanistic evidence showing that effector and activated T cells cause pathological inflammation at the maternal-fetal interface, in the mother, and in the fetus, inducing preterm labor and birth and adverse neonatal outcomes. Such adverse effects can be prevented by treatment with progesterone, a clinically approved strategy.
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Affiliation(s)
- Marcia Arenas-Hernandez
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI 48201.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201.,Departamento de Biomedicina Molecular, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Mexico City 07360, Mexico
| | - Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI 48201.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109.,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI 48824.,Center for Molecular Obstetrics and Genetics, Wayne State University, Detroit, MI 48201
| | - Yi Xu
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI 48201.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201
| | - Bogdan Panaitescu
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI 48201.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201
| | - Valeria Garcia-Flores
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI 48201.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201
| | - Derek Miller
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI 48201.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201
| | - Hyunyoung Ahn
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201
| | - Bogdan Done
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI 48201.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201
| | - Sonia S Hassan
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI 48201.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201.,Department of Physiology, Wayne State University School of Medicine, Detroit, MI 48201
| | - Chaur-Dong Hsu
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201.,Department of Physiology, Wayne State University School of Medicine, Detroit, MI 48201
| | - Adi L Tarca
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI 48201.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201.,Department of Computer Science, Wayne State University College of Engineering, Detroit, MI 48202; and
| | - Carmen Sanchez-Torres
- Departamento de Biomedicina Molecular, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Mexico City 07360, Mexico
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, MI 48201; .,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI 48201.,Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, MI 48201
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Cho GJ, Choi S, Lee K, Han SW, Kim HY, Ahn K, Hong S, Kim H, Oh M. Women with threatened preterm labour followed by term delivery have an increased risk of spontaneous preterm birth in subsequent pregnancies: a population‐based cohort study. BJOG 2019; 126:901-905. [DOI: 10.1111/1471-0528.15653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2019] [Indexed: 11/30/2022]
Affiliation(s)
- GJ Cho
- Department of Obstetrics and Gynaecology Korea University College of Medicine Seoul Korea
| | - S‐J Choi
- Department of Obstetrics and Gynaecology Samsung Medical Centre Sungkyunkwan University School of Medicine Seoul Korea
| | - K‐M Lee
- School of Industrial Management Engineering Korea University Seoul Korea
| | - SW Han
- School of Industrial Management Engineering Korea University Seoul Korea
| | - HY Kim
- Department of Obstetrics and Gynaecology Korea University College of Medicine Seoul Korea
| | - K‐H Ahn
- Department of Obstetrics and Gynaecology Korea University College of Medicine Seoul Korea
| | - S‐C Hong
- Department of Obstetrics and Gynaecology Korea University College of Medicine Seoul Korea
| | - H‐J Kim
- Department of Obstetrics and Gynaecology Korea University College of Medicine Seoul Korea
| | - M‐J Oh
- Department of Obstetrics and Gynaecology Korea University College of Medicine Seoul Korea
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Elovitz MA, Gajer P, Riis V, Brown AG, Humphrys MS, Holm JB, Ravel J. Cervicovaginal microbiota and local immune response modulate the risk of spontaneous preterm delivery. Nat Commun 2019; 10:1305. [PMID: 30899005 PMCID: PMC6428888 DOI: 10.1038/s41467-019-09285-9] [Citation(s) in RCA: 215] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/27/2019] [Indexed: 12/26/2022] Open
Abstract
Failure to predict and understand the causes of preterm birth, the leading cause of neonatal morbidity and mortality, have limited effective interventions and therapeutics. From a cohort of 2000 pregnant women, we performed a nested case control study on 107 well-phenotyped cases of spontaneous preterm birth (sPTB) and 432 women delivering at term. Using innovative Bayesian modeling of cervicovaginal microbiota, seven bacterial taxa were significantly associated with increased risk of sPTB, with a stronger effect in African American women. However, higher vaginal levels of β-defensin-2 lowered the risk of sPTB associated with cervicovaginal microbiota in an ethnicity-dependent manner. Surprisingly, even in Lactobacillus spp. dominated cervicovaginal microbiota, low β-defensin-2 was associated with increased risk of sPTB. These findings hold promise for diagnostics to accurately identify women at risk for sPTB early in pregnancy. Therapeutic strategies could include immune modulators and microbiome-based therapeutics to reduce this significant health burden.
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Affiliation(s)
- Michal A Elovitz
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Pawel Gajer
- Institute for Genome Sciences and Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Valerie Riis
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Amy G Brown
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Michael S Humphrys
- Institute for Genome Sciences and Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Johanna B Holm
- Institute for Genome Sciences and Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Jacques Ravel
- Institute for Genome Sciences and Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
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216
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Boelig RC, Della Corte L, Ashoush S, McKenna D, Saccone G, Rajaram S, Berghella V. Oral progesterone for the prevention of recurrent preterm birth: systematic review and metaanalysis. Am J Obstet Gynecol MFM 2019; 1:50-62. [PMID: 31172132 PMCID: PMC6547359 DOI: 10.1016/j.ajogmf.2019.03.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE DATA The purpose of this study was to perform a systematic review and metaanalysis of randomized controlled trials on oral progesterone compared with placebo or other interventions for preterm birth prevention in singleton pregnancies with previous spontaneous preterm birth. The primary outcome was preterm birth at <37 weeks gestation; the secondary outcomes included preterm birth rate at <34 weeks gestation, neonatal morbidity/death, and maternal side-effects. STUDY Searches were performed in PubMed, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE, and the Cochrane Register with the use of a combination of words related to "preterm birth," "preterm delivery," "progesterone," "progestogens," and "oral" from inception of each database to April 2018. Additionally, systematic reviews on progesterone for preterm birth prevention that were identified in our search were also reviewed for additional studies. We included all randomized trials of asymptomatic singleton gestations with previous spontaneous singleton preterm birth that had been randomized to prophylactic treatment with oral progesterone vs placebo, no treatment, or other preterm birth intervention. Exclusion criteria included quasirandomized trials, trials that involved women with preterm labor/membrane rupture at the time of randomization or multiple gestations. STUDY APPRAISAL AND SYNTHESIS METHODS The risk of bias and quality of evidence were assessed for each study. All analyses were done with an intention-to-treat approach. The primary outcome was incidence of preterm birth at <37 weeks gestation; the secondary outcomes included preterm birth at <34 and <28 weeks gestation, maternal adverse events, maternal serum progesterone level, and neonatal morbidity and death. Summary measures were reported as relative risk or mean difference. I2 >30% was used to identify heterogeneity. RESULTS The search strategy identified 79 distinct studies. Three trials on oral progesterone vs placebo (involved 386 patients: 196 in oral progesterone and 190 in placebo) met the inclusion criteria; there were no studies on oral progesterone vs other intervention that met inclusion criteria. Metaanalysis demonstrated a significantly decreased risk of preterm birth at <37 weeks gestation (42% vs 63%; P=.0005; relative risk, 0.68; 95% confidence interval, 0.55-0.84), preterm birth at <34 weeks gestation (29% vs 53%; P<.00001; relative risk, 0.55; 95% confidence interval, 0.43-0.71), and increased gestational age of delivery (mean difference, 1.71 weeks; 95% confidence interval, 1.11-2.30) with oral progesterone compared with placebo. There was a significantly lower rate of perinatal death (5% vs 17%; P=.001; relative risk 0.32; 95% confidence interval, 0.16-0.63), neonatal intensive care admission (relative risk, 0.39; 95% confidence interval, 0.25-0.61), respiratory distress syndrome (relative risk, 0.21; 95% confidence interval, 0.05-0.93), and higher birthweight (mean difference, 435.06 g; 95% confidence interval, 324.59-545.52) with oral progesterone. There was a higher rate of maternal adverse effects with oral progesterone that included dizziness (relative risk, 2.95; 95% confidence interval, 1.47-5.90), somnolence (relative risk, 2.06; 95% confidence interval, 1.29-3.30), and vaginal dryness (relative risk, 2.37; 95% confidence interval, 1.10-5.11); no serious adverse effects were noted. CONCLUSION Oral progesterone appears to be effective for the prevention of recurrent preterm birth and a reduction in perinatal morbidity and mortality rates in asymptomatic singleton gestations with a history of previous spontaneous preterm birth compared with placebo. There were also increased adverse effects with oral progesterone therapy compared with placebo, although none were serious. Further randomized study on oral progesterone compared with other established therapies for the prevention of recurrent preterm birth are warranted.
