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He B, Zhou Y, Cao L, Yao B, Gao H, Zhang H. Cervical elastography in predicting spontaneous preterm birth in singleton pregnancy with a short cervix receiving progesterone treatment at 18 to 24 weeks' gestation. J Matern Fetal Neonatal Med 2024; 37:2347954. [PMID: 38714523 DOI: 10.1080/14767058.2024.2347954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 04/22/2024] [Indexed: 05/10/2024]
Abstract
BACKGROUND A short cervix in the second trimester is known to increase the risk of preterm birth, which can be reduced with the administration of vaginal progesterone. However, some studies have suggested that a significant number of cases still experience preterm birth despite progesterone treatment. OBJECTIVE This study was aimed to investigate the potential value of transvaginal cervical elasticity measured by E-Cervix as a predictor for spontaneous preterm birth (sPTB) in singleton pregnancies receiving progesterone treatment for a short cervix (CL ≤ 2.5 cm) diagnosed at 18 to 24 weeks' gestation. STUDY DESIGN This prospective study was conducted at a single center premature high-risk clinic from January 2020 to July 2022. Singleton pregnancies with a short cervix at 18 to 24 weeks' gestation were enrolled. Cervical elastography using E-Cervix was performed, and maternal and neonatal demographic characteristics, cervical length (CL), elasticity contrast index (ECI), cervical hardness ratio, mean internal os strain (IOS), and mean external os strain (EOS) were compared before and after progesterone treatment in sPTB and term birth groups. Multivariate logistic regression was used to analyze the association between elasticity parameters and spontaneous preterm birth. The screening performance of CL and optimal cervical elasticity parameters in predicting sPTB was evaluated using receiver-operating characteristic (ROC) curve analysis. RESULTS A total of 228 singleton pregnant women were included in the study, among which 26 (11.4%) had sPTB. There were no significant differences in maternal characteristics and gestational age at enrollment between women with and without sPTB. At the start of progesterone treatment, there were no significant differences in cervical elasticity parameters between the two groups. After two weeks of progesterone treatment, women who had sPTB showed significantly higher levels of ECI, IOS, EOS (p = 0.0108, 0.0001, 0.016), and lower hardness ratio (p = 0.011) compared to those who had a full-term birth. Cervical length did not show significant differences between the two groups, regardless of whether progesterone treatment was administered before or after. Among the post-treatment cervical elasticity parameters, IOS and EOS were associated with a 3.38-fold and 2.29-fold increase in the risk of sPTB before 37 weeks (p = 0.032, 0.047, respectively). The AUROC of the combined model including CL, IOS, and EOS (0.761, 95% CI0.589-0.833) was significantly higher than the AUROC of CL alone (0.618, 95% CI 0.359-0.876). At a fixed false-positive of 13%, the addition of IOS and EOS in the CL model increased sensitivity from 34.6% to 57.6%, PPV from 25.7% to 36.5%, and NPV from 91.1% to 94.1%. CONCLUSION When assessing the risk of sPTB in singleton pregnancies with a short cervix receiving progesterone therapy, relying solely on cervical length is insufficient. It is crucial to also evaluate cervical stiffness, particularly the strain of the internal and external os, using cervical elastography.
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Affiliation(s)
- Biyuan He
- Department of Ultrasound, Shanghai Changning Maternity and Infant Health Hospital, East China Normal University, Shanghai, China
| | - Yuqing Zhou
- Department of Ultrasound, Shanghai Changning Maternity and Infant Health Hospital, East China Normal University, Shanghai, China
| | - Li Cao
- Department of Ultrasound, Shanghai Changning Maternity and Infant Health Hospital, East China Normal University, Shanghai, China
| | - Bingyi Yao
- Department of Obstetrics, Shanghai Changning Maternity and Infant Health Hospital, East China Normal University, Shanghai, China
| | - Haihuan Gao
- Department of Ultrasound, Shanghai Changning Maternity and Infant Health Hospital, East China Normal University, Shanghai, China
| | - Huiping Zhang
- Department of Ultrasound, Shanghai Changning Maternity and Infant Health Hospital, East China Normal University, Shanghai, China
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Tolosa JE, Boelig RC, Bell J, Martínez-Baladejo M, Stoltzfus J, Mateus J, Quiñones JN, Galeano-Herrera S, Pereira L, Burwick R, López-Torres L, Valencia C, Berghella V. Concurrent progestogen and cerclage to reduce preterm birth: a multicenter international retrospective cohort. Am J Obstet Gynecol MFM 2024; 6:101351. [PMID: 38513806 DOI: 10.1016/j.ajogmf.2024.101351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Both progestogens and cerclage are individually effective in preterm birth prevention in high risk pregnancies. However, national and international guidelines cite a lack of data available to comment on the potential benefit of concurrent progestogen therapy after cerclage has been placed. Studies to date have been small with mixed results regarding benefit of concurrent progestogen with cerclage leaving uncertainty regarding best clinical practice. OBJECTIVE This study aimed to evaluate whether cerclage with progestogen therapy was superior to cerclage alone in the prevention of spontaneous preterm birth in singleton pregnancies. METHODS This is an international retrospective cohort study of singleton pregnancies, without major anomaly or aneuploidy, and with cerclage placed at 10 different institutions in the United States and Colombia from June 2016 to June 2020. Exclusion criteria were lack of documentation regarding whether progestogen was prescribed, unavailable delivery outcome, and pregnancy termination (spontaneous or induced) before 16 weeks' gestation. The exposure of interest was progestogen use with cerclage placement, which included those who continued to use progestogen or who started progestogen after cerclage. The comparison group consisted of those without progestogen use after cerclage placement, which included those who had no progestogen use during the entire pregnancy or who initiated progestogen and then stopped it after cerclage placement. Progestogen type, cerclage indication, maternal baseline characteristics, and maternal/neonatal outcomes were collected. The primary outcome was spontaneous preterm birth at <37 weeks. The secondary outcomes were spontaneous preterm birth at <34 weeks, gestational age at delivery, and a composite neonatal outcome including ≥1 of the following: perinatal mortality, confirmed sepsis, grade III or IV intraventricular hemorrhage, retinopathy of prematurity, respiratory distress syndrome, and bronchopulmonary dysplasia. There were planned subgroup analyses by cerclage indication, progestogen type (vaginal progesterone vs 17-hydroxyprogesterone caproate), preterm birth history, and site. Continuous variables were compared in adjusted analyses with analysis of covariance, and categorical variables were compared with multivariable logistic regression, adjusting for potential confounders with adjusted odds ratio. A Cox regression survival curve was generated to compare latency to spontaneous delivery, censored after 37 weeks. RESULTS During the study period, a total of 699 singletons met the inclusion criteria: 561 in the progestogen with cerclage group and 138 with cerclage alone. Baseline characteristics were similar, except the higher likelihood of previous spontaneous preterm birth in the progestogen group (61% vs 41%; P<.001). Within the progestogen group, 52% were on 17-hydroxyprogesterone caproate weekly, 44% on vaginal progesterone daily, and 3% on oral progesterone daily. Progestogen with cerclage was associated with a significantly lower frequency of spontaneous preterm birth <37 weeks (31% vs 39%; adjusted odds ratio, 0.59 [0.39-0.89]; P=.01) and <34 weeks (19% vs 27%; adjusted odds ratio, 0.55 [0.35-0.87]; P=.01), increased latency to spontaneous delivery (hazard ratio for spontaneous preterm birth <37 weeks, 0.66 [0.49-0.90]; P=.009), and lower frequency of perinatal death (7% vs 16%; adjusted odds ratio, 0.37 [0.20-0.67]; P=.001). In planned subgroup analyses, association with reduced odds of preterm birth <37 weeks persisted in those on vaginal progesterone, those without a previous preterm birth, those with ultrasound- or examination-indicated cerclage, those who started progestogen therapy before cerclage, and in sites restricted to the United States. CONCLUSION Use of progestogen with cerclage was associated with reduced rates of spontaneous preterm birth and early spontaneous preterm birth compared with cerclage alone. Although this study was not sufficiently powered for subgroup analysis, the strength of evidence for benefit appeared greatest for those with ultrasound- or examination-indicated cerclage, and with vaginal progesterone. El resumen está disponible en Español al final del artículo.
