Meta-analysis of randomized controlled trials comparing 17α-hydroxyprogesterone caproate and vaginal progesterone for the prevention of recurrent spontaneous preterm delivery

Prevention of Pregnancy Loss: Combining Progestogen Treatment and Psychological Support

Pregnancy loss can be defined as a loss before either 20 or 24 weeks of gestation (based on the first day of the last menstrual period) or the loss of an embryo or fetus less than 400 g in weight if the gestation age is unknown. Approximately 23 million pregnancy losses occur worldwide every year, equating to 15-20% of all clinically recognized pregnancies. A pregnancy loss is usually associated with physical consequences, such as early pregnancy bleeding ranging in severity from spotting to hemorrhage. However, it can also be associated with profound psychological distress, which can be felt by both partners and may include feelings of denial, shock, anxiety, depression, post-traumatic stress disorder, and suicide. Progesterone plays a key part in the maintenance of a pregnancy, and progesterone supplementation has been assessed as a preventative measure in patients at increased risk of experiencing a pregnancy loss. The primary objective of this piece is to assess the evidence for various progestogen formulations in the treatment of threatened and recurrent pregnancy loss, postulating that an optimal treatment plan would preferably include a validated psychological support tool as an adjunct to appropriate pharmacological treatment.

Physical Activity and Its Relationship with Preterm Birth in the Presence of Depressive Symptomology

OBJECTIVE

To examine the relationship between physical activity (PA) and preterm birth (PTB) within the context of depressive symptoms (DS).

METHODS

Data are from the Life-course Influences of Fetal Environments (LIFE) Study, a cohort comprised of 1410 Black women, age 18-45 years who delivered a singleton in Metropolitan Detroit, MI. DS were measured with the Center for Epidemiologic Studies Depression Scale (CES-D); a score > 23 indicates severe DS. Traditional leisure time PA (LTPA) and non-LTPA during pregnancy (walking for a purpose, climbing stairs) were both measured. Modified Poisson regression models were used to estimate the association between PTB and PA. Effect modification by severe DS was assessed via stratification.

RESULTS

Approximately 16% of women had a PTB; 20% had CES-D scores > 23. Walking for a purpose was the most frequently reported type of PA (79%), followed by any LTPA (37.7%) and climbing stairs (13.5%). Compared with women who reported no PA, women who reported walking for a purpose (PR = 0.70, 95% CI 0.61, 1.10), partaking in LTPA (PR = 0.67, 95% CI 0.50, 0.90), or climbing stairs (PR = 0.61, 95% CI 0.45, 0.81) were less likely to have PTB. Results stratified by severe DS show the association between LTPA and PTB was more pronounced in women with severe DS, while the non-LTPA relationship with PTB was more heterogeneous.

CONCLUSIONS

Women who participated in traditional LTPA (any or walking only) and non-LTPA experienced improved birth outcomes. LTPA may buffer against PTB among pregnant Black women with severe DS as well as none or mild DS.

Prediction and Prevention of Spontaneous Preterm Birth: ACOG Practice Bulletin, Number 234

Preterm birth is among the most complex and important challenges in obstetrics. Despite decades of research and clinical advancement, approximately 1 in 10 newborns in the United States is born prematurely. These newborns account for approximately three-quarters of perinatal mortality and more than one half of long-term neonatal morbidity, at significant social and economic cost (1-3). Because preterm birth is the common endpoint for multiple pathophysiologic processes, detailed classification schemes for preterm birth phenotype and etiology have been proposed (4, 5). In general, approximately one half of preterm births follow spontaneous preterm labor, about a quarter follow preterm prelabor rupture of membranes (PPROM), and the remaining quarter of preterm births are intentional, medically indicated by maternal or fetal complications. There are pronounced racial disparities in the preterm birth rate in the United States. The purpose of this document is to describe the risk factors, screening methods, and treatments for preventing spontaneous preterm birth, and to review the evidence supporting their roles in clinical practice. This Practice Bulletin has been updated to include information on increasing rates of preterm birth in the United States, disparities in preterm birth rates, and approaches to screening and prevention strategies for patients at risk for spontaneous preterm birth.