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Affiliation(s)
- Rupsa C Boelig
- Maternal Fetal Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Sherif Ashoush
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - David McKenna
- Maternal Fetal Medicine, Wright State University, Dayton, OH
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Shalini Rajaram
- Department of Obstetrics and Gynecology, University College of Medical Sciences & Guru Teg Bahadur Hospital, Delhi, India
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217
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Progesterone for preterm birth prevention: the importance of informed consent. Am J Obstet Gynecol 2019; 220:290. [PMID: 30550768 DOI: 10.1016/j.ajog.2018.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 12/05/2018] [Indexed: 11/23/2022]
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218
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Price JT, Vwalika B, Freeman BL, Cole SR, Mulenga HB, Winston J, Mbewe FM, Chomba E, Mofenson LM, Rouse DJ, Goldenberg RL, Stringer JSA. Intramuscular 17-hydroxyprogesterone caproate to prevent preterm birth among HIV-infected women in Zambia: study protocol of the IPOP randomized trial. BMC Pregnancy Childbirth 2019; 19:81. [PMID: 30813934 PMCID: PMC6391830 DOI: 10.1186/s12884-019-2224-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 02/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Each year, an estimated 15 million babies are born preterm, a global burden borne disproportionately by families in lower-income countries. Maternal HIV infection increases a woman's risk of delivering prematurely, and antiretroviral therapy (ART) may compound this risk. While prenatal progesterone prophylaxis prevents preterm birth among some high-risk women, it is unknown whether HIV-infected women could benefit from this therapy. We are studying the efficacy of progesterone supplementation to reduce the risk of preterm birth among pregnant women with HIV in Lusaka, Zambia. METHODS The Improving Pregnancy Outcomes with Progesterone (IPOP) study is a Phase III double-masked, placebo-controlled, randomized trial of intramuscular 17-alpha hydroxprogesterone caproate (17P) to prevent preterm birth in HIV-infected women. A total of 800 women will be recruited prior to 24 weeks of gestation and randomly allocated to 17P or placebo administered by weekly intramuscular injection. The primary outcome will be a composite of live birth prior to 37 completed gestational weeks or stillbirth at any gestational age. Secondary outcomes will include very preterm birth (< 34 weeks), extreme preterm birth (< 28 weeks), small for gestational age (<10th centile), low birth weight (< 2500 g), and neonatal outcomes. In secondary analysis, we will assess whether specific HIV-related covariates, including the timing of maternal ART initiation relative to conception, is associated with progesterone's prophylactic efficacy, if any. DISCUSSION We hypothesize that weekly prenatal 17P will reduce the risk of HIV-related preterm birth. An inexpensive intervention to prevent preterm birth among pregnant women with HIV could have substantial global public health impact. TRIAL REGISTRATION NCT03297216 ; September 29, 2017.
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Affiliation(s)
- Joan T Price
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, 3009 Old Clinic Building, Campus Box 7577, Chapel Hill, NC, 27599-7577, USA. .,Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia.
| | - Bellington Vwalika
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, 3009 Old Clinic Building, Campus Box 7577, Chapel Hill, NC, 27599-7577, USA.,Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | - Bethany L Freeman
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, 3009 Old Clinic Building, Campus Box 7577, Chapel Hill, NC, 27599-7577, USA
| | - Stephen R Cole
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Jennifer Winston
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, 3009 Old Clinic Building, Campus Box 7577, Chapel Hill, NC, 27599-7577, USA
| | | | - Elwyn Chomba
- Department of Paediatrics, University Teaching Hospital, Lusaka, Zambia
| | | | - Dwight J Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, RI, USA
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Jeffrey S A Stringer
- Division of Global Women's Health, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, 3009 Old Clinic Building, Campus Box 7577, Chapel Hill, NC, 27599-7577, USA
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219
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Prevention of spontaneous preterm birth. Arch Gynecol Obstet 2019; 299:1261-1273. [DOI: 10.1007/s00404-019-05095-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/06/2019] [Indexed: 10/27/2022]
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220
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Lichter KE, Sheffield J, Graham EM, Eke AC. Adjuvant 17-hydroxyprogesterone caproate in women withultrasound-indicated cerclage: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2019; 33:3177-3184. [PMID: 30626240 DOI: 10.1080/14767058.2019.1568406] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To assess the additional benefits of 17-hydroxyprogesterone caproate (17-OHPC) therapy in preventing recurrent spontaneous preterm birth in women with an ultrasound-indicated cerclage.Methods: Electronic databases (Medline, Scopus, ClinicalTrials.gov, PROSPERO, Embase, Scielo, and the Cochrane Central Register of Controlled Trials) were searched for studies published before September 2018. Keywords included "preterm birth", "ultrasound-indicated cerclage", "pregnancy" and "17-hydroxyprogesterone caproate". Studies comparing ultrasound-indicated cerclage alone to cerclage plus 17-OHPC were included. The primary outcome measure was preterm birth at <35 weeks of gestation. Secondary outcome measures include preterm birth <24 weeks, <28 weeks, <32 weeks and <37 weeks of gestation, necrotizing enterocolitis (NEC), fetal birth weight, and intraventricular hemorrhage (grades III and IV). Meta-analysis was performed using the random effects model of DerSimonian and Laird. Risk of bias and quality assessment was performed using the risk of bias in nonrandomized studies of interventions (ROBINS-I).Results: Four studies met inclusion criteria and were included in the final analysis. Of the 396 women who received ultrasound-indicated cerclage, 142 (35.9%) received adjuvant 17-OHPC. The primary outcome, preterm birth <35 weeks of gestation, was present in three studies and 332/396 singleton pregnancies. Though there was a trend towards a reduced risk of preterm birth, the summary estimate of effect was not statistically significant when comparing cerclage alone to cerclage plus 17-OHPC at <35 weeks (relative risk (RR) 0.95, 95% CI 0.77-1.17). Similarly, we found no differences in preterm birth at <24 weeks (RR 0.30, 95% CI 0.06-1.60), <28 weeks (RR 0.57, 95% CI 0.13-2.53), and <32 weeks (RR 0.99, 95% CI 0.44-2.27) when comparing cerclage alone to cerclage plus 17-OHPC. There were no differences in fetal birth weight, intraventricular hemorrhage and necrotizing enterocolitis comparing cerclage alone to cerclage plus 17-OHPC.Conclusion: Intramuscular 17-OHPC in combination with ultrasound-indicated cerclage in women with prior preterm birth had no additional effect in reducing spontaneous recurrent preterm birth or improving perinatal outcomes.
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Affiliation(s)
- Katie E Lichter
- Department of Public Health Program, Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Jeanne Sheffield
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine and Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ernest M Graham
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine and Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahizechukwu C Eke
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine and Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Graduate Training Program in Clinical Investigation (GTPCI), Johns Hopkins University School of Public Health, Baltimore, MD, USA
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221
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Wheeler S, DeNoble A, Wynn C, Weaver K, Swamy G, Janko M, Lantos P. Beyond the Window: Patient Characteristics and Geographic Locations Associated with Late Prenatal Care in Women Eligible for 17-P Preterm Birth Prevention. J Racial Ethn Health Disparities 2019; 6:563-569. [PMID: 30632084 DOI: 10.1007/s40615-018-00555-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/30/2018] [Accepted: 12/18/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION To reduce the risk of recurrence, women with a history of spontaneous preterm birth (PTB) are recommended to receive 17-hydroxyprogesterone caproate (17-P) injections starting by the 20th week of pregnancy. In women eligible for 17-P, we aimed to identify patient factors and geospatial locations associated with increased risk of presentation beyond 20 weeks gestation. METHODS We conducted a secondary analysis of a retrospective cohort study including all women meeting criteria for 17-P within a single academic medical center over a 2-year period. We compared early (< 20 6/7 weeks) with late (> 21 weeks) presenters via demographics, social history, and index pregnancy outcomes using standard and Bayesian statistical models. Geospatial mapping was performed to determine residential areas with high risk for late presentation. RESULTS Geocoded address data was available for 351 women in whom the mean gestational age at first visit was 14.9 weeks, and 63 of whom were late presenters (17.9%). Younger maternal age, current smoking, and lack of health insurance were predictors of late presentation with greater than 95% probability. Hispanic ethnicity and black race were associated with higher odds of late presentation with 87 and 69% probability, respectively. The area with the latest gestational age at presentation was located within central Durham City and to the northeast. DISCUSSION Our study identified patient-level risk factors and geographic locations associated with presentation beyond the recommend window for 17-P initiation. These findings suggest an urgent need for intervention to improve early prenatal care initiation and a target location where such interventions will be most impactful.