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Affiliation(s)
- Jorge E Tolosa
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA (Drs Tolosa and Bell); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR (Drs Tolosa and Pereira); FUNDARED-MATERNA, Bogotá, Colombia (Drs Tolosa, Burwick, and Valencia)
| | - Rupsa C Boelig
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Philadelphia, PA (Drs Boelig and Berghella).
| | - Joseph Bell
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA (Drs Tolosa and Bell)
| | - María Martínez-Baladejo
- Departments of Research and Innovation and Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA (Dr Martínez-Baladejo)
| | - Jill Stoltzfus
- Graduate Medical Education Data Measurement and Outcomes Assessment, Lewis Katz School of Medicine at Temple University/St. Luke's University Health Network, Bethlehem, PA (Dr Stoltzfus)
| | - Julio Mateus
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Atrium Health, Wake Forest University School of Medicine, Charlotte, NC (Dr Mateus)
| | - Joanne N Quiñones
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA (Dr Quiñones)
| | - Santiago Galeano-Herrera
- Departamento de Ginecología y Obstetricia, Clínica del Prado, Universidad Remington, Medellín, Colombia (Dr Galeano-Herrera)
| | - Leonardo Pereira
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR (Drs Tolosa and Pereira)
| | - Richard Burwick
- Division of Maternal Fetal Medicine, San Gabriel Valley Perinatal Medical Group, Pomona Valley Hospital Medical Center, Pomona, CA (Dr Burwick); FUNDARED-MATERNA, Bogotá, Colombia (Drs Tolosa, Burwick, and Valencia)
| | - Luisa López-Torres
- Departamento de Ginecología y Obstetricia, Medicina Materno-Fetal, Universidad Pontificia Bolivariana, Medellín, Colombia (Dr López-Torres)
| | - Catalina Valencia
- Universidad CES, Clínica del Prado, Medellín, Colombia (Dr Valencia); FUNDARED-MATERNA, Bogotá, Colombia (Drs Tolosa, Burwick, and Valencia)
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Philadelphia, PA (Drs Boelig and Berghella)
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Romero R, Meyyazhagan A, Hassan SS, Creasy GW, Conde-Agudelo A. Vaginal Progesterone to Prevent Spontaneous Preterm Birth in Women With a Sonographic Short Cervix: The Story of the PREGNANT Trial. Clin Obstet Gynecol 2024; 67:433-457. [PMID: 38576410 PMCID: PMC11047312 DOI: 10.1097/grf.0000000000000867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
The PREGNANT trial was a randomized, placebo-controlled, multicenter trial designed to determine the efficacy and safety of vaginal progesterone (VP) to reduce the risk of birth < 33 weeks and of neonatal complications in women with a sonographic short cervix (10 to 20 mm) in the mid-trimester (19 to 23 6/7 wk). Patients allocated to receive VP had a 45% lower rate of preterm birth (8.9% vs 16.1%; relative risk = 0.55; 95% CI: 0.33-0.92). Neonates born to mothers allocated to VP had a 60% reduction in the rate of respiratory distress syndrome. This article reviews the background, design, execution, interpretation, and impact of the PREGNANT Trial.
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Affiliation(s)
- Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, Maryland
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan
| | - Arun Meyyazhagan
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, Maryland
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
- Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | - Sonia S. Hassan
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
- Office of Women’s Health, Integrative Biosciences Center, Wayne State University, Detroit, Michigan
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan
| | - George W. Creasy
- Center for Biomedical Research, Population Council, New York, New York
| | - Agustin Conde-Agudelo
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
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Hernandez-Andrade E, Huntley ES, Sibai B, Blackwell SC, Soto-Torres EE. Reduction in cervical length after vaginal progesterone in women with short cervix is significantly associated with preterm delivery at ≤ 34 weeks and < 37 weeks of gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:644-649. [PMID: 37916641 DOI: 10.1002/uog.27527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 10/05/2023] [Accepted: 10/19/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To evaluate the association between changes in cervical length (CL) after vaginal progesterone treatment and preterm delivery (PTD). METHODS This was a retrospective cohort study that included 197 singleton pregnancies without (n = 178) and with (n = 19) a history of PTD which were found to have a short cervix (≤ 25 mm) between 18 + 0 and 23 + 6 weeks' gestation with a follow-up transvaginal CL measurement taken at least 1 week after vaginal progesterone treatment started. Receiver-operating-characteristics (ROC)-curve analysis was performed and three CL shortening patterns were evaluated: (1) ≥ 10% reduction; (2) ≥ 20% reduction; and (3) ≥ 5 mm reduction relative to the first CL measurement. The predictive performance of each CL reduction cut-off and its association with PTD ≤ 34 weeks and PTD < 37 weeks were evaluated. RESULTS Overall, the rate of PTD ≤ 34 weeks was 16.8% (33/197) and that of PTD < 37 weeks was 36.5% (72/197). The area under the ROC curve of cervical shortening expressed in % for predicting PTD ≤ 34 weeks and PTD < 37 weeks was 0.703 and 0.608, respectively. Cervical shortening was observed in 60/197 (30.5%) patients, with 49/60 (81.7%) women showing ≥ 10% reduction, 32/60 (53.3%) ≥ 20% reduction and 27/60 (45.0%) ≥ 5 mm reduction in CL. Sensitivity and specificity for PTD ≤ 34 weeks were, respectively, 48.5% and 79.9% for ≥ 10% reduction; 36.4% and 87.8% for ≥ 20% reduction; and 27.3% and 89.0% for ≥ 5 mm reduction in CL. For PTD < 37 weeks, sensitivity and specificity were, respectively, 36.1% and 81.6% for ≥ 10% reduction; 27.8% and 90.4% for ≥ 20% reduction; and 20.8% and 90.4% for ≥ 5 mm reduction in CL. The highest positive likelihood ratios for PTD ≤ 34 and < 37 weeks were for ≥ 20% CL reduction (2.98 (95% CI, 1.62-5.49) and 2.89 (95% CI, 1.52-5.57), respectively). Despite significant differences in sensitivity among the different cut-offs for cervical shortening, favoring the ≥ 10% reduction cut-off, a reduction of ≥ 20% in CL showed the strongest association with PTD ≤ 34 weeks (odds ratio (OR), 4.11 (95% CI, 1.75-9.62)) and < 37 weeks (OR, 3.62 (95% CI, 1.65-7.96)), as compared with a less pronounced reduction in CL. CONCLUSIONS In women with a short cervix treated with vaginal progesterone, a reduction in CL on a subsequent ultrasound scan can predict PTD ≤ 34 and < 37 weeks. A ≥ 20% reduction in CL had the highest positive likelihood ratio and strongest association with PTD ≤ 34 and < 37 weeks compared with ≥ 10% or ≥ 5 mm reduction. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E Hernandez-Andrade
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - E S Huntley
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - B Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - S C Blackwell
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - E E Soto-Torres
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas, Health Science Center at Houston (UTHealth), Houston, TX, USA
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Rana T, Gulersen M, Roman A, Boelig RC, Berghella V. Reply to Letter to Editor 'Vaginal progesterone should be offered to patients with a singleton gestation and a history of spontaneous preterm birth only if a cervical length ≤25 mm is detected at midtrimester'. Am J Obstet Gynecol MFM 2024; 6:101216. [PMID: 37931780 DOI: 10.1016/j.ajogmf.2023.101216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Affiliation(s)
- Tanvi Rana
- Department of Obstetrics and Gynecology, TriHealth, Cincinnati, OH
| | - Moti Gulersen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA
| | - Amanda Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA
| | - Rupsa C Boelig
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA.
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Berghella V, Gulersen M, Roman A, Boelig RC. Vaginal progesterone for the prevention of recurrent spontaneous preterm birth. Am J Obstet Gynecol MFM 2023; 5:101116. [PMID: 37543143 DOI: 10.1016/j.ajogmf.2023.101116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/21/2023] [Accepted: 07/29/2023] [Indexed: 08/07/2023]
Abstract
After the United States Food and Drug Administration pulled 17-alpha hydroxyprogesterone caproate from the market for its use in prevention of recurrent spontaneous preterm birth, national societies have had mixed recommendations regarding the management of patients with a singleton pregnancy and previous spontaneous preterm birth. Herein we highlight the randomized trial data and translational evidence supporting the use of vaginal progesterone for prevention of recurrent spontaneous preterm birth in singleton pregnancies. Prophylactic vaginal progesterone starting at 16 weeks and 0 days every night should be offered to patients with singletons and previous singleton spontaneous preterm birth regardless of cervical length, and continued along with placement of cerclage if a transvaginal ultrasound cervical length ≤25 mm is detected at <24 weeks.
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Affiliation(s)
- Vincenzo Berghella
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Sidney Kimmel Medical College, Philadelphia, PA.
| | - Moti Gulersen
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Sidney Kimmel Medical College, Philadelphia, PA
| | - Amanda Roman
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Sidney Kimmel Medical College, Philadelphia, PA
| | - Rupsa C Boelig
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Sidney Kimmel Medical College, Philadelphia, PA
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Motomura K, Miller D, Galaz J, Liu TN, Romero R, Gomez-Lopez N. The effects of progesterone on immune cellular function at the maternal-fetal interface and in maternal circulation. J Steroid Biochem Mol Biol 2023; 229:106254. [PMID: 36681283 PMCID: PMC10038932 DOI: 10.1016/j.jsbmb.2023.106254] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 01/16/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
Progesterone is a sex steroid hormone that plays a critical role in the establishment and maintenance of pregnancy. This hormone drives numerous maternal physiological adaptations to ensure the continuation of pregnancy and to facilitate fetal growth, including broad and potent modulation of the maternal immune system to promote maternal-fetal tolerance. In this brief review, we provide an overview of the immunomodulatory functions of progesterone in the decidua, placenta, myometrium, and maternal circulation during pregnancy. Specifically, we summarize current evidence of the regulated functions of innate and adaptive immune cells induced by progesterone and its downstream effector molecules in these compartments, including observations in human pregnancy and in animal models. Our review highlights the gaps in knowledge of interactions between progesterone and maternal cellular immunity that may direct future research.
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Affiliation(s)
- Kenichiro Motomura
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Derek Miller
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Jose Galaz
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA; Division of Obstetrics and Gynecology, School of Medicine, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Tzu Ning Liu
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA; Detroit Medical Center, Detroit, MI, USA
| | - Nardhy Gomez-Lopez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA; Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit, MI, USA.