Vaginal compared with intramuscular progestogen for preventing preterm birth in high-risk pregnant women (VICTORIA study): a multicentre, open-label randomised trial and meta-analysis

OBJECTIVE

To compare the efficacy of two types of progestogen therapy for preventing preterm birth (PTB) and to review the relevant literature.

DESIGN

A multicentre, randomised, open-label, equivalence trial and a meta-analysis.

SETTING

Tertiary referral hospitals in South Korea.

POPULATION

Pregnant women with a history of spontaneous PTB or short cervical length (<25 mm).

METHODS

Eligible women were screened and randomised at 16-22 weeks of gestation to receive either 200 mg of vaginal micronised progesterone daily (vaginal group) or an intramuscular injection of 250 mg 17α-hydroxyprogesterone caproate weekly (IM group). Stratified randomisation was carried out according to participating centres and indications for progestogen therapy. This trial was registered at ClinicalTrials.gov (NCT02304237).

MAIN OUTCOME MEASURE

Preterm birth (PTB) before 37 weeks of gestation.

RESULTS

A total of 266 women were randomly assigned and a total of 247 women (119 and 128 women in the vaginal and IM groups, respectively) were available for the intention-to-treat analysis. Risks of PTB before 37 weeks of gestation did not significantly differ between the two groups (22.7 versus 25.8%, P = 0.571). The difference in PTB risk between the two groups was 3.1% (95% CI -7.6 to 13.8%), which was within the equivalence margin of 15%. The meta-analysis results showed no significant differences in the risk of PTB between the vaginal and IM progestogen treatments.

CONCLUSION

Compared with vaginal progesterone, treatment with intramuscular progestin might increase the risk of PTB before 37 weeks of gestation by as much as 13.8%, or reduce the risk by as much as 7.6%, in women with a history of spontaneous PTB or with short cervical length.

TWEETABLE ABSTRACT

Vaginal and intramuscular progestogen showed equivalent efficacy for preventing preterm birth before 37 weeks of gestation.

Mehanizam kontrakcije i relaksacije miometrijuma, interakcija okcitocina i prostaglandina

Regulation of uterine activity during pregnancy is due to the nature of the loss of humoral sympathetic, holinergical and peptidergic inervation. So far, nothing found that would indicated that the mechanism of premature birth and its pathogenesis different from the normal mechanism of delivery, except for different maturity of the fetus. Since a large number of substances that participate in the contraction and relaxation of miometrium (estrogen, progesterone, cortisol, etc.). Today's modern research has focused on prostaglandins and oxytocin, or their interaction. Accepting oxytocin as substance initiation deliveries it is difficult for two reasons: the level of oxytocin in the blood can not lift before the delivery and release of oxytocin remains constant during pregnancy. Oxytocin probably plays a role in support delivery for decidual cells stimulates the synthesis of uterine PGF2a.

Intramuscular 17α-hydroxyprogesterone caproate to decrease preterm delivery in women with placenta praevia: a randomised controlled trial