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Affiliation(s)
- Sarahn Wheeler
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Duke University School of Medicine, 2608 Erwin Road, Suite 210, Durham, NC, 27710, USA.
| | - Anna DeNoble
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Duke University School of Medicine, 2608 Erwin Road, Suite 210, Durham, NC, 27710, USA
| | - Clara Wynn
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Duke University School of Medicine, 2608 Erwin Road, Suite 210, Durham, NC, 27710, USA
| | - Kristin Weaver
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Duke University School of Medicine, 2608 Erwin Road, Suite 210, Durham, NC, 27710, USA
| | - Geeta Swamy
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Duke University School of Medicine, 2608 Erwin Road, Suite 210, Durham, NC, 27710, USA
| | - Mark Janko
- Global Health Institute, Duke University School of Medicine, Durham, NC, USA
| | - Paul Lantos
- Global Health Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine and Pediatrics, Division of infectious Diseases, Duke University School of Medicine, Durham, NC, USA
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Robot-assisted transabdominal cerclage for the prevention of preterm birth: A multicenter experience. Eur J Obstet Gynecol Reprod Biol 2019; 232:70-74. [DOI: 10.1016/j.ejogrb.2018.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/08/2018] [Accepted: 11/11/2018] [Indexed: 11/19/2022]
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223
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Jarde A, Lutsiv O, Beyene J, McDonald SD. Vaginal progesterone, oral progesterone, 17-OHPC, cerclage, and pessary for preventing preterm birth in at-risk singleton pregnancies: an updated systematic review and network meta-analysis. BJOG 2018; 126:556-567. [DOI: 10.1111/1471-0528.15566] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2018] [Indexed: 11/29/2022]
Affiliation(s)
- A Jarde
- Department of Obstetrics and Gynecology; McMaster University; Hamilton ON Canada
| | - O Lutsiv
- Provincial Council for Maternal and Child Health; Toronto ON Canada
| | - J Beyene
- Department of Clinical Epidemiology and Biostatistics; McMaster University; Hamilton ON Canada
| | - SD McDonald
- Department of Obstetrics and Gynecology; McMaster University; Hamilton ON Canada
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224
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Di Renzo GC, Cabero Roura L, Facchinetti F, Helmer H, Hubinont C, Jacobsson B, Jørgensen JS, Lamont RF, Mikhailov A, Papantoniou N, Radzinsky V, Shennan A, Ville Y, Wielgos M, Visser GHA. Preterm Labor and Birth Management: Recommendations from the European Association of Perinatal Medicine. J Matern Fetal Neonatal Med 2018; 30:2011-2030. [PMID: 28482713 DOI: 10.1080/14767058.2017.1323860] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- G C Di Renzo
- a Department of Obstetrics and Gynecology , University of Perugia , Perugia , Italy
| | - L Cabero Roura
- b Department of Obstetrics and Gynecology , Hospital Vall D'Hebron , Barcelona , Spain
| | - F Facchinetti
- c Mother-Infant Department, School of Midwifery , University of Modena and Reggio Emilia , Italy
| | - H Helmer
- d Department of Obstetrics and Gynaecology , General Hospital, University of Vienna , Vienna , Austria
| | - C Hubinont
- e Department of Obstetrics , Saint Luc University Hospital, Université de Louvain , Brussels , Belgium
| | - B Jacobsson
- f Department of Obstetrics and Gynecology , Institute of Clinical Sciences, University of Gothenburg , Gothenburg , Sweden
| | - J S Jørgensen
- g Department of Obstetrics and Gynaecology , Odense University Hospital , Odense , Denmark
| | - R F Lamont
- h Department of Gynaecology and Obstetrics , University of Southern Denmark, Odense University Hospital , Odense , Denmark.,i Division of Surgery , University College London, Northwick Park Institute of Medical Research Campus , London , UK
| | - A Mikhailov
- j Department of Obstetrics and Gynecology , 1st Maternity Hospital, State University of St. Petersburg , Russia
| | - N Papantoniou
- k Department of Obstetrics and Gynaecology , Athens University School of Medicine , Athens , Greece
| | - V Radzinsky
- l Department of Medicine , Peoples' Friendship University of Russia , Moscow , Russia
| | - A Shennan
- m St. Thomas Hospital, Kings College London , UK
| | - Y Ville
- n Service d'Obstétrique et de Médecine Foetale , Hôpital Necker Enfants Malades , Paris , France
| | - M Wielgos
- p Department of Obstetrics and Gynecology , Medical University of Warsaw , Warsaw , Poland
| | - G H A Visser
- o Department of Obstetrics , University Medical Center , Utrecht , The Netherlands
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225
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Saade GR, Thom EA, Grobman WA, Iams JD, Mercer BM, Reddy UM, Tita ATN, Rouse DJ, Sorokin Y, Wapner RJ, Leveno KJ, Blackwell SC, Esplin MS, Tolosa JE, Thorp JM, Caritis SN, Vandorsten JP. Cervical funneling or intra-amniotic debris and preterm birth in nulliparous women with midtrimester cervical length less than 30 mm. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:757-762. [PMID: 29155504 PMCID: PMC5960623 DOI: 10.1002/uog.18960] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/13/2017] [Accepted: 10/20/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To evaluate whether the presence of cervical funneling or intra-amniotic debris identified in the second trimester is associated with a higher rate of preterm birth (PTB) in asymptomatic nulliparous pregnant women with a midtrimester cervical length (CL) less than 30 mm (i.e. below the 10th percentile). METHODS This was a secondary cohort analysis of data from a multicenter trial in nulliparous women between 16 and 22 weeks' gestation with a singleton gestation and CL less than 30 mm on transvaginal ultrasound, randomized to treatment with either 17-alpha-hydroxyprogesterone caproate or placebo. Sonographers were centrally certified in CL measurement, as well as in identification of intra-amniotic debris and cervical funneling. Univariable and multivariable analysis was performed to assess the associations of cervical funneling and intra-amniotic debris with PTB. RESULTS Of the 657 women randomized, 112 (17%) had cervical funneling only, 33 (5%) had intra-amniotic debris only and 45 (7%) had both on second-trimester ultrasound. Women with either of these findings had a shorter median CL than those without (21.0 mm vs 26.4 mm; P < 0.001). PTB prior to 37 weeks was more likely in women with cervical funneling (37% vs 21%; odds ratio (OR), 2.2 (95% CI, 1.5-3.3)) or intra-amniotic debris (35% vs 23%; OR, 1.7 (95% CI, 1.1-2.9)). Results were similar for PTB before 34 and before 32 weeks' gestation. After multivariable adjustment that included CL, PTB < 34 and < 32 weeks continued to be associated with the presence of intra-amniotic debris (adjusted OR (aOR), 1.85 (95% CI, 1.00-3.44) and aOR, 2.78 (95% CI, 1.42-5.45), respectively), but not cervical funneling (aOR, 1.17 (95% CI, 0.63-2.17) and aOR, 1.45 (95% CI, 0.71-2.96), respectively). CONCLUSIONS Among asymptomatic nulliparous women with midtrimester CL less than 30 mm, the presence of intra-amniotic debris, but not cervical funneling, is associated with an increased risk for PTB before 34 and 32 weeks' gestation, independently of CL. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - E A Thom
- The George Washington University Biostatistics Center, Washington, DC, USA
| | | | - J D Iams
- Ohio State University, Columbus, OH, USA
| | - B M Mercer
- MetroHealth Medical Center-Case Western Reserve University, Cleveland, OH, USA
| | - U M Reddy
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - A T N Tita
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - D J Rouse
- Brown University, Providence, RI, USA
| | - Y Sorokin
- Wayne State University, Detroit, MI, USA
| | | | - K J Leveno
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - S C Blackwell
- The University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, TX, USA
| | - M S Esplin
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - J E Tolosa
- Oregon Health & Science University, Portland, OR, USA
| | - J M Thorp
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S N Caritis
- University of Pittsburgh, Pittsburgh, PA, USA
| | - J P Vandorsten
- Medical University of South Carolina, Charleston, SC, USA
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Caritis SN, Hauspurg A, Venkataramanan R, Lemon L. Defining the clinical response to 17-alpha hydroxyprogesterone caproate. Am J Obstet Gynecol 2018; 219:623-625. [PMID: 30171841 DOI: 10.1016/j.ajog.2018.08.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 11/26/2022]
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227
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Shen SY, Chen QZ, Zhang LF, He JR, Lu JH, Li WD, Xiao WQ, Zhou ZH, Morse AN, Keung Cheng K, Mol BWJ, Xia HM, Qiu X. Association between serum progesterone concentration in early pregnancy and duration of pregnancy: a cohort study. J Matern Fetal Neonatal Med 2018; 33:2096-2102. [PMID: 30474453 DOI: 10.1080/14767058.2018.1540580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To examine the association between progesterone concentration in early pregnancy and duration of pregnancy and risk of preterm delivery.Methods: Women enrolled in the Born in Guangzhou Cohort Study from 2013-2014, with a singleton pregnancy, who had serum progesterone measured at least one time between 4 and 10 weeks of gestation were included. The association between progesterone concentration both continuous and as categorical variable (quartile) and the risk of preterm delivery was assessed with Cox proportional hazards regression. Differences of length of gestation in four progesterone concentration quartiles were assessed using the Log-rank test.Results: We studied 1860 mother-newborn pairs. The mean overall progesterone concentration was 65.7 ± 21.3 nmol/L, with mean progesterone concentrations in the four quartiles of 42.4 ± 6.2 nmol/L (n = 463), 56.2 ± 3.3 nmol/L (n = 462), 68.9 ± 4.5 nmol/L (n = 470), and 95.1 ± 15.3 nmol/L (n = 465). There was no significantly difference in duration of gestation in four progesterone concentration groups (p=.511). There was no relation between progesterone level and preterm delivery (adjusted hazard ratio (HR) per 10 nmol/l progesterone level 1.00 (95% confidence interval (CI) 0.90, 1.11)). After adjusting for potential confounders, the HR of any preterm delivery for quartiles 1, 2 and 3 versus the highest quartile of progesterone level (> 77.3 nmol/L) was 1.04 (95% CI 0.52, 2.07), 1.17 (95% CI 0.60, 2.28), and 1.46 (95% CI 0.76, 2.78), respectively. When analysis was done for spontaneous preterm delivery only, also no association with first trimester progesterone was found.Conclusion: Lower first trimester serum progesterone concentration is not associated with reduction of length of gestation or increased risk of preterm delivery.