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8
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Ninkov T, Nathan EA, Belcher CN, White SW, Newnham JP. The clinical utility of ongoing sonographic cervix length surveillance in pregnancies prescribed vaginal progesterone therapy. Aust N Z J Obstet Gynaecol 2023; 63:198-203. [PMID: 35897131 DOI: 10.1111/ajo.13592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 07/03/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Vaginal progesterone therapy significantly reduces preterm birth (PTB) rates in those high-risk pregnancies with a sonographic short cervix (≤25 mm) and/or a history of spontaneous PTB. Cervical length (CL) is routinely measured at the midtrimester morphology scan; however, CL surveillance thereafter is not currently recommended. Progesterone's precise mechanism of action remains unknown, though if it indeed influences CL, shortening after treatment initiation could indicate therapeutic failure and risk of PTB. AIMS The aim was to explore the utility of serial transvaginal ultrasound (TVU) measurement of CL at 16, 19 and 22 weeks for predicting PTB in high-risk pregnancies prescribed progesterone therapy. METHODS A retrospective cohort study was conducted involving women who attended the King Edward Memorial Hospital PTB Prevention Clinic from 2015 to 2019 and were prescribed progesterone therapy. CL was measured at 16, 19 and 22 weeks by TVU. CL change across three time points was assessed using linear mixed models; then relationships between CL change between 16-19 and 19-22 weeks and PTB were analysed using logistic regression models. RESULTS Term birth was most likely when CL did not decrease across both time periods. The addition of 16-19 week decrease in CL to a model, including CL at 19 weeks alone, for predicting PTB increased sensitivity from 43.2 to 56.3%, specificity from 73.2 to 77.4%, and overall accuracy from 61.7 to 70.2%. CONCLUSION For high-risk women prescribed vaginal progesterone therapy, serial measurement of the cervix at 16 and 19 weeks improves clinical ability to predict PTB from current recommendations of 19-week measurement alone.
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Affiliation(s)
| | - Elizabeth A Nathan
- Women and Infants Research Foundation, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Cathryn N Belcher
- Maternal-Fetal Medicine Service, King Edward Memorial Hospital, Perth, WA, Australia
| | - Scott W White
- Division of Obstetrics and Gynaecology, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Women and Infants Research Foundation, King Edward Memorial Hospital, Perth, Western Australia, Australia
- Maternal-Fetal Medicine Service, King Edward Memorial Hospital, Perth, WA, Australia
| | - John P Newnham
- Division of Obstetrics and Gynaecology, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Women and Infants Research Foundation, King Edward Memorial Hospital, Perth, Western Australia, Australia
- Maternal-Fetal Medicine Service, King Edward Memorial Hospital, Perth, WA, Australia
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9
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O'Brien JM. Personalized obstetrics: the importance of specificity. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:155-162. [PMID: 34580940 DOI: 10.1002/uog.24783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/25/2021] [Accepted: 09/16/2021] [Indexed: 06/13/2023]
Affiliation(s)
- J M O'Brien
- University of Kentucky, Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Lexington, KY, USA
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10
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Hayashi M, Oi R, Otsuki K, Yoneda N, Nagamatsu T, Kumasaka R, Miyakoshi K, Aoki H, Tanaka K, Kumazawa K, Ohkuchi A, Matsuda Y, Nakai A. Effects of prophylactic vaginal progesterone administration on mild cervical shortening (TROPICAL study): a multicenter, double-blind, randomized trial. J Matern Fetal Neonatal Med 2021; 35:8012-8018. [PMID: 34182873 DOI: 10.1080/14767058.2021.1940935] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Vaginal progesterone reduces the preterm birth frequency among high-risk women with a cervical length ≤25 mm at midtrimester. However, the strategy may promote no substantial reduction in overall preterm birth rates, because such high-risk women are only approximately 2% of all pregnant women, which restrict the number of participants. Our purpose was to determine whether prophylactic vaginal progesterone administration can preserve cervical length and reduce preterm birth rates among women with mild cervical shortening.This multicenter, parallel-arm, double-blind, randomized, placebo-controlled trial involved vaginal progesterone administration (200 mg daily from 16 to 33 weeks of gestation) among asymptomatic women with a singleton pregnancy and a sonographic cervical length of 25 to <30 mm between 16 and 23 weeks of gestation. The primary and secondary endpoints were cervical shortening rates at 34 weeks of gestation and preterm birth rates, respectively. The trial was registered at the University Hospital Medical Information Network (UMIN000013518) in Japan.Between April 2014 and March 2018, 119 women were randomly assigned to the progesterone group (n = 59) and the placebo group (n = 60). No significant differences in the frequency of women with a cervical length ≥20 mm at 34 weeks of gestation were observed between both groups. All preterm births occurred after 34 weeks of gestation, except for one patient in the placebo group. The progesterone group had a lower rate of preterm birth before 37 weeks than the placebo group (3.4% vs. 15.0%, respectively; p < .05).Despite having no effect on preserving cervical length, prophylactic vaginal progesterone administration reduced preterm birth frequency among women with mild cervical shortening. Our results are suggesting that women with mild cervical shortening are at risk for late preterm birth and the need for expanding progesterone treatment indications to include not only high-risk but also low-risk populations.
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Affiliation(s)
- Masako Hayashi
- Japanese Organization of Prevention of Preterm Delivery (JOPP), Tokyo, Japan.,Department Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan
| | - Rie Oi
- Japanese Organization of Prevention of Preterm Delivery (JOPP), Tokyo, Japan.,Ito Medical Clinic, Tokyo, Japan
| | - Katsufumi Otsuki
- Japanese Organization of Prevention of Preterm Delivery (JOPP), Tokyo, Japan.,Department of Obstetrics, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Noriko Yoneda
- Japanese Organization of Prevention of Preterm Delivery (JOPP), Tokyo, Japan.,Department of Obstetrics and Gynecology, University of Toyama, Toyama, Japan
| | - Takeshi Nagamatsu
- Japanese Organization of Prevention of Preterm Delivery (JOPP), Tokyo, Japan.,Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryota Kumasaka
- Japanese Organization of Prevention of Preterm Delivery (JOPP), Tokyo, Japan.,Department of Obstetrics and Gynecology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Kei Miyakoshi
- Japanese Organization of Prevention of Preterm Delivery (JOPP), Tokyo, Japan.,Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Hiroaki Aoki
- Japanese Organization of Prevention of Preterm Delivery (JOPP), Tokyo, Japan.,Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kei Tanaka
- Japanese Organization of Prevention of Preterm Delivery (JOPP), Tokyo, Japan.,Department of Obstetrics and Gynecology, Kyorin University, Tokyo, Japan
| | - Kazumasa Kumazawa
- Japanese Organization of Prevention of Preterm Delivery (JOPP), Tokyo, Japan.,Department of Obstetrics and Gynecology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Akihide Ohkuchi
- Japanese Organization of Prevention of Preterm Delivery (JOPP), Tokyo, Japan.,Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Yoshio Matsuda
- Japanese Organization of Prevention of Preterm Delivery (JOPP), Tokyo, Japan
| | - Akihito Nakai
- Japanese Organization of Prevention of Preterm Delivery (JOPP), Tokyo, Japan.,Department Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan
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Eleje GU, Eke AC, Ikechebelu JI, Ezebialu IU, Okam PC, Ilika CP. Cervical stitch (cerclage) in combination with other treatments for preventing spontaneous preterm birth in singleton pregnancies. Cochrane Database Syst Rev 2020; 9:CD012871. [PMID: 32970845 PMCID: PMC8094629 DOI: 10.1002/14651858.cd012871.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Preterm birth (PTB) remains the foremost global cause of perinatal morbidity and mortality. Thus, the prevention of spontaneous PTB still remains of critical importance. In an attempt to prevent PTB in singleton pregnancies, cervical cerclage, in combination with other treatments, has been advocated. This is because, cervical cerclage is an intervention that is commonly recommended in women with a short cervix at high risk of preterm birth but, despite this, many women still deliver prematurely, as the biological mechanism is incompletely understood. Additionally, previous Cochrane Reviews have been published on the effectiveness of cervical cerclage in singleton and multiple pregnancies, however, none has evaluated the effectiveness of using cervical cerclage in combination with other treatments. OBJECTIVES To assess whether antibiotics administration, vaginal pessary, reinforcing or second cerclage placement, tocolytic, progesterone, or other interventions at the time of cervical cerclage placement prolong singleton gestation in women at high risk of pregnancy loss based on prior history and/or ultrasound finding of 'short cervix' and/or physical examination. History-indicated cerclage is defined as a cerclage placed usually between 12 and 15 weeks gestation based solely on poor prior obstetrical history, e.g. multiple second trimester losses due to painless dilatation. Ultrasound-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation for transvaginal ultrasound cervical length < 20 mm in a woman without cervical dilatation. Physical exam-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation because of cervical dilatation of one or more centimetres detected on physical (manual) examination. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (26 September 2019), and reference lists of retrieved studies. SELECTION CRITERIA We included published, unpublished or ongoing randomised controlled trial (RCTs). Studies using a cluster-RCT design were also eligible for inclusion in this review but none were identified. We excluded quasi-RCTs (e.g. those randomised by date of birth or hospital number) and studies using a cross-over design. We also excluded studies that specified addition of the combination therapy after cervical cerclage because the woman subsequently became symptomatic. We included studies comparing cervical cerclage in combination with one, two or more interventions with cervical cerclage alone in singleton pregnancies. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts of all retrieved articles, selected studies for inclusion, extracted data, assessed risk of bias, and evaluated the certainty of the evidence for this review's main outcomes. Data were checked for accuracy. Standard Cochrane review methods were used throughout. MAIN RESULTS We identified two studies (involving a total of 73 women) comparing cervical cerclage alone to a different comparator. We also identified three ongoing studies (one investigating vaginal progesterone after cerclage, and two investigating cerclage plus pessary). One study (20 women), conducted in the UK, comparing cervical cerclage in combination with a tocolytic (salbutamol) with cervical cerclage alone in women with singleton pregnancy did not provide any useable data for this review. The other study (involving 53 women, with data from 50 women) took place in the USA and compared cervical cerclage in combination with a tocolytic (indomethacin) and antibiotics (cefazolin or clindamycin) versus cervical cerclage alone - this study did provide useable data for this review (and the study authors also provided additional data on request) but meta-analyses were not possible. This study was generally at a low risk of bias, apart from issues relating to blinding. We downgraded the certainty of evidence for serious risk of bias and imprecision (few participants, few events and wide 95% confidence intervals). Cervical cerclage in combination with an antibiotic and tocolytic versus cervical cerclage alone (one study, 50 women/babies) We are unclear about the effect of cervical cerclage in combination with antibiotics and a tocolytic compared with cervical cerclage alone on the risk of serious neonatal morbidity (RR 0.62, 95% CI 0.31 to 1.24; very low-certainty evidence); perinatal loss (data for miscarriage and stillbirth only - data not available for neonatal death) (RR 0.46, 95% CI 0.13 to 1.64; very low-certainty evidence) or preterm birth < 34 completed weeks of pregnancy (RR 0.78, 95% CI 0.44 to 1.40; very low-certainty evidence). There were no stillbirths (intrauterine death at 24 or more weeks). The trial authors did not report on the numbers of babies discharged home healthy (without obvious pathology) or on the risk of neonatal death. AUTHORS' CONCLUSIONS Currently, there is insufficient evidence to evaluate the effect of combining a tocolytic (indomethacin) and antibiotics (cefazolin/clindamycin) with cervical cerclage compared with cervical cerclage alone for preventing spontaneous PTB in women with singleton pregnancies. Future studies should recruit sufficient numbers of women to provide meaningful results and should measure neonatal death and numbers of babies discharged home healthy, as well as other important outcomes listed in this review. We did not identify any studies looking at other treatments in combination with cervical cerclage. Future research needs to focus on the role of other interventions such as vaginal support pessary, reinforcing or second cervical cerclage placement, 17-alpha-hydroxyprogesterone caproate or dydrogesterone or vaginal micronised progesterone, omega-3 long chain polyunsaturated fatty acid supplementation and bed rest.