We tested the hypothesis that 17α-hydroxyprogesterone caproate (17α-OHP-C) may decrease preterm delivery (PTD) in women with placenta praevia. This was a randomised controlled trial included 114 women with placenta praevia (between 24 and 28 weeks). They were randomly assigned to group I (17α-OHP-C) who received weekly injection of 17α-OHP-C (250 mg/IM) till completing 37 weeks' gestation or group II (Non 17α-OHP-C). The percentage of placenta praevia patients went into PTD in the 17α-OHP-C group was significantly less in comparison to the PTD in the Non 17α-OHP-C group (∼37% vs. 63.5%, p = .004). Furthermore, the mean gestational age was significantly longer (36.7 ± 0.7 vs. 34.9 ± 1.2 weeks, p < .000), the mean number of bleeding attacks was significantly less and the mean birth weight was significantly higher (2841 ± 159 vs. 2561 ± 168 g, p < .000). In conclusion, maintenance tocolysis with intramuscular 17α-OHP-C in placenta praevia women appears beneficial in decreasing the number of bleeding attacks, the percentage of PTD and the neonatal ICU admission.IMPACT STATEMENTWhat is already known on this subject? Over the last two decades, a large number of studies indicated that placenta praevia is a major risk factor for preterm labour and prematurity with its neonatal complications. Increasing caesarean section rates had proportionally increased the incidence of placenta praevia.What do the results of this study add? Up to now, the effective and safe tocolytic agent among these patients is not established. The results of this study (prospective, randomised and controlled with calculated sample size) added a considerable support for hydroxyprogesterone caproate as an effective, safe and cheap tocolytic agent with excellent patient compliance.What are the implications of these findings for clinical practice and/or further research? Our findings may prompt researchers to conduct a large multicentre study to evaluate the prophylactic use of hydroxyprogesterone caproate to decrease preterm labour due to placenta praevia.

Progesterone for the Prevention of Preterm Birth - an Update of Evidence-Based Indications

The prevention and treatment of preterm birth remains one of the biggest challenges in obstetrics. Worldwide, 11% of all children are born prematurely with far-reaching consequences for the children concerned, their families and the health system. Experimental studies suggest that progesterone inhibits uterine contractions, stabilises the cervix and has immunomodulatory effects. Recent years have seen the publication of numerous clinical trials using progestogens for the prevention of preterm birth. As a result of different inclusion criteria and the use of different progestogens and their methods of administration, it is difficult to draw comparisons between these studies. A critical evaluation of the available studies was therefore carried out on the basis of a search of the literature (1956 to 09/2018). Taking into account the most recent randomised, controlled studies, the following evidence-based recommendations emerge: In asymptomatic women with singleton pregnancies and a short cervical length on ultrasound of ≤ 25 mm before 24 weeks of gestation (WG), daily administration of vaginal progesterone (200 mg capsule or 90 mg gel) up until 36 + 6 WG leads to a significant reduction in the preterm birth rate and an improvement in neonatal outcome. The latest data also suggest positive effects of treatment with progesterone in cases of twin pregnancies with a short cervical length on ultrasound of ≤ 25 mm before 24 WG. The study data for the administration of progesterone in women with singleton pregnancies with a previous preterm birth have become much more heterogeneous, however. It is not possible to make a general recommendation for this indication at present, and decisions must therefore be made on a case-by-case basis. Even if progesterone use is considered to be safe in terms of possible long-term consequences, exposure should be avoided where it is not indicated. Careful patient selection is crucial for the success of treatment.

Adjuvant 17-hydroxyprogesterone caproate in women withultrasound-indicated cerclage: a systematic review and meta-analysis

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.

Progestogen for treating threatened miscarriage

BACKGROUND

Miscarriage is a common complication encountered during pregnancy. It is defined as spontaneous pregnancy loss before 20 weeks' gestation. Progesterone's physiological role is to prepare the uterus for the implantation of the embryo, enhance uterine quiescence and suppress uterine contractions, hence, it may play a role in preventing rejection of the embryo. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss. This update of the Cochrane Review first published in 2007, and previously updated in 2011, investigates the evidence base for this practice.

OBJECTIVES

To determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (8 August 2017) and reference lists of retrieved trials.

SELECTION CRITERIA

Randomised, quasi-randomised or cluster-randomised controlled trials, that compared progestogen with placebo, no treatment or any other treatment for the treatment of threatened miscarriage in women carrying singleton pregnancy.

DATA COLLECTION AND ANALYSIS

At least two review authors assessed the trials for inclusion in the review, assessed trial quality and extracted the data and graded the body of evidence.