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Affiliation(s)
- Song-Ying Shen
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Qiao-Zhu Chen
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Li-Fang Zhang
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Woman and Child Health, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jian-Rong He
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Woman and Child Health, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jin-Hua Lu
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Woman and Child Health, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wei-Dong Li
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Woman and Child Health, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wan-Qing Xiao
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Woman and Child Health, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Ze-Hong Zhou
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Abraham N Morse
- Urogynecology and OBGYN Academic Program Development, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Kar Keung Cheng
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - Hui-Min Xia
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Neonatal Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xiu Qiu
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.,Department of Woman and Child Health, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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Allen TK, Nazzal MN, Feng L, Buhimschi IA, Murtha AP. Progestins Inhibit Tumor Necrosis Factor α-Induced Matrix Metalloproteinase 9 Activity via the Glucocorticoid Receptor in Primary Amnion Epithelial Cells. Reprod Sci 2018; 26:1193-1202. [PMID: 30453830 DOI: 10.1177/1933719118811646] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Progestins have been recommended for preterm birth prevention in high-risk women; however, their mechanism of action still remains an area of debate. Medroxyprogesterone acetate (MPA) has previously been shown to significantly inhibit tumor necrosis factor α (TNFα)-induced matrix metalloproteinase 9 (MMP9) messenger RNA (mRNA) expression and activity in primary amnion epithelial cells, a process that may lead to preterm premature rupture of membranes. A mechanism that explains MPA's inhibition of TNFα-induced MMP9 mRNA expression and activity in primary amnion epithelial cells is unclear since these cells lack the classic nuclear progesterone receptor but express a membrane-associated progesterone receptor-progesterone receptor membrane component 1 (PGRMC1) along with the glucocorticoid receptor (GR). Primary amnion epithelial cells harvested from healthy term pregnant women at cesarean section were treated with PGRMC1 (to knockdown PGRMC1 expression), GR (to knockdown GR expression), or control small interfering RNA (siRNA; 10 nm) for 72 hours, pretreated with ethanol or MPA (10-6 M) for 6 hours, and then stimulated with or without TNFα 10 ng/mL for 24 hours. Real-time quantitative polymerase chain reaction and gelatin zymography were used to quantify MMP9 mRNA expression and activity, respectively. Experimental groups were compared using 1-way analysis of variance. Both TNFα-induced MMP9 mRNA expression and activity were significantly inhibited by pretreatment with MPA; however, only the inhibition of TNFα-induced MMP9 activity was partially reversed with PGRMC1 siRNA. However, GR siRNA reversed both the inhibition of TNFα-induced MMP9 mRNA expression and activity by MPA. This study demonstrates that MPA mediates its anti-inflammatory effects primarily through GR and partially through PGRMC1 in primary amnion epithelial cells.
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Affiliation(s)
- Terrence K Allen
- 1 Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Matthew N Nazzal
- 2 Department of Obstetrics and Gynecology, Duke University Hospital, Durham, NC, USA
| | - Liping Feng
- 2 Department of Obstetrics and Gynecology, Duke University Hospital, Durham, NC, USA
| | - Irina A Buhimschi
- 3 Perinatal Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
| | - Amy P Murtha
- 2 Department of Obstetrics and Gynecology, Duke University Hospital, Durham, NC, USA
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229
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Eke AC, Sheffield J, Graham EM. Adjuvant 17-hydroxyprogesterone caproate in women with history-indicated cerclage: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2018; 98:139-153. [PMID: 30339274 DOI: 10.1111/aogs.13488] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/14/2018] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate whether there are additional benefits of 17-hydroxyprogesterone caproate (17-OHPC) supplementation in preventing recurrent spontaneous preterm birth in women with a prophylactic cerclage. MATERIAL AND METHODS Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE, Scielo and the Cochrane Central Register of Controlled Trials) were searched for studies published before June 2018. Keywords included "preterm birth", "prophylactic cerclage", "history-indicated cerclage", "pregnancy" and "17-hydroxyprogesterone caproate". Studies comparing history-indicated cerclage alone with cerclage+17-OHPC were included. The primary outcome measure was preterm birth at <24 weeks of gestation. Secondary outcome measures include preterm birth at <28 weeks, <32 weeks and <37 weeks of gestation, respiratory distress syndrome, necrotizing enterocolitis, fetal birthweight, neonatal intensive care unit stay, mean gestational age at delivery, fetal/neonatal death, neurological morbidity (intraventricular hemorrhage plus periventricular leukomalacia), neonatal sepsis and a composite of severe neonatal morbidity. Severe neonatal morbidity was defined as a composite measure of periventricular leukomalacia, intraventricular hemorrhage (grades III and IV), necrotizing enterocolitis or respiratory distress syndrome. Meta-analysis was performed using the random-effects model of DerSimonian and Laird. Risk of bias and quality assessment were performed using the ROBINS-I and GRADE tools, respectively. PROSPERO Registration Number: CRD42018094559. RESULTS Five studies met the inclusion criteria and were included in the final analysis. Of the 546 women, 357 (75%) received history-indicated cerclage alone and 189 (35%) received adjuvant 17-OHPC. The composite endpoint, severe neonatal morbidity, was present in 84 of 1515 neonates. Though there was a trend toward a reduced risk of preterm birth, the summary estimate of effect was not statistically significant when comparing cerclage alone with cerclage+17-OHPC at <24 weeks (relative risk [RR] .86, 95% confidence interval [CI] .45-1.65). Similarly, we found no differences in preterm birth at <37 weeks (RR .90, 95% CI .70-1.17) and <28 weeks (RR .85, 95% CI .54-1.32) when comparing cerclage alone with cerclage+17-OHPC. There were no differences in fetal birthweight, respiratory distress syndrome or necrotizing enterocolitis comparing cerclage alone with cerclage+17-OHPC. CONCLUSIONS Intramuscular 17-OHPC in combination with prophylactic cerclage in women with prior preterm birth had no synergistic effect in reducing spontaneous recurrent preterm birth or improving perinatal outcomes.