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Affiliation(s)
- George U Eleje
- Effective Care Research Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, PMB 5001, Nnewi, Nigeria
| | - Ahizechukwu C Eke
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph I Ikechebelu
- Department of Obstetrics/Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Ifeanyichukwu U Ezebialu
- Department of Obstetrics and Gynaecology, Faculty of Clinical medicine, College of Medicine, Anambra State University Amaku, Awka, Nigeria
| | - Princeston C Okam
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
| | - Chito P Ilika
- Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
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Maged AM, Shoab AY, Hussein EA, Alsawaf AH, Mahmoud DS, AbdAllah AA, Dahab S, Darwish M, Ali YZ, Badran H. The Effect of Antenatal Vaginal Progesterone Administration on Uterine, Umbilical, and Fetal Middle Cerebral Artery Doppler Flow: A Cohort Study. Am J Perinatol 2020; 37:491-496. [PMID: 30866028 DOI: 10.1055/s-0039-1683438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study aimed to evaluate the effect of vaginal progesterone (P) administration during the second and third trimesters of pregnancy on Doppler velocimetry of uterine, umbilical, and middle cerebral vessels. STUDY DESIGN A prospective cohort study conducted on 80 women at risk for preterm labor. Uterine artery, umbilical artery, and middle cerebral artery (MCA) Doppler indices were measured before and after 1 week of administration of 200 mg twice daily vaginal P. The primary outcome parameter was the change of MCA pulsatility index (PI) after P administration. Secondary outcomes included changes in uterine artery and umbilical artery Doppler measurement. RESULTS There was no significant changes of umbilical artery resistance index (RI) (0.69 ± 0.049 vs. 0.68 ± 0.041), umbilical artery PI (1.14 ± 0.118 vs. 1.11 ± 0.116), uterine artery RI (0.66 ± 0.12 vs. 0.66 ± 0.107), uterine artery PI (1.00 ± 0.26 vs. 1.016 ± 0.24), and MCA PI (1.27 ± 0.18 vs. 1.26 ± 0.23) measurements before and after 1 week of P administration, respectively. CONCLUSION Administration of vaginal P has no significant effects on uterine artery, umbilical artery, and MCA Doppler indices.
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Affiliation(s)
- Ahmed M Maged
- Department of Obstetrics and Gynecology, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
| | - Amira Y Shoab
- Department of Obstetrics and Gynecology, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
| | - Eman A Hussein
- Department of Obstetrics and Gynecology, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
| | - Ahmed H Alsawaf
- Department of Obstetrics and Gynecology, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
| | - Doaa S Mahmoud
- Department of Obstetrics and Gynecology, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
| | - Ameer A AbdAllah
- Department of Obstetrics and Gynecology, Minia University, Minia, Egypt
| | - Sherif Dahab
- Department of Obstetrics and Gynecology, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
| | - Mohamed Darwish
- Department of Gynecology and Obstetrics, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Yahia Z Ali
- Department of Gynecology and Obstetrics, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Haitham Badran
- Department of Gynecology and Obstetrics, Faculty of Medicine, Fayoum University, Fayoum, Egypt
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13
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Dodd JM, Grivell RM, OBrien CM, Dowswell T, Deussen AR. Prenatal administration of progestogens for preventing spontaneous preterm birth in women with a multiple pregnancy. Cochrane Database Syst Rev 2019; 2019:CD012024. [PMID: 31745984 PMCID: PMC6864412 DOI: 10.1002/14651858.cd012024.pub3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Multiple pregnancy is a strong risk factor for preterm birth, and more than 50% of women with a twin pregnancy will give birth prior to 37 weeks' gestation. Infants born preterm are recognised to be at increased risk of many adverse health outcomes, contributing to more than half of overall perinatal mortality. Progesterone is produced naturally in the body and has a role in maintaining pregnancy, although it is not clear whether administering progestogens to women with multiple pregnancy at high risk of early birth is effective and safe. Since publication of this new review in Issue 10, 2017, we have now moved one study (El-Refaie 2016) from included to studies awaiting classification, pending clarification about the study data. OBJECTIVES To assess the benefits and harms of progesterone administration for the prevention of preterm birth in women with a multiple pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 November 2016) and reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials examining the administration of a progestogen by any route for the prevention of preterm birth in women with multiple pregnancy. We did not include quasi-randomised or cross-over studies. DATA COLLECTION AND ANALYSIS Two review authors independently assessed reports identified by the search for eligibility, extracted data, assessed risk of bias and graded the quality of the evidence. MAIN RESULTS We included 16 trials, which all compared either vaginal or intramuscular (IM) progesterone with a placebo or no treatment, and involved a total of 4548 women. The risk of bias for the majority of included studies was low, with the exception of three studies that had inadequate blinding, or significant loss to follow-up or both, or were not reported well enough for us to make a judgement. We graded the evidence low to high quality, with downgrading for statistical heterogeneity, design limitations in some of the studies contributing data, and imprecision of the effect estimate. 1 IM progesterone versus no treatment or placebo More women delivered at less than 34 weeks' gestation in the IM progesterone group compared with placebo (risk ratio (RR) 1.54, 95% confidence interval (CI) 1.06 to 2.26; women = 399; studies = 2; low-quality evidence). Although the incidence of perinatal death in the progesterone group was higher, there was considerable uncertainty around the effect estimate and high heterogeneity between studies (average RR 1.45, 95% CI 0.60 to 3.51; infants = 3089; studies = 6; I2 = 71%; low-quality evidence). No studies reported maternal mortality or major neurodevelopmental disability at childhood follow-up. There were no clear group differences found in any of the other maternal or infant outcomes (preterm birth less than 37 weeks (RR 1.05, 95% CI 0.98 to 1.13; women = 2010; studies = 5; high-quality evidence); preterm birth less than 28 weeks (RR 1.08, 95% CI 0.75 to 1.55; women = 1920; studies = 5; moderate-quality evidence); infant birthweight less than 2500 g (RR 0.99, 95% CI 0.90 to 1.08; infants = 4071; studies = 5; I2 = 76%, moderate-quality evidence)). No childhood outcomes were reported in the trials. 2 Vaginal progesterone versus no treatment or placebo by dose There were no clear group differences in incidence of preterm birth before 34 weeks (average RR 0.90, 95% CI 0.66 to 1.23; women = 1503; studies = 5; I2 = 36%; low-quality evidence). Although fewer births before 34 weeks appeared to occur in the progesterone group, the CIs crossed the line of no effect. Incidence of perinatal death was higher in the progesterone group, although there was considerable uncertainty in the effect estimate and the quality of the evidence was low for this outcome (RR 1.23, 95% CI 0.74 to 2.06; infants = 2287; studies = 3; low-quality evidence). No studies reported maternal mortality or major neurodevelopmental disability at childhood follow-up. There were no clear group differences found in any of the other maternal or infant outcomes (preterm birth less than 37 weeks (average RR 0.97, 95% CI 0.89 to 1.06; women = 1597; studies = 6; moderate-quality evidence); preterm birth less than 28 weeks (RR 1.53, 95% CI 0.79 to 2.97; women = 1345; studies = 3; low-quality evidence); infant birthweight less than 2500 g (average RR 0.95, 95% CI 0.84 to 1.07; infants = 2640; studies = 3; I2 = 66%, moderate-quality evidence)). No childhood outcomes were reported in the trials. For secondary outcomes, there were no clear group differences found in any of the other maternal outcomes except for caesarean section, where women who received vaginal progesterone did not have as many caesarean sections as those in the placebo group, although the difference between groups was not large (8%) (RR 0.92, 95% CI 0.86 to 0.98; women = 1919; studies = 5; I2 = 0%). There were no clear group differences found in any of the infant outcomes except for mechanical ventilation, which was required by fewer infants whose mothers had received the vaginal progesterone (RR 0.70, 95% CI 0.52 to 0.94; infants = 2695; studies = 4). AUTHORS' CONCLUSIONS Overall, for women with a multiple pregnancy, the administration of progesterone (either IM or vaginal) does not appear to be associated with a reduction in risk of preterm birth or improved neonatal outcomes. Future research could focus on a comprehensive individual participant data meta-analysis including all of the available data relating to both IM and vaginal progesterone administration in women with a multiple pregnancy, before considering the need to conduct trials in subgroups of high-risk women (for example, women with a multiple pregnancy and a short cervical length identified on ultrasound).