MAIN RESULTS

We included seven trials (involving 696 participants) in this update of the review. The included trials were conducted in different countries, covering the full spectrum of the World Bank's economic classification, which enhances the applicability of evidence drawn from this review. Two trials were conducted in Germany and Italy which are high-income countries, while four trials were conducted in upper-middle income countries; two in Iran, one in Malaysia and the fourth in Turkey, and the seventh trial was conducted in Jordan, which is a lower-middle income country. In six trials all the participants met the inclusion criteria and in the seventh study, we included in the meta-analysis only the subgroup of participants who met the inclusion criteria. We assessed the body of evidence for the main outcomes using the GRADE tool and the quality of the evidence ranged from very low to moderate. Downgrading of evidence was based on the high risk of bias in six of the seven included trials and a small number of events and wide confidence intervals for some outcomes.Treatment of miscarriage with progestogens compared to placebo or no treatment probably reduces the risk of miscarriage; (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.47 to 0.87; 7 trials; 696 women; moderate-quality evidence). Treatment with oral progestogen compared to no treatment also probably reduces the miscarriage rate (RR 0.57, 95% CI 0.38 to 0.85; 3 trials; 408 women; moderate-quality evidence). However treatment with vaginal progesterone compared to placebo, probably has little or no effect in reducing the miscarriage rate (RR 0.75, 95% CI 0.47 to 1.21; 4 trials; 288 women; moderate-quality evidence). The subgroup interaction test indicated no difference according to route of administration between the oral and vaginal subgroups of progesterone.Treatment of preterm birth with the use of progestogens compared to placebo or no treatment may have little or no effect in reducing the rate of preterm birth (RR 0.86, 95% CI 0.52 to 1.44; 5 trials; 588 women; low-quality evidence).We are uncertain if treatment of threatened miscarriage with progestogens compared to placebo or no treatment has any effect on the rate of congenital abnormalities because the quality of the evidence is very low (RR 0.70, 95% CI 0.10 to 4.82; 2 trials; 337 infants; very-low quality evidence).

AUTHORS' CONCLUSIONS

The results of this Cochrane Review suggest that progestogens are probably effective in the treatment of threatened miscarriage but may have little or no effect in the rate of preterm birth. The evidence on congenital abnormalities is uncertain, because the quality of the evidence for this outcome was based on only two small trials with very few events and was found to be of very low quality.

Healthy Singleton Pregnancies From Restorative Reproductive Medicine (RRM) After Failed IVF

Objectives: To determine the live birth rate for patients who chose to undergo treatment with Restorative Reproductive Medicine (RRM) after previous IVF (includes ICSI). To look at birth outcomes with RRM after IVF, particularly rates of twin and higher order pregnancies, premature birth, low birth weight, and potential cost savings achieved with RRM.

Setting: Two outpatient clinics in Ireland providing advanced RRM treatment of infertility.

Materials and methods: All patients presenting between January 2004 and January 2010, with a history of infertility and previous IVF treatment were included if they proceeded beyond the initial consultation and began treatment. Main outcome is live birth per couple calculated using life table analysis.

Results: 403 patients met the study criteria, among which 74 had a subsequent live birth. These women had significant negative predictive characteristics for healthy live birth including: advanced reproductive age (average 37.2 years), an average of 5.8 years of infertility with 2.1 (range 1–9) previous IVF attempts, with only 5% having previously had a live birth from IVF. Despite these undesirable prognostic indicators, the overall RRM live birth rate was 32.1% (crude 18.4%). Women aged 35–38 had a live birth rate of 37.5% (crude 23.6%) and older women over 40 had a live birth rate of 27.4% (crude 16.0%). The average birth weight was 3374g (7lb 7oz) with 92% being born at 37+ weeks and no very low birth weight babies. There was only one twin pregnancy in the study population; the potential health care savings for avoidable multiple pregnancies in these patients was estimated at £205 672 (USD$284 915).

Conclusions: Patients who have already tried IVF can achieve comparable live birth outcomes with RRM compared to another cycle of IVF. RRM has a low risk of twin or multiple births, and very good neonatal outcomes with a potential cost savings to the health care system.