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Affiliation(s)
- Ahizechukwu C Eke
- Division of Maternal Fetal Medicine & Clinical Pharmacology, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Graduate Training Program in Clinical Investigation (GTPCI), Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Jeanne Sheffield
- Division of Maternal Fetal Medicine & Clinical Pharmacology, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ernest M Graham
- Division of Maternal Fetal Medicine & Clinical Pharmacology, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Cross-Barnet C, Benatar S, Courtot B, Hill I, Johnston E, Cheeks M. Inequality and Innovation: Barriers and Facilitators to 17P Administration to Prevent Preterm Birth among Medicaid Participants. Matern Child Health J 2018; 22:1607-1616. [PMID: 29956128 DOI: 10.1007/s10995-018-2556-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objectives Strategies to prevent preterm birth are limited. 17 Alpha-Hydroxyprogesterone Caproate (17P) injections have been shown to be effective, but the intervention is under-used. This mixed methods study investigates barriers and facilitators to 17P administration among Medicaid and CHIP participants enrolled in Strong Start for Mothers and Newborns, a federal preterm birth prevention program. Methods Twenty-seven awardees with more than 200 sites in 30 states, the District of Columbia, and Puerto Rico enrolled approximately 46,000 women in Strong Start from 2013 to 2016. Participant data, including data on preterm birth and 17P, was collected for each woman. Intensive interviews (n = 211) conducted with Strong Start program staff and providers (n = 314) included questions about 17P provision. Results Of women whose data included a valid response regarding 17P initiation, 3919 had a prior preterm birth and current singleton pregnancy; 14.95% received 17P. Barriers to 17P administration include late entry to prenatal care, administrative burden of preauthorization, cost risks to providers, limits in scope of practice for non-physician providers, and social barriers among participants. Facilitators for provision include streamlined work flows and the option of home administration. Conclusions for Practice A universal insurance authorization process could mitigate many barriers to 17P use. Providers need continuing education regarding the effectiveness of 17P, and expanding scope of practice for non-physician prenatal care providers would increase access. Targeted program interventions can help to overcome social barriers Medicaid participants face in accessing care. Streamlined work processes and the option of home health services are two effective program-based facilitators for providing 17P to a Medicaid population.
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Affiliation(s)
- Caitlin Cross-Barnet
- Center for Medicare and Medicaid Innovation (CMMI), 7500 Security Boulevard, WB-19-72, Baltimore, MD, 21244, USA.
| | - Sarah Benatar
- Urban Institute, 2100 M St NW, Washington, DC, 20037, USA
| | | | - Ian Hill
- Urban Institute, 2100 M St NW, Washington, DC, 20037, USA
| | - Emily Johnston
- Urban Institute, 2100 M St NW, Washington, DC, 20037, USA
| | - Morgan Cheeks
- Urban Institute, 2100 M St NW, Washington, DC, 20037, USA
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231
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Progesterone treatment enhances the expansion of placental immature myeloid cells in a mouse model of premature labor. J Reprod Immunol 2018; 131:7-12. [PMID: 30391857 DOI: 10.1016/j.jri.2018.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/22/2018] [Accepted: 10/25/2018] [Indexed: 12/28/2022]
Abstract
INTRODUCTION immature-myeloid cells (IMCs) are proangiogenic bone marrow (BM)-derived cells that normally differentiate into inflammatory cells such as neutrophils, monocytes and dendritic cells (DCs). We characterized placental IMCs comparing their gene expression and subpopulations to tumor IMCs, and tested our hypothesis that progesterone that inhibits preterm labor, may affect their abundance and differentiation. METHODS differences between IMC-subpopulations in subcutaneous tumors versus placentas in C57BL/6 or ICR (CD-1) mice were analyzed by flow cytometry and gene expression was detected by microarrays. BM- and placental cells were incubated with or without progesterone and IMC subpopulations were analyzed. For preterm labor induction pregnant mice pretreated or not with progesterone were or were not treated with Lipopolysaccharide (LPS). RESULTS we detected enrichment of granulocytic-IMCs in placentas compared to tumors, paralleled by a decrease in monocytic-IMCs. mRNA expression of placenta- versus tumor IMCs revealed profound transcriptional alterations. Progesterone treated BM-CD11b+ cells ex-vivo induced enrichment of granulocytic-IMCs and a decrease in monocytic-IMCs and DCs. LPS treatment in-vivo led to an increase in BM-IMCs in both progesterone pretreated or non-pretreated mice. In the placenta LPS decreased the IMC population while progesterone led to complete abrogation of this effect. DISCUSSION placental IMCs differ from tumor-IMCs in both subpopulations and gene expression. Progesterone enhances the proliferation of placenta-specific granulocytic IMCs ex-vivo and LPS induced labor is accompanied by a decrease in placental IMCs only in progesterone non-pretreated mice. We thus speculate that the protective effect of progesterone in preventing preterm labor may be explained at least in part by this specific anti-inflammatory effect.
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232
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Gallagher JR, Gudeman J, Heap K, Vink J, Carroll S. Understanding if, How, and Why Women with Prior Spontaneous Preterm Births are Treated with Progestogens: A National Survey of Obstetrician Practice Patterns. AJP Rep 2018; 8:e315-e324. [PMID: 30393580 PMCID: PMC6212295 DOI: 10.1055/s-0038-1675556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/20/2018] [Indexed: 11/03/2022] Open
Abstract
Objective In 2017, the Society for Maternal-Fetal Medicine (SMFM) Guideline Committee reaffirmed that 17 α -hydroxyprogesterone caproate (17-OHPC) to prevent preterm birth (PTB) is underutilized. We sought to determine what drove progestogen treatment choice of obstetricians managing pregnant women with histories of 1+ singleton spontaneous PTBs (< 37 weeks) who then delivered singleton gestations within the previous 12 months. Subjects We recruited a nationally representative random sample of obstetricians to abstract medical records of study-qualified patients. Of the 423 study-qualified physicians contacted, 358 (85%) participated; 56 (16%) maternal fetal medicine specialists and 302 (84%) general obstetrician/gynecologists (OB/GYNs) extracted data from 991 eligible patient charts. Results Almost three-fourths of patients (73.6%) were treated with 17-OHPC; 18.6% received vaginal progesterone, and 11.8% were not treated. Key drivers of physicians' choice to (1) prescribe branded 17-OHPC were "FDA (Food and Drug Administration) approval" (52% relative influence [RI]) and "SMFM guidelines" (24% RI); (2) prescribe vaginal progesterone were "ease of administration" (32% RI) and "shortened cervix" (16% RI); and (3) not provide prophylaxis were "patient not informed of risk" (35% RI) and "no shortened cervix" (29% RI). Conclusion Study findings support SMFM's contention of continued 17-OHPC underutilization to prevent PTB. Need for additional physician education merits assessment along with appropriate follow-up actions.
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Affiliation(s)
- Jack R Gallagher
- Clarity Pharma Research, Limited Liability Corporation, Department of Analytics, Spartanburg, South Carolina
| | - Jennifer Gudeman
- Women's Health, AMAG Pharmaceuticals, Inc., Waltham, Massachusetts
| | - Kylee Heap
- Clarity Pharma Research, Limited Liability Corporation, Department of Analytics, Spartanburg, South Carolina
| | - Joy Vink
- Division of Maternal Fetal Medicine, Department of Obstetrics/Gynecology, Columbia University Medical Center, New York, New York
| | - Susan Carroll
- Clarity Pharma Research, Limited Liability Corporation, Department of Analytics, Spartanburg, South Carolina
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233
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Ananth CV, Friedman AM, Goldenberg RL, Wright JD, Vintzileos AM. Association Between Temporal Changes in Neonatal Mortality and Spontaneous and Clinician-Initiated Deliveries in the United States, 2006-2013. JAMA Pediatr 2018; 172:949-957. [PMID: 30105352 PMCID: PMC6233764 DOI: 10.1001/jamapediatrics.2018.1792] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Preterm and postterm deliveries have declined since 2005 in the United States, but the association between these changes and neonatal mortality remains unknown. OBJECTIVE To estimate changes in the gestational age distribution among spontaneous and clinician-initiated deliveries between 2006 and 2013 and associated changes in neonatal mortality. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort analysis was conducted of 22 million singleton live births without major malformations in the United States from 2006 to 2013. Data analysis was performed from August to October 2017. MAIN OUTCOMES AND MEASURES Changes in gestational age distribution among spontaneous and clinician-initiated deliveries at extremely preterm (20-27 weeks), very preterm (28-31 weeks), moderately preterm (32-33 weeks), late preterm (34-36 weeks), early term (37-38 weeks), term (39-40), late term (41 weeks), and postterm (42-44 weeks) gestations and changes in neonatal mortality rates at less than 28 days between 2006 and 2013. These changes were estimated from log-linear Poisson regression models with robust variance, adjusted for confounders. RESULTS Among 22 million births, 12 493 531 (56.7%) were spontaneous and 9 557 815 (43.3%) were clinician-initiated deliveries. Among spontaneous deliveries, the proportion of births at 20 to 27, 28 to 31, 32 to 33, 34 to 36, and 37 to 38 weeks declined. Among clinician-initiated deliveries, the proportion of births at 34 to 36 and 37 to 38 weeks declined and the proportion at 39 to 40 weeks increased. Among spontaneous deliveries, overall neonatal mortality rates declined from 1.8 to 1.3 per 1000 live births, mainly at 20 to 27 weeks (adjusted annual decline, 1%; 95% CI, -2% to -1%) and 28 to 31 weeks (adjusted annual decline, 6%; 95% CI, -8% to -5%). Among clinician-initiated deliveries, overall mortality rates remained unchanged (2.1 to 2.2 per 1000 live births). However, mortality rates declined (0.6 to 0.5 per 1000 live births) at 39 to 40 weeks by 1% (95% CI, -3% to -0.4%) annually, adjusted for confounders. CONCLUSIONS AND RELEVANCE In the United States, there was a decline in spontaneous deliveries associated with an overall decline in neonatal mortality. Although clinician-initiated deliveries increased at 39 to 40 weeks, neonatal mortality at that gestation declined.