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Affiliation(s)
- Jodie M Dodd
- The University of Adelaide, Women's and Children's HospitalSchool of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Rosalie M Grivell
- Flinders University and Flinders Medical CentreDepartment of Obstetrics and GynaecologyBedford ParkSouth AustraliaAustraliaSA 5042
| | - Cecelia M OBrien
- Robinson Research Institute, The University of AdelaideWomen's and Babies Division, Discipline of Obstetrics and GynaecologyBrougham PlaceNorth AdelaideSAAustralia5006
| | - Therese Dowswell
- The University of LiverpoolC/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Andrea R Deussen
- The University of Adelaide, Women's and Children's HospitalSchool of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideSouth AustraliaAustralia5006
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14
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Prevention of spontaneous preterm birth: universal cervical length assessment and vaginal progesterone in women with a short cervix: time for action! Am J Obstet Gynecol 2018; 218:151-158. [PMID: 29422255 DOI: 10.1016/j.ajog.2017.12.222] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/20/2017] [Indexed: 01/12/2023]
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15
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Polymeric gels for intravaginal drug delivery. J Control Release 2018; 270:145-157. [DOI: 10.1016/j.jconrel.2017.12.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/30/2017] [Accepted: 12/05/2017] [Indexed: 12/14/2022]
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16
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Martell B, DiBenedetti DB, Weiss H, Zhou X, Reynolds M, Berghella V, Hassan SS. Screening and treatment for short cervical length in pregnancy: a physician survey in the United States. Arch Gynecol Obstet 2017; 297:601-611. [PMID: 29270729 DOI: 10.1007/s00404-017-4619-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 12/04/2017] [Indexed: 01/27/2023]
Abstract
PURPOSE To evaluate how physicians in the United States (US) screen for, define, and treat a short cervix to prevent preterm birth. METHODS This was a cross-sectional, web-based survey of 500 physicians treating pregnant patients with a short cervix in the US. Respondents' geographic region was monitored to ensure balance across the nine US Census divisions. RESULTS Respondents were predominantly obstetrician/gynecologists (86%, 429/500; mean age 49 years). Physicians reported that a median of 90% of their pregnant patients undergo cervical length screening; 81% (407/500) use transvaginal ultrasound. Physicians consult multiple evidence sources to inform their patient care, most commonly clinical guidelines (83%; 413/500) and published research (70%; 349/500). Most physicians (98%; 490/500) reported treating pregnant patients with a short cervix; 95% (474/500) use synthetic and/or natural progestogen, alone or in combination with other treatment modalities. If reimbursement was not a concern, 47% of physicians (230/500) would choose vaginal progesterone as their preferred treatment to prevent preterm birth in all patients with a short cervix, and 45% (218/500) would choose a synthetic progestogen. CONCLUSION US guidelines recommend transvaginal ultrasound for cervical length screening; 81% of physicians in this study reported using this method. Most physicians surveyed use progestogens to treat a short cervix, with approximately half choosing a synthetic progestin (45%) and half choosing natural progesterone (47%) as their preferred treatment, despite national guidelines recommending only vaginal natural progesterone for this indication. Additional physician education is required to implement current and best practices.
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Affiliation(s)
- Bridget Martell
- Juniper Pharmaceuticals, 33 Arch Street, 31st Floor, Boston, MA, 02110, USA
| | | | - Herman Weiss
- Juniper Pharmaceuticals, 33 Arch Street, 31st Floor, Boston, MA, 02110, USA.
| | - Xiaolei Zhou
- RTI Health Solutions, Research Triangle Park, NC, USA
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17
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Agra IKR, Carvalho MHB, Hernandez WR, Francisco RPV, Zugaib M, Brizot ML. The effect of prenatal vaginal progesterone on cervical length in nonselected twin pregnancies. J Matern Fetal Neonatal Med 2017; 32:1245-1249. [PMID: 29117757 DOI: 10.1080/14767058.2017.1403577] [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: 10/18/2022]
Abstract
PURPOSE The aim of this study was to investigate the influence of vaginal progesterone on cervical length (CL) in asymptomatic nonselected twin gestations. METHODS This was a secondary analysis of a randomized, double-blind, placebo-controlled trial of twin pregnancies exposed to vaginal progesterone or placebo. The CL was examined at six different time periods: 18-21+6 weeks (T1), 21-23+6 weeks (T2), 24-26+6 weeks (T3), 27-29+6 weeks (T4), 30-32+6 weeks (T5) and 33-34+6 weeks (T6). The rate of cervical shortening per week and the percent cervical shortening were compared between the groups, with analyses of the entire cohort and of those who delivered spontaneously according to gestational age at birth. RESULTS The final analysis included 184 women in the progesterone group and 188 women in the placebo group. The baseline characteristics were similar in both groups. No differences in cervical shortening in terms of absolute value or percent shortening were observed between the groups at each time period or throughout gestation. Furthermore, no difference was found in cervical shortening for those who delivered spontaneously. CONCLUSION Cervical shortening in asymptomatic nonselected twin pregnancies occurred at a similar rate, regardless of vaginal progesterone treatment.