Repurposing and repositioning neurosteroids in the treatment of traumatic brain injury: A report from the trenches

The field of neuroprotection after brain injuries has been littered with failed clinical trials. Finding a safe and effective treatment for acute traumatic brain injury remains a serious unmet medical need. Repurposing drugs that have been in use for other disorders is receiving increasing attention as a strategy to move candidate drugs more quickly to trial while reducing the very high cost of new drug development. This paper describes our own serendipitous discovery of progesterone's neuroprotective potential, and the strategies we are using in repurposing and developing this hormone for use in brain injuries-applications very different from its classical uses in treating disorders of the reproductive system. We have been screening and testing a novel analog that maintains progesterone's therapeutic properties while overcoming its physiochemical challenges, and testing progesterone in combination treatment with another pleiotropic hormone, vitamin D. Finally, our paper, in the context of the problems and pitfalls we have encountered, surveys some of the factors we found to be critical in the clinical translation of repurposed drugs. This article is part of the Special Issue entitled 'Drug Repurposing: old molecules, new ways to fast track drug discovery and development for CNS disorders'.

Progestogens and pregnancy loss

Progestational agents are often prescribed to prevent pregnancy loss. Progestogens affect implantation, cytokine balance, natural killer cell activity, arachidonic acid release and myometrial contractility. Progestogens have therefore been used at all stages of pregnancy including luteal-phase support prior to pregnancy, threatened miscarriage, recurrent miscarriage, and to prevent preterm labor. In luteal support, a Cochrane review reported that progestogens were associated with a higher rate of live births or ongoing pregnancy in the progesterone group (odds ratio 1.77, 95% confidence interval (CI) 1.09-2.86). Evidence suggests that progestogens are also effective for treating threatened miscarriage. Again, in a Cochrane Database review, progestogens were associated with a reduced odds ratio of 0.53 (95% CI 0.35-0.79) when progestogens were used. In recurrent miscarriage, progestogens also seem to have a beneficial effect. A meta-analysis of progestational agents showed a 28% increase in the live birth rate (relative risk 0.72, 95% CI 0.53-0.97). For the last 30 years, progestogens have been used to prevent preterm labor. Recent meta-analyses also report beneficial effects. This review summarizes the literature and the author's experience using progestogens to prevent pregnancy loss.

Progesterone improves perinatal neuromotor outcomes in a mouse model of intrauterine inflammation via immunomodulation of the placenta

To assess the fetal neuroprotective potential of progesterone using a well-validated mouse model of lipopolysaccharide (LPS)-induced intrauterine inflammation (IUI). Embryonic day 17 pregnant mouse dams (n = 69) were randomly allocated to receive 17-hydroxyprogesterone caproate (17-OHPC), micronized progesterone (MP), or vehicle 1 hour prior to intrauterine injection of phosphate-buffered saline (PBS) or LPS. After 6 hours, mice were killed for the collection of placentas and fetal brains, or pregnancy continued for the evaluation of preterm birth (PTB) and offspring neuromotor function. Placentas and fetal brains were analyzed by mini-mRNA array for 96 immune markers with individual confirmatory qPCR. Progesterone pre-treatment before LPS-induced IUI improved neuromotor tests in offspring at PND5 compared to no pre-treatment (P < .05). In placentas, 17-OHPC, but not MP, significantly reduced CXCL9 (P < .05) with a trend toward a lower level of CXCL10. In fetal brains, 17-OHPC significantly reduced CXCL9 compared to no pre-treatment (P < .05) and IL-1β compared to pre-treatment with MP (P < .01). Progesterone pre-treatment prior to LPS-induced IUI improved offspring neuromotor outcomes. 17-OHPC, but not MP, resulted in greater immunomodulation of T cell-mediated immunity in placenta and fetal brain, suggesting a possible mechanism for the observed neuroprotective effects.