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Affiliation(s)
- Cande V. Ananth
- Department of Health Policy and Management, Joseph L. Mailman School of Public Health, Columbia University, New York, New York
| | - Alexander M. Friedman
- Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Robert L. Goldenberg
- Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Jason D. Wright
- Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Anthony M. Vintzileos
- Department of Obstetrics and Gynecology, Winthrop Hospital, New York University, Mineola
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234
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Weatherborn M, Mesiano S. Rationale for current and future progestin-based therapies to prevent preterm birth. Best Pract Res Clin Obstet Gynaecol 2018; 52:114-125. [DOI: 10.1016/j.bpobgyn.2018.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/28/2018] [Accepted: 03/29/2018] [Indexed: 01/16/2023]
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235
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Efficacy of progesterone for prevention of preterm birth. Best Pract Res Clin Obstet Gynaecol 2018; 52:126-136. [DOI: 10.1016/j.bpobgyn.2018.08.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 08/24/2018] [Indexed: 12/24/2022]
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236
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Rosta K, Ott J, Kelemen F, Temsch W, Lahner T, Reischer T, Helmer H, Somogyi A. Is vaginal progesterone treatment associated with the development of gestational diabetes? A retrospective case-control study. Arch Gynecol Obstet 2018; 298:1079-1084. [PMID: 30225687 PMCID: PMC6244685 DOI: 10.1007/s00404-018-4895-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 09/06/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine the incidence of gestational diabetes mellitus (GDM) in pregnant women who received vaginal progesterone due to short cervical length or to prevent recurrent preterm birth. METHODS In this retrospective study, we included 190 women with singleton pregnancies at risk for preterm birth who received vaginal natural progesterone (200 mg daily between gestational weeks 16 + 0 and 36 + 0) for a minimum of 4 weeks and delivered > 28 weeks. The control group consisted of 242 age- and body mass index (BMI)-matched patients without progesterone administration. Data were acquired from a database containing prospectively collected information. Patients with pre-existing diabetes, and conception after in vitro fertilisation procedure were excluded. RESULTS The incidence of GDM did not differ significantly between the progesterone-treated and the control group (14.7% vs. 16.9%, respectively; p = 0.597). In a binary regression model, patients with higher pre-pregnancy BMI (OR 1.1; p = 0.006), and those with a family history of diabetes had a higher risk for GDM development (OR 1.8; p = 0.040), whereas vaginal progesterone treatment had no significant influence (p = 0.580). CONCLUSION The use of vaginal progesterone for the prevention of recurrent preterm delivery and in women with a short cervix does not seem to be associated with an increased risk of GDM.
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Affiliation(s)
- Klara Rosta
- Department of Obstetrics and Gynecology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Johannes Ott
- Department of Obstetrics and Gynecology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Fanni Kelemen
- University of Szeged, 12 Dóm tér, 6720, Szeged, Hungary
| | - Wilhelm Temsch
- Center for Medical Statistic and Informatics and Intelligent Systems, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Tobias Lahner
- Department of Obstetrics and Gynecology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Theresa Reischer
- Department of Obstetrics and Gynecology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Hanns Helmer
- Department of Obstetrics and Gynecology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Aniko Somogyi
- 2nd Department of Internal Medicine, Semmelweis University, Szentkirályi u.46, Budapest, Hungary
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237
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Venkatesh KK, Manuck TA. Maternal body mass index and cervical length among women with a history of spontaneous preterm birth †. J Matern Fetal Neonatal Med 2018; 33:825-830. [PMID: 30049238 DOI: 10.1080/14767058.2018.1505856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objectives: To evaluate whether women with a prior spontaneous preterm birth (SPTB) with a higher body mass index (BMI) have a lower risk of a shortened cervix in a subsequent pregnancy.Study Design: A secondary analysis of the Maternal-Fetal Medicine Units Network RCT of omega-3 fatty acid supplementation for recurrent SPTB prevention. All women had ≥1 prior SPTB <37 weeks, a singleton pregnancy, and initiated 17-alpha hydroxyprogesterone caproate(17-OHPC). The primary exposure was pre-pregnancy BMI. The primary outcome was the shortest transvaginal cervical length <30 mm.Results: Of the 356 women with a prior SPTB receiving 17-OHPC and a cervical length available, 108 (30%) were overweight and 103 (29%) obese; 12% had a cervical length <30 mm. Fewer overweight/obese women had a shortened cervix compared to normal-weight women (43 versus 57%; odds ratio: 0.47 [95%CI: 0.25-0.89]). After adjusting for maternal age, number of prior SPTBs, and tobacco use, overweight/obese women were less than half as likely to have a shortened cervix compared to normal-weight women (adjusted odds ratio: 0.46, 95%CI: 0.24-0.89).Conclusions: Overweight and obese women with a prior SPTB receiving 17-OHPC have longer cervical lengths compared to normal weight women, and this finding could explain a possible mechanism between the decreased rate of SPTB and larger BMI.
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Affiliation(s)
- Kartik K Venkatesh
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Tracy A Manuck
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
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Govindaswami B, Jegatheesan P, Nudelman M, Narasimhan SR. Prevention of Prematurity: Advances and Opportunities. Clin Perinatol 2018; 45:579-595. [PMID: 30144857 DOI: 10.1016/j.clp.2018.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Preterm birth (PTB) rate varies widely and has significant racial and ethnic disparities. Although causal mechanisms are ill understood, socioenvironment, phenotype, and genotype provide insight into pathways for preventing PTB. Data suggest varied response to current medical interventions is explicable Approved by underlying pharmacogenomics. Currently, prevention focuses on minimizing iatrogenic PTB and risk reduction especially in those with prior PTB using proven medical and public health strategies. In the future, preventive approaches will be based on better understanding of sociodemography, nutrition, lifestyles, and underlying individual genetic and epigenetic variation. Statistical approaches and "big-data" models are critical in future study.
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Affiliation(s)
- Balaji Govindaswami
- Division of Neonatology, Pediatrics, Santa Clara Valley Medical Center: Hospital and Clinics, 751 South Bascom Avenue, San Jose, CA 95128, USA.