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Affiliation(s)
- Isabela K R Agra
- a Department of Obstetrics and Gynecology , São Paulo University Medical School , São Paulo , Brazil
| | - Mário H B Carvalho
- a Department of Obstetrics and Gynecology , São Paulo University Medical School , São Paulo , Brazil
| | - Wagner R Hernandez
- a Department of Obstetrics and Gynecology , São Paulo University Medical School , São Paulo , Brazil
| | - Rossana P V Francisco
- a Department of Obstetrics and Gynecology , São Paulo University Medical School , São Paulo , Brazil
| | - Marcelo Zugaib
- a Department of Obstetrics and Gynecology , São Paulo University Medical School , São Paulo , Brazil
| | - Maria L Brizot
- a Department of Obstetrics and Gynecology , São Paulo University Medical School , São Paulo , Brazil
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18
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Eleje GU, Ikechebelu JI, Eke AC, Okam PC, Ezebialu IU, Ilika CP. Cervical cerclage in combination with other treatments for preventing preterm birth in singleton pregnancies. Hippokratia 2017. [DOI: 10.1002/14651858.cd012871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- George U Eleje
- Faculty of Medicine, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus; Effective Care Research Unit, Department of Obstetrics and Gynaecology; PMB 5001, Nnewi Anambra State Nigeria
| | - Joseph I Ikechebelu
- Nnamdi Azikiwe University Teaching Hospital; Department of Obstetrics/Gynaecology; Nnewi Nigeria
| | - Ahizechukwu C Eke
- Johns Hopkins University School of Medicine; Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics; 600 N Wolfe Street Phipps 228 Baltimore Maryland USA 21287-1228
| | - Princeston C Okam
- Nnamdi Azikiwe University Teaching Hospital; Department of Obstetrics and Gynaecology; PMB 5025 Nnewi Anambra Nigeria
| | - Ifeanyichukwu U Ezebialu
- Faculty of Clinical medicine, College of Medicine, Anambra State University Amaku; Department of Obstetrics and Gynaecology; Awka Nigeria
| | - Chito P Ilika
- Nnamdi Azikiwe University Teaching Hospital; Department of Obstetrics and Gynaecology; PMB 5025 Nnewi Anambra Nigeria
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19
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Dodd JM, Grivell RM, OBrien CM, Dowswell T, Deussen AR. Prenatal administration of progestogens for preventing spontaneous preterm birth in women with a multiple pregnancy. Cochrane Database Syst Rev 2017; 10:CD012024. [PMID: 29086920 PMCID: PMC6485912 DOI: 10.1002/14651858.cd012024.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Multiple pregnancy is a strong risk factor for preterm birth, and more than 50% of women with a twin pregnancy will give birth prior to 37 weeks' gestation. Infants born preterm are recognised to be at increased risk of many adverse health outcomes, contributing to more than half of overall perinatal mortality. Progesterone is produced naturally in the body and has a role in maintaining pregnancy, although it is not clear whether administering progestogens to women with multiple pregnancy at high risk of early birth is effective and safe. OBJECTIVES To assess the benefits and harms of progesterone administration for the prevention of preterm birth in women with a multiple pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 November 2016) and reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials examining the administration of a progestogen by any route for the prevention of preterm birth in women with multiple pregnancy. We did not include quasi-randomised or cross-over studies. DATA COLLECTION AND ANALYSIS Two review authors independently assessed reports identified by the search for eligibility, extracted data, assessed risk of bias and graded the quality of the evidence. MAIN RESULTS We included 17 trials, which all compared either vaginal or intramuscular (IM) progesterone with a placebo or no treatment, and involved a total of 4773 women. The risk of bias for the majority of included studies was low, with the exception of four studies that had inadequate blinding, or significant loss to follow-up or both, or were not reported well enough for us to make a judgement. We graded the evidence low to high quality, with downgrading for statistical heterogeneity, design limitations in some of the studies contributing data, and imprecision of the effect estimate. 1 IM progesterone versus no treatment or placeboMore women delivered at less than 34 weeks' gestation in the IM progesterone group compared with placebo (risk ratio (RR) 1.54, 95% confidence interval (CI) 1.06 to 2.26; women = 399; studies = 2; low-quality evidence). Although the incidence of perinatal death in the progesterone group was higher, there was considerable uncertainty around the effect estimate and high heterogeneity between studies (average RR 1.45, 95% CI 0.60 to 3.51; infants = 3089; studies = 6; I2 = 71%; low-quality evidence). No studies reported maternal mortality or major neurodevelopmental disability at childhood follow-up.There were no clear group differences found in any of the other maternal or infant outcomes (preterm birth less than 37 weeks (RR 1.05, 95% CI 0.98 to 1.13; women = 2010; studies = 5; high-quality evidence); preterm birth less than 28 weeks (RR 1.08, 95% CI 0.75 to 1.55; women = 1920; studies = 5; moderate-quality evidence); infant birthweight less than 2500 g (RR 0.99, 95% CI 0.90 to 1.08; infants = 4071; studies = 5; I2 = 76%, moderate-quality evidence)). No childhood outcomes were reported in the trials. 2 Vaginal progesterone versus no treatment or placebo by doseThere were no clear group differences in incidence of preterm birth before 34 weeks (average RR 0.83, 95% CI 0.63 to 1.09; women = 1727; studies = 6; I2 = 46%; low-quality evidence). Although fewer births before 34 weeks appeared to occur in the progesterone group, the CIs crossed the line of no effect. Incidence of perinatal death was higher in the progesterone group, although there was considerable uncertainty in the effect estimate and the quality of the evidence was low for this outcome (RR 1.23, 95% CI 0.74 to 2.06; infants = 2287; studies = 3; low-quality evidence). No studies reported maternal mortality or major neurodevelopmental disability at childhood follow-up.There were no clear group differences found in any of the other maternal or infant outcomes (preterm birth less than 37 weeks (average RR 0.97, 95% CI 0.89 to 1.06; women = 1597; studies = 6; moderate-quality evidence); preterm birth less than 28 weeks (RR 1.22, 95% CI 0.68 to 2.21; women = 1569; studies = 4; low-quality evidence); infant birthweight less than 2500 g (RR 0.95, 95% CI 0.88 to 1.03; infants = 3079; studies = 4; I2 = 49%, moderate-quality evidence)). No childhood outcomes were reported in the trials.For secondary outcomes, there were no clear group differences found in any of the other maternal outcomes except for caesarean section, where women who received vaginal progesterone did not have as many caesarean sections as those in the placebo group, although the difference between groups was not large (7%) (RR 0.93, 95% CI 0.88 to 0.98; women = 2143; studies = 6; I2 = 0%). There were no clear group differences found in any of the infant outcomes except for mechanical ventilation, which was required by fewer infants whose mothers had received the vaginal progesterone (RR 0.61, 95% CI 0.48 to 0.77; infants = 3134; studies = 5). AUTHORS' CONCLUSIONS Overall, for women with a multiple pregnancy, the administration of progesterone (either IM or vaginal) does not appear to be associated with a reduction in risk of preterm birth or improved neonatal outcomes.Future research could focus on a comprehensive individual participant data meta-analysis including all of the available data relating to both IM and vaginal progesterone administration in women with a multiple pregnancy, before considering the need to conduct trials in subgroups of high-risk women (for example, women with a multiple pregnancy and a short cervical length identified on ultrasound).
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Affiliation(s)
- Jodie M Dodd
- The University of Adelaide, Women's and Children's HospitalSchool of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideAustralia5006
| | - Rosalie M Grivell
- Flinders University and Flinders Medical CentreDepartment of Obstetrics and GynaecologyBedford ParkAustraliaSA 5042
| | - Cecelia M OBrien
- Robinson Research Institute, The University of AdelaideWomen's and Babies Division, Discipline of Obstetrics and GynaecologyBrougham PlaceNorth AdelaideAustralia5006
| | - Therese Dowswell
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Andrea R Deussen
- The University of Adelaide, Women's and Children's HospitalSchool of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideAustralia5006
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Tarca AL, Fitzgerald W, Chaemsaithong P, Xu Z, Hassan SS, Grivel J, Gomez‐Lopez N, Panaitescu B, Pacora P, Maymon E, Erez O, Margolis L, Romero R. The cytokine network in women with an asymptomatic short cervix and the risk of preterm delivery. Am J Reprod Immunol 2017; 78:e12686. [PMID: 28585708 PMCID: PMC5575567 DOI: 10.1111/aji.12686] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/20/2017] [Indexed: 01/06/2023] Open
Abstract
PROBLEM To characterize the amniotic fluid (AF) inflammatory-related protein (IRP) network in patients with a sonographic short cervix (SCx) and to determine its relation to early preterm delivery (ePTD). METHOD OF STUDY A retrospective cohort study included women with a SCx (≤25 mm; n=223) who had amniocentesis and were classified according to gestational age (GA) at diagnosis and delivery (ePTD <32 weeks of gestation). RESULTS (i) In women with a SCx ≤ 22 1/7 weeks, the concentration of most IRPs increased as the cervix shortened; those with ePTD had a higher rate of increase in MIP-1α, MCP-1, and IL-6 concentrations than those delivering later; and (ii) the concentration of most IRPs and the correlation between several IRP pairs were higher in the ePTD group than for those delivering later. CONCLUSION Women with a SCx at 16-22 1/7 weeks have a unique AF cytokine network that correlates with cervical length at diagnosis and GA at delivery. This network may aid in predicting ePTD.
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Affiliation(s)
- Adi L. Tarca
- Perinatology Research BranchProgram for Perinatal Research and ObstetricsDivision of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMD, and Detroit, MIUSA
- Department of Obstetrics and GynecologyWayne State University School of MedicineDetroitMIUSA
| | - Wendy Fitzgerald
- Section on Intercellular InteractionsProgram on Physical BiologyEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMDUSA
| | - Piya Chaemsaithong
- Perinatology Research BranchProgram for Perinatal Research and ObstetricsDivision of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMD, and Detroit, MIUSA
- Department of Obstetrics and GynecologyWayne State University School of MedicineDetroitMIUSA
| | - Zhonghui Xu
- Perinatology Research BranchProgram for Perinatal Research and ObstetricsDivision of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMD, and Detroit, MIUSA
| | - Sonia S. Hassan
- Perinatology Research BranchProgram for Perinatal Research and ObstetricsDivision of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMD, and Detroit, MIUSA
- Department of Obstetrics and GynecologyWayne State University School of MedicineDetroitMIUSA
| | - Jean‐Charles Grivel
- Division of Translational MedicineSidra Medical and Research CenterDohaQatar
| | - Nardhy Gomez‐Lopez
- Perinatology Research BranchProgram for Perinatal Research and ObstetricsDivision of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMD, and Detroit, MIUSA
- Department of Obstetrics and GynecologyWayne State University School of MedicineDetroitMIUSA
- Department of ImmunologyMicrobiology and BiochemistryWayne State University School of MedicineDetroitMIUSA
| | - Bogdan Panaitescu
- Perinatology Research BranchProgram for Perinatal Research and ObstetricsDivision of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMD, and Detroit, MIUSA
- Department of Obstetrics and GynecologyWayne State University School of MedicineDetroitMIUSA
| | - Percy Pacora
- Perinatology Research BranchProgram for Perinatal Research and ObstetricsDivision of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMD, and Detroit, MIUSA
- Department of Obstetrics and GynecologyWayne State University School of MedicineDetroitMIUSA
| | - Eli Maymon
- Perinatology Research BranchProgram for Perinatal Research and ObstetricsDivision of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMD, and Detroit, MIUSA
- Department of Obstetrics and GynecologyWayne State University School of MedicineDetroitMIUSA
| | - Offer Erez
- Perinatology Research BranchProgram for Perinatal Research and ObstetricsDivision of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMD, and Detroit, MIUSA
- Department of Obstetrics and GynecologyWayne State University School of MedicineDetroitMIUSA
| | - Leonid Margolis
- Section on Intercellular InteractionsProgram on Physical BiologyEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMDUSA
| | - Roberto Romero
- Perinatology Research BranchProgram for Perinatal Research and ObstetricsDivision of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMD, and Detroit, MIUSA
- Department of Obstetrics and GynecologyUniversity of MichiganAnn ArborMIUSA
- Department of Epidemiology and BiostatisticsMichigan State UniversityEast LansingMIUSA
- Center for Molecular Medicine and GeneticsWayne State UniversityDetroitMIUSA
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Pierce S, Roberson AE, Hyatt K, Singleton K, Deschamps D, Myers DA. Interaction Between Progesterone and Interleukin-1β in Modulating Progesterone Receptor Expression and the Inflammatory Phenotype in Human Cervical Fibroblasts. Reprod Sci 2017; 25:598-608. [PMID: 28820025 DOI: 10.1177/1933719117725826] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Progesterone helps maintain cervical structure during pregnancy via the progesterone receptor (PR). Two PR isoforms exist, PR-A and PR-B, which have overlapping as well as isoform-specific target genes. During late gestation, leukocytes infiltrate the cervical stroma accompanied by increased cervical cytokine levels, resembling an inflammatory process. We examined interleukin (IL)-1β regulation of the expression of PR-A, PR-B, and genes governing prostaglandin synthesis in human cervical fibroblasts (HCFs). Since progesterone has been shown to exert anti-inflammatory actions, we also examined the capacity of progesterone (R5020) to ameliorate the actions of IL-1β in HCFs. Interleukin-1β induced both PR-A and PR-B mRNA in HCFs. Interleukin-1β induced a rapid and transient loss of both PR-A and PR-B protein, followed by a latent (24 hours) increase in both PR isoforms. R5020 negated the IL-1β-induced increase in PR-A and PR-B mRNA and protein as well as the rapid IL-1β-induced downregulation of nuclear PR. Interleukin-1β induced prostaglandin G/H synthase-2 (PGHS-2), but not prostaglandin G/H synthase-1 (PGHS-1), as well as prostaglandin E synthase-1 (PGES-1), but not prostaglandin F synthase (PGFS). R5020 did not ameliorate IL-1β induction of PGHS-2 or PGES-1. Blockade of prostaglandin synthesis (indomethacin) prevented both the IL-1β-induced increase in PR mRNA and the acute decrease in PR-A and PR-B protein, implicating a role for prostaglandins in regulating PR expression in HCFs. Although progesterone may function to maintain PR expression in a milieu of increasing cytokines in the late gestation human cervix, it does not exert an anti-inflammatory role with regard to prostaglandin E2 (PGE2) production.
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Affiliation(s)
- Stephanie Pierce
- 1 Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Amy E Roberson
- 2 Department of Cell Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Kimberly Hyatt
- 1 Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Krista Singleton
- 1 Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - David Deschamps
- 1 Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Dean A Myers
- 2 Department of Cell Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Pirjani R, Heidari R, Rahimi-Foroushani A, Bayesh S, Esmailzadeh A. 17-alpha-hydroxyprogesterone caproate versus vaginal progesterone suppository for the prevention of preterm birth in women with a sonographically short cervix: A randomized controlled trial. J Obstet Gynaecol Res 2016; 43:57-64. [DOI: 10.1111/jog.13151] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 06/23/2016] [Accepted: 08/07/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Reihaneh Pirjani
- Perinatology Division, Obstetrics and Gynecology Department, Arash Hospital; Tehran University of Medical Sciences; Tehran Iran
| | - Reza Heidari
- School of Medicine; Tehran University of Medical Sciences; Tehran Iran
| | - Abbas Rahimi-Foroushani
- Epidemiology and Biostatistics Department, School of Public Health Sciences; Tehran University of Medical Sciences; Tehran Iran
| | | | - Arezoo Esmailzadeh
- Perinatology Division, Obstetrics and Gynecology Department, Arash Hospital; Tehran University of Medical Sciences; Tehran Iran
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Melamed N, Pittini A, Hiersch L, Yogev Y, Korzeniewski SS, Romero R, Barrett J. Serial cervical length determination in twin pregnancies reveals 4 distinct patterns with prognostic significance for preterm birth. Am J Obstet Gynecol 2016; 215:476.e1-476.e11. [PMID: 27207277 PMCID: PMC5045791 DOI: 10.1016/j.ajog.2016.05.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 05/06/2016] [Accepted: 05/10/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Women with a twin gestation are at increased risk for preterm birth (PTB), and sonographic cervical length (CL) is a powerful predictor for spontaneous PTB. Obstetricians frequently monitor CL in multiple gestations; yet, the optimal method to integrate and interpret the results of serial sonographic CL has not been determined. OBJECTIVE We sought to determine whether there are different patterns of cervical shortening in twin gestations, and whether such patterns are related to the risk of PTB. STUDY DESIGN We conducted a retrospective study of all women with twins followed up in a single tertiary referral center during 2012 through 2014. All women underwent serial measurements of CL every 2-3 weeks starting from 14-18 weeks and until 28-32 weeks of gestation. Changes in CL were analyzed and classified into distinct patterns that were initially identified by visual inspection of all individual cases. Each pattern was then characterized by several parameters including information about when cervical shortening began, the rate of shortening, and whether a plateau was observed. Locally weighted regression mean profiles were generated to describe each pattern of CL over time. The association of these patterns with spontaneous PTB was determined. The specific characteristics of each pattern that further determined the risk of PTB were identified using multivariable logistic regression analysis. RESULTS We studied 441 women who had a total of 2826 measurements of CL done. Overall, 4 main patterns of change in CL were identified: pattern I, stable cervix (n = 196); pattern II, early and rapid shortening (n = 18); pattern III, late shortening (n = 109); and pattern IV, early shortening with a plateau (n = 118). The rate of PTB at <34 weeks was lowest in cases of pattern I (11.7%), followed by pattern IV (14.4%) and pattern III (20.2%), and was highest for women with pattern II (44.4%) (P < .001). In cases with pattern III (late shortening), the most important factors affecting the risk of PTB were the shortening rate, the gestational age at the onset of cervical shortening, and the initial plateau of CL. In the case of pattern IV (early shortening with a plateau), it was only the new plateau at which cervical shortening stopped that was associated with the risk of PTB. CONCLUSION Changes in sonographic CL over time in twin gestations can be classified into 4 patterns, each associated with a different risk of PTB.
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Affiliation(s)
- Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
| | - Alex Pittini
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Liran Hiersch
- Department of Obstetrics and Gynecology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yariv Yogev
- Department of Obstetrics and Gynecology, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Steven S Korzeniewski
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Jon Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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Goya M, de la Calle M, Pratcorona L, Merced C, Rodó C, Muñoz B, Juan M, Serrano A, Llurba E, Higueras T, Carreras E, Cabero L. Cervical pessary to prevent preterm birth in women with twin gestation and sonographic short cervix: a multicenter randomized controlled trial (PECEP-Twins). Am J Obstet Gynecol 2016; 214:145-152. [PMID: 26627728 DOI: 10.1016/j.ajog.2015.11.012] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/28/2015] [Accepted: 11/12/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Spontaneous preterm birth (SPB) is the leading cause of perinatal morbidity and mortality. In twins, the rate of preterm birth is higher than in singletons; interventions to prevent preterm birth are needed in this high-risk population. OBJECTIVE We sought to test whether a cervical pessary reduces the preterm birth rate in twin pregnancies with sonographic short cervix. STUDY DESIGN A prospective, open-label, multicenter, randomized clinical trial was conducted in 5 hospitals in Spain. The ethics committees of all participating hospitals approved the protocol. The trial was registered as ClinicalTrials.gov, number NCT01242410. Eligible women were scanned in Spain. The primary outcome was SPB <34 weeks of gestation. Neonatal morbidity and mortality were also evaluated. RESULTS Cervical length was measured in 2287 women; 137 pregnant women with a sonographic cervical length ≤25 mm (of 154 detected with a short cervix) were randomly assigned to receive a cervical pessary or expectant management (1:1 ratio). SPB <34 weeks of gestation was significantly less frequent in the pessary group than in the expectant management group (11/68 [16.2%] vs 26/66 [39.4%]; relative risk, 0.41; 95% confidence interval, 0.22-0.76). Pessary use was associated with a significant reduction in the rate of birthweight <2500 g (P = .01). No significant differences were observed in composite neonatal morbidity outcome (8/136 [5.9%] vs 12/130 [9.1%]; relative risk, 0.64; 95% confidence interval, 0.27-1.50) or neonatal mortality (none) between the groups. No serious adverse effects associated with the use of a cervical pessary were observed. CONCLUSION The insertion of a cervical pessary was associated with a significant reduction in the SPB rate. We propose the use of a cervical pessary for preventing preterm birth in twin pregnancies of mothers with a short cervix.