| | - Priya Jegatheesan
- Division of Neonatology, Pediatrics, Santa Clara Valley Medical Center: Hospital and Clinics, 751 South Bascom Avenue, San Jose, CA 95128, USA
| | - Matthew Nudelman
- Division of Neonatology, Pediatrics, Santa Clara Valley Medical Center: Hospital and Clinics, 751 South Bascom Avenue, San Jose, CA 95128, USA
| | - Sudha Rani Narasimhan
- Division of Neonatology, Pediatrics, Santa Clara Valley Medical Center: Hospital and Clinics, 751 South Bascom Avenue, San Jose, CA 95128, USA
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239
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Frappaolo A, Vadnais M. Response to 17-alpha hydroxyprogesterone caproate. Am J Obstet Gynecol 2018; 219:217. [PMID: 29698618 DOI: 10.1016/j.ajog.2018.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/16/2018] [Indexed: 10/17/2022]
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240
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Baradwan S, Baradwan A, Bashir M, Al-Jaroudi D. The birth weight in pregnant women with Asherman syndrome compared to normal intrauterine cavity: A case-control study. Medicine (Baltimore) 2018; 97:e11797. [PMID: 30095642 PMCID: PMC6133566 DOI: 10.1097/md.0000000000011797] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/15/2018] [Indexed: 11/26/2022] Open
Abstract
Women with Asherman syndrome (AS) have damaged endometrium and reduced blood flow to the uterus and placenta which may lead to low birth weight and several obstetric complications.The objective is to determine the association between low birth weight and obstetrical complications in women with AS compared to women with normal intrauterine cavity.A retrospective case-control study was conducted in Women's Specialized Hospital, King Fahad Medical City, from December 2008 to December 2015. Pregnant women with AS undergoing hysteroscopic adhesiolysis who presented to our clinic were matched for age, parity, body mass index, methods of conception, and gestational age to pregnant women without AS based on a 1:3 ratio. The main outcome measure included birth weight and obstetrical complications.The study included 56 women with 14 cases and 42 controls. Pregnant women with AS had significantly lower birth weight (2.23 ± 0.28 kg) compared with pregnant women without AS (3.13 ± 0.383 kg) (P < .001 odds ratio [OR] 0.029, 95% confidence interval [CI] 0.006-0.148, P = .001). Complications of delivery including retained placenta, placenta previa, and fetal death were significantly higher in patients with AS compared with controls 28.6% 7.1%, and 7.1% compared to 4.8%, 0%, and 0%, respectively. This was statistically significant (P < .001).Pregnant women with AS delivered low birth weight newborns and had more obstetrical complications as compared with pregnant women with normal cavity.
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Affiliation(s)
- Saeed Baradwan
- Department of Obstetrics and Gynecology, King Fahad Medical City, Riyadh
| | - Afnan Baradwan
- Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah
| | | | - Dania Al-Jaroudi
- Reproductive Endocrine and Infertility Medicine Department, King Fahad Medical City, Riyadh, Saudi Arabia
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241
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Nelson DB, McIntire DD, Leveno KJ. Reply. Am J Obstet Gynecol 2018; 219:218-220. [PMID: 29702066 DOI: 10.1016/j.ajog.2018.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 04/16/2018] [Indexed: 12/19/2022]
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242
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Travanty MN, Calawa B, Shalaby WS, Jozwiakowski MJ, Haraldsen KB. Development and usability of a new subcutaneous auto-injector device to administer hydroxyprogesterone caproate to reduce the risk of recurrent preterm birth. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2018; 11:241-252. [PMID: 30100767 PMCID: PMC6064158 DOI: 10.2147/mder.s157114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Current administration of hydroxyprogesterone caproate (HPC) by intramuscular injection is associated with limitations, including the potential for human error and contamination, patient anxiety, and increased risk of needlestick injury. Objective To describe the design of an auto-injector for subcutaneous (SC) administration of HPC and the results of studies that evaluated the target user's understanding of the proper use of this device. Materials and methods A single-use, prefilled, fixed-dose, disposable auto-injector intended for the SC administration of HPC was developed, and its usability by health care providers was evaluated in 3 formative (N=32, 64 injections) and 3 validation studies (N=45, 90 injections). These studies consisted of one-on-one testing sessions performed in a simulated home environment. Analyses were based on observed use error or use difficulty during the performance of specific tasks, including those considered critical (associated with high severity harms). Results In the formative studies, the majority of participants correctly administered an injection with the auto-injector, but prior training improved performance. Specific errors were noted, including holding the device at the injection site for a period inconsistent with its instructions for use (IFU). The IFU was modified to reduce potential occurrence of these errors. Use errors were subsequently observed on critical tasks in the first and second validation studies, including hold-time errors that were attributed to using visual cues rather than counting seconds. For the third validation study, the IFU was modified to focus on visual cues and all users were able to successfully perform the injection per the IFU. Conclusion An auto-injector device for SC administration of HPC for reduction in risk of recurrent preterm birth was successfully developed through iterative design and validation testing. The device design provides high usability and acceptance of this device by health care professionals.
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Affiliation(s)
| | - Bryon Calawa
- Research Department, Design Science, Philadelphia, PA, USA
| | | | | | - Kyle B Haraldsen
- Technical Operations & Project Management, AMAG Pharmaceuticals, Inc., Waltham, MA, USA,
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243
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Effect of progesterone on Smad signaling and TGF-β/Smad-regulated genes in lung epithelial cells. PLoS One 2018; 13:e0200661. [PMID: 30001393 PMCID: PMC6042760 DOI: 10.1371/journal.pone.0200661] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/29/2018] [Indexed: 11/20/2022] Open
Abstract
The effect of endogenous progesterone and/or exogenous pre- or postnatal progesterone application on lung function of preterm infants is poorly defined. While prenatal progesterone substitution may prevent preterm birth, in vitro and in vivo data suggest a benefit of postnatal progesterone replacement on the incidence and severity of bronchopulmonary dysplasia (BPD). However, the molecular mechanisms responsible for progesterone's effects are undefined. Numerous factors are involved in lung development, airway inflammation, and airway remodeling: the transforming growth factor beta (TGF-β)/mothers against decapentaplegic homolog (Smad) signaling pathway and TGF-β-regulated genes, such as connective tissue growth factor (CTGF), transgelin (TAGLN), and plasminogen activator inhibitor-1 (PAI-1). These processes contribute to the development of BPD. The aim of the present study was to clarify whether progesterone could affect TGF-β1-activated Smad signaling and CTGF/transgelin/PAI-1 expression in lung epithelial cells. The pharmacological effect of progesterone on Smad signaling was investigated using a TGF-β1-inducible luciferase reporter and western blotting analysis of phosphorylated Smad2/3 in A549 lung epithelial cells. The regulation of CTGF, transgelin, and PAI-1 expression by progesterone was studied using a promoter-based luciferase reporter, quantitative real-time PCR, and western blotting in the same cell line. While progesterone alone had no direct effect on Smad signaling in lung epithelial cells, it dose-dependently inhibited TGF-β1-induced Smad3 phosphorylation, as shown by luciferase assays and western blotting analysis. Progesterone also antagonized the TGF-β1/Smad-induced upregulation of CTGF, transgelin, and PAI-1 at the promoter, mRNA, and/or protein levels. The present study highlights possible new molecular mechanisms involving progesterone, including inhibition of TGF-β1-activated Smad signaling and TGF-β1-regulated genes involved in BPD pathogenesis, which are likely to attenuate the development of BPD by inhibiting TGF-β1-mediated airway remodeling. Understanding these mechanisms might help to explain the effects of pre- or postnatal application of progesterone on lung diseases of preterm infants.
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244
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Vaginal progesterone is an alternative to cervical cerclage in women with a short cervix and a history of preterm birth. Am J Obstet Gynecol 2018; 219:5-9. [PMID: 29941278 DOI: 10.1016/j.ajog.2018.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 05/07/2018] [Indexed: 01/09/2023]
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245
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MANUCK TA, SMEESTER L, MARTIN EM, TOMLINSON MS, SMITH C, VARNER MW, FRY RC. Epigenetic Regulation of the Nitric Oxide Pathway, 17-α Hydroxyprogesterone Caproate, and Recurrent Preterm Birth. Am J Perinatol 2018; 35:721-728. [PMID: 29241278 PMCID: PMC6002888 DOI: 10.1055/s-0037-1613682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We sought to evaluate nitric oxide pathway placental gene expression and the epigenome (CpG methylation) among women receiving 17-α hydroxyprogesterone caproate (17-OHPC) with and without recurrent preterm birth (PTB). STUDY DESIGN This was a case-control study. We prospectively recruited women with ≥ 1 prior singleton spontaneous PTB <34 weeks receiving 17-OHPC. DNA and RNA were isolated from placentas. RNA abundance (gene expression) and the methylome were analyzed for 84 genes in nitric oxide pathways. Women with recurrent PTB <34 weeks (cases) were compared with those delivering at term (controls). Statistical analysis included multivariable models with Bonferroni's corrected p-values. RESULTS In this study, 17 women met inclusion criteria; 7 preterm cases (delivered at 22.6 ± 2.9 weeks) and 10 term controls (delivered at 38.5 ± 0.8 weeks). Groups had similar PTB history, race/ethnicity, and socioeconomic risk factors for PTB. Twenty-seven nitric oxide genes displayed differential expression (p < 0.05 and q < 0.10) when comparing placentas from preterm cases and term controls; all were downregulated in preterm cases. Eight hundred sixty corresponding CpG sites were differentially methylated between the preterm cases and term controls (Bonferroni's p-value <0.05). CONCLUSION CpG methylation and gene expression patterns in nitric oxide pathway genes differ among placentas from recurrent PTB compared with term birth following 17-OHPC exposure.
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Affiliation(s)
- Tracy A. MANUCK
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Lisa SMEESTER
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Elizabeth M. MARTIN
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Martha S. TOMLINSON
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Christina SMITH
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Michael W. VARNER
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah School of Medicine, Salt Lake City, UT,Intermountain Healthcare Women and Newborns Clinical Program, Salt Lake City, UT
| | - Rebecca C. FRY
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC
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246
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Feng T, Allen JC, Ng MJ, Yeo GSH, Kwek KYC, Chern BSM, Tan KH. The association between serum progesterone level and preterm delivery. Int J Gynaecol Obstet 2018; 142:308-314. [PMID: 29885043 DOI: 10.1002/ijgo.12564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 04/18/2018] [Accepted: 06/07/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate the association of serum progesterone level and preterm delivery. METHODS The present prospective cohort study enrolled women with singleton pregnancies attending their first prenatal visit at the outpatient specialist clinics at KK Women's and Children's Hospital, Singapore, between September 1, 2010, and August 31, 2014. Progesterone levels were measured at four clinical visits (visit 1: 9-14 weeks; visit 2: 18-22 weeks; visit 3: 28-32 weeks; visit 4: >34 weeks) and were compared (after adjusting for potential confounders) between patients who had term and preterm deliveries, and among subgroups of spontaneous preterm and iatrogenic preterm deliveries. RESULTS There were 708 patients included. Serum progesterone levels at visit 3 were higher in the preterm delivery group than in the term delivery group (P=0.036). The levels did not differ between the two groups at other visits (all P>0.05). In the subgroup analysis, progesterone levels were higher in the iatrogenic preterm delivery subgroup than the term subgroup at visits 1 and 3. A progesterone cut-off level of 304.5 nmol/L demonstrated 81.8% sensitivity, 40.1% specificity, and negative and positive predictive values of 97.5% and 7.2%, respectively, as a predictor of preterm delivery. CONCLUSION Higher serum progesterone levels at 28-32 weeks of pregnancy were observed in women who had preterm deliveries; it was weakly predictive of preterm delivery.
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Affiliation(s)
| | | | - M Jack Ng
- Division of Obstetrics & Gynecology, KK Women's and Children's Hospital, Singapore
| | - George S H Yeo
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Kenneth Y C Kwek
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Bernard S M Chern
- Division of Obstetrics & Gynecology, KK Women's and Children's Hospital, Singapore
| | - Kok H Tan
- Duke-NUS Medical School, Singapore.,Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
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247
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Boelig RC, Jiang E, Scheidemantle B, Villani M, Berghella V. Utilization of progesterone and cervical length screening for prevention of recurrent preterm birth. J Matern Fetal Neonatal Med 2018; 32:4146-4153. [PMID: 29792058 DOI: 10.1080/14767058.2018.1481035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Objective: To assess utilization of progesterone and cervical length (CL) screening among women with prior spontaneous preterm birth (sPTB).Methods: This is a retrospective cohort study of women with prior sPTB. Primary outcomes were the use of progesterone and CL screening. Secondary outcomes were reasons for failure to utilize interventions and factors associated with use of recommended interventions.Results: 180 women had a prior sPTB. Of 171 women eligible for progesterone, 125 (74%) utilized it. Women who utilized progesterone were more likely to have a prior sPTB <28 weeks (50% vs 26%, OR 2.54 (1.18-5.42) p = .006) and a higher number of prior sPTB (1.5 ± 0.9 vs 1.2 ± 0.5, p = .02), and less likely to have a prior full term delivery (54% vs 72%, OR 0.47 (0.22-0.99), p = .04). Of 176 women eligible for CL screening, 157 (89%) utilized it. Women who utilized CL screening were less likely to have a prior full term delivery (59% vs 84%, OR 0.27 (0.07-0.95, p = .01)). The most frequent reason for lack of progesterone and CL screening was patient declining.Conclusion: Most women with prior sPTB received progesterone and CL screening. Those at highest risk for PTB based on obstetric history are more likely to utilize recommended interventions.
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Affiliation(s)
- Rupsa C Boelig
- Division of Maternal Fetal Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Eva Jiang
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Philadelphia, PA, USA
| | - Brooke Scheidemantle
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michela Villani
- Atherosclerosis and Thrombosis Unit, I.R.C.C.S. "Casa Sollievo della Sofferenza", S. Giovanni Rotondo (Foggia), Italy
| | - Vincenzo Berghella
- Division of Maternal Fetal Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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248
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Affiliation(s)
- P. Piette
- Consultant at Besins Healthcare Global, Department of R & D, Scientific & Medical Affairs, Brussels, Belgium
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249
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Abstract
Objective To review fetal and infant deaths from women enrolled in Indianapolis Healthy Start using the National Fetal and Infant Mortality Review (FIMR) methods to provide strategies for prevention. METHODS Marion County Public Health Department (MCPHD) FIMR staff identified and reviewed 22 fetal and infant deaths to Indianapolis Healthy Start program participants between 2005 and 2012. Trained FIMR nurses completed 13 of 20 maternal interviews and compiled case summaries of all deaths from the MCPHD FIMR database.. Results Case review teams identified a total of 349 family strengths, 219 contributing factors, and made 220 recommendations for future pregnancies. FIMR deliberation values for Healthy Start program participant deaths were similar to other infant deaths in Marion County during the same time period. Common themes that emerged from the reviews included lack of social support, absence of paternal involvement, substance abuse, non-compliance, and poor health behaviors leading to chronic health conditions that complicated many pregnancies. Conclusions A number of the infant deaths in this review could have been prevented with preconception and inter-conception education and by improving the quality and content of prenatal care.
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250
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Vani K, Facco FL, Himes KP. Pregnancy after periviable birth: making the case for innovative delivery of interpregnancy care. J Matern Fetal Neonatal Med 2018; 32:3577-3580. [PMID: 29681199 DOI: 10.1080/14767058.2018.1468432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Objective: Women who have had a spontaneous periviable delivery are at high risk for recurrent preterm delivery. The objective of our study was to determine interpregnancy interval (IPI) after periviable birth as well as percentage of women taking 17 alpha hydroxyprogesteronecaproate (17OHP-C) after periviable birth. We then examined the association between adherence with a postpartum visit after a periviable birth and IPI as well as receipt of 17OHP-C. Materials and methods: We included all women with a periviable delivery (20-26-week gestation) due to spontaneous preterm birth at Magee Women's Hospital between 2009 and 2014, who had their subsequent delivery at our institution during or before May of 2016. Information on maternal, fetal, and neonatal outcomes was obtained from the Magee Obstetrical Medical and Infant (MOMI) database as well as chart abstraction. We calculated IPI, proportion of women who received 17OHP-C in their next pregnancy, and attendance rates with a postpartum visit. The relationship between attendance with a postpartum visit and IPI, and receipt of 17OHP-C was examined with a logistic regression. Results: During the study period, 361 women had a spontaneous periviable birth. A total of 60 women had a subsequent delivery at Magee Women's Hospital. Only 33/60 (52.5%) presented for a postpartum visit after their periviable delivery. The median IPI for the cohort was 12.5 months (interquartile range: 6.4, 17.5 months) and 21.0% (n = 13) had an IPI less than 6 months. Adherence with the postpartum visit was not associated with an IPI less than 6 months. A total of 18.33% (11 women) did not receive 17OHP-C in their subsequent pregnancy. Women who attended a postpartum visit were much more likely to receive 17OHP-C (p = .001). Conclusions: Many women with a history of a periviable birth do not optimize strategies to reduce their risk of recurrent preterm birth. While attendance with a postpartum visit was associated with greater receipt of 17OHP-C in the subsequent pregnancy, given the overall poor rate of attendance with the postpartum visit in this cohort, novel strategies to counsel women about interpregnancy health are needed.
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Affiliation(s)
- Kavita Vani
- a Department of Obstetrics and Gynecology , University of Pittsburgh , Pittsburgh , PA , USA
| | - Francesca L Facco
- a Department of Obstetrics and Gynecology , University of Pittsburgh , Pittsburgh , PA , USA.,b Magee-Women's Research Institute , Pittsburgh , PA , USA
| | - Katherine P Himes
- a Department of Obstetrics and Gynecology , University of Pittsburgh , Pittsburgh , PA , USA.,b Magee-Women's Research Institute , Pittsburgh , PA , USA
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