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Affiliation(s)
- Maria Goya
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona.
| | | | - Laia Pratcorona
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
| | - Carme Merced
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
| | - Carlota Rodó
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
| | | | | | | | - Elisa Llurba
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
| | - Teresa Higueras
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
| | - Elena Carreras
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
| | - Luis Cabero
- Maternal Fetal Medicine Units, Department of Obstetrics at Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona
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Kuhrt K, Smout E, Hezelgrave N, Seed PT, Carter J, Shennan AH. Development and validation of a tool incorporating cervical length and quantitative fetal fibronectin to predict spontaneous preterm birth in asymptomatic high-risk women. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:104-109. [PMID: 25846437 DOI: 10.1002/uog.14865] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 03/29/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To develop a predictive tool for spontaneous preterm birth (sPTB) in asymptomatic high-risk women that includes quantification of fetal fibronectin (fFN) along with cervical length (CL) measurement and other clinical factors. METHODS Data were analyzed that had been collected prospectively from 1249 women at high risk for sPTB attending preterm surveillance clinics. Clinicians were blinded to quantitative measurements of fFN (qfFN), although they were aware of qualitative fFN results. Parametric survival models for sPTB, with time-updated covariates, were developed and the best was selected using the Akaike and Bayesian information criteria. The model was developed on the first 624 consecutive women and validated on the subsequent 625. Fractional polynomials were used to accommodate possible non-linear effects of qfFN and CL. The estimated probability of delivery before 30, 34 or 37 weeks' gestation and within 2 or 4 weeks of testing was calculated for each patient and analyzed as a predictive test for the actual occurrence of each event. Predictive statistics were calculated to compare training and validation sets. RESULTS The final model that was selected used a log-normal survival curve with CL, √qfFN and previous sPTB/preterm prelabor rupture of membranes as predictors. Predictive statistics were similar for training and validation sets. Areas under the receiver-operating characteristics curves ranged from 0.77 to 0.99, indicating accurate prediction across all five delivery outcomes. CONCLUSIONS sPTB in high-risk asymptomatic women can be predicted accurately using a model combining qfFN and CL, which supersedes the single-threshold fFN test, demographic information and obstetric history. This algorithm has been incorporated into an App (QUiPP) for widespread use.
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Affiliation(s)
- K Kuhrt
- Woman's Health Academic Centre, Kings College London, London, UK
| | - E Smout
- Woman's Health Academic Centre, Kings College London, London, UK
| | - N Hezelgrave
- Woman's Health Academic Centre, Kings College London, London, UK
| | - P T Seed
- Woman's Health Academic Centre, Kings College London, London, UK
| | - J Carter
- Woman's Health Academic Centre, Kings College London, London, UK
| | - A H Shennan
- Woman's Health Academic Centre, Kings College London, London, UK
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O’Brien JM, Lewis DF. Prevention of preterm birth with vaginal progesterone or 17-alpha-hydroxyprogesterone caproate: a critical examination of efficacy and safety. Am J Obstet Gynecol 2016; 214:45-56. [PMID: 26558340 DOI: 10.1016/j.ajog.2015.10.934] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 10/29/2015] [Accepted: 10/30/2015] [Indexed: 11/25/2022]
Abstract
Progestogens are the first drugs to demonstrate reproducibly a reduction in the rate of early preterm birth. The efficacy and safety of progestogens are related to individual pharmacologic properties of each drug within this class of medication and characteristics of the population that is treated. The synthetic 17-hydroxyprogesterone caproate and natural progesterone have been studied with the use of a prophylactic strategy in women with a history of preterm birth and in women with a multiple gestation. Evidence from a single large comparative efficacy trial suggests that vaginal natural progesterone is superior to 17-hydroxyprogesterone caproate as a prophylactic treatment in women with a history of mid-trimester preterm birth. Progestogen therapy is indicated for women with this highest risk profile based on evidence from 2 trials. A therapeutic approach based on the identification of a sonographic short cervix has been studied in several phase III trials. Independent phase III trials and an individual patient metaanalysis suggest that vaginal progesterone is efficacious and safe in women with a singleton and a short cervix. Two trials that tested 17-hydroxyprogesterone caproate in women with a short cervix showed no benefit. No consistent benefit for the prophylactic or therapeutic use of progestogens has been demonstrated in larger trials of women whose pregnancies were complicated by a multiple gestation (twins or triplets), preterm labor, or preterm rupture of membranes. Unfortunately, several large randomized trials in multiple gestations have identified harm related to 17-hydroxyprogesterone caproate exposure, and the synthetic drug is contraindicated in this population. The current body of evidence is evaluated by the Grading of Recommendations Assessment, Development, and Evaluation guidelines to derive the strength of recommendation in each of these populations. A large confirmatory trial that is testing 17-hydroxyprogesterone caproate exposure in women with a singleton pregnancy and a history of preterm birth is near completion. Additional study of the efficacy and safety of progestogens is suggested in well-selected populations based on the presence of biomarkers.
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Furcron AE, Romero R, Plazyo O, Unkel R, Xu Y, Hassan SS, Chaemsaithong P, Mahajan A, Gomez-Lopez N. Vaginal progesterone, but not 17α-hydroxyprogesterone caproate, has antiinflammatory effects at the murine maternal-fetal interface. Am J Obstet Gynecol 2015; 213:846.e1-846.e19. [PMID: 26264823 DOI: 10.1016/j.ajog.2015.08.010] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 06/25/2015] [Accepted: 08/04/2015] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Progestogen (vaginal progesterone or 17-alpha-hydroxyprogesterone caproate [17OHP-C]) administration to patients at risk for preterm delivery is widely used for the prevention of preterm birth (PTB). The mechanisms by which these agents prevent PTB are poorly understood. Progestogens have immunomodulatory functions; therefore, we investigated the local effects of vaginal progesterone and 17OHP-C on adaptive and innate immune cells implicated in the process of parturition. STUDY DESIGN Pregnant C57BL/6 mice received vaginal progesterone (1 mg per 200 μL, n = 10) or Replens (control, 200 μL, n = 10) from 13 to 17 days postcoitum (dpc) or were subcutaneously injected with 17OHP-C (2 mg per 100 μL, n = 10) or castor oil (control, 100 μL, n = 10) on 13, 15, and 17 dpc. Decidual and myometrial leukocytes were isolated prior to term delivery (18.5 dpc) for immunophenotyping by flow cytometry. Cervical tissue samples were collected to determine matrix metalloproteinase (MMP)-9 activity by in situ zymography and visualization of collagen content by Masson's trichrome staining. Plasma concentrations of progesterone, estradiol, and cytokines (interferon [IFN]γ, interleukin (IL)-1β, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12p70, keratinocyte-activated chemokine/growth-related oncogene, and tumor necrosis factor-α) were quantified by enzyme-linked immunosorbent assays. Pregnant mice pretreated with vaginal progesterone or Replens were injected with 10 μg of an endotoxin on 16.5 dpc (n = 10 each) and monitored via infrared camera until delivery to determine the effect of vaginal progesterone on the rate of PTB. RESULTS The following results were found: (1) vaginal progesterone, but not 17OHP-C, increased the proportion of decidual CD4+ regulatory T cells; (2) vaginal progesterone, but not 17OHP-C, decreased the proportion of decidual CD8+CD25+Foxp3+ T cells and macrophages; (3) vaginal progesterone did not result in M1→M2 macrophage polarization but reduced the proportion of myometrial IFNγ+ neutrophils and cervical active MMP-9-positive neutrophils and monocytes; (4) 17OHP-C did not reduce the proportion of myometrial IFNγ+ neutrophils; however, it increased the abundance of cervical active MMP-9-positive neutrophils and monocytes; (5) vaginal progesterone immune effects were associated with reduced systemic concentrations of IL-1β but not with alterations in progesterone or estradiol concentrations; and (6) vaginal progesterone pretreatment protected against endotoxin-induced PTB (effect size 50%, P = 0.011). CONCLUSION Vaginal progesterone, but not 17OHP-C, has local antiinflammatory effects at the maternal-fetal interface and the cervix and protects against endotoxin-induced PTB.
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Conde-Agudelo A, Romero R. Predictive accuracy of changes in transvaginal sonographic cervical length over time for preterm birth: a systematic review and metaanalysis. Am J Obstet Gynecol 2015; 213:789-801. [PMID: 26070703 DOI: 10.1016/j.ajog.2015.06.015] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 05/29/2015] [Accepted: 06/04/2015] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To determine the accuracy of changes in transvaginal sonographic cervical length over time in predicting preterm birth in women with singleton and twin gestations. DATA SOURCES PubMed, Embase, Cinahl, Lilacs, and Medion (all from inception to June 30, 2015), bibliographies, Google scholar, and conference proceedings. Cohort or cross-sectional studies reporting on the predictive accuracy for preterm birth of changes in cervical length over time. STUDY APPRAISAL AND SYNTHESIS METHODS Two reviewers independently selected studies, assessed the risk of bias, and extracted the data. Summary receiver-operating characteristic curves, pooled sensitivities and specificities, and summary likelihood ratios were generated. RESULTS Fourteen studies met the inclusion criteria, of which 7 provided data on singleton gestations (3374 women) and 8 on twin gestations (1024 women). Among women with singleton gestations, the shortening of cervical length over time had a low predictive accuracy for preterm birth at <37 and <35 weeks of gestation with pooled sensitivities and specificities, and summary positive and negative likelihood ratios ranging from 49% to 74%, 44% to 85%, 1.3 to 4.1, and 0.3 to 0.7, respectively. In women with twin gestations, the shortening of cervical length over time had a low to moderate predictive accuracy for preterm birth at <34, <32, <30, and <28 weeks of gestation with pooled sensitivities and specificities, and summary positive and negative likelihood ratios ranging from 47% to 73%, 84% to 89%, 3.8 to 5.3, and 0.3 to 0.6, respectively. There were no statistically significant differences between the predictive accuracies for preterm birth of cervical length shortening over time and the single initial and/or final cervical length measurement in 8 of 11 studies that provided data for making these comparisons. In the largest and highest-quality study, a single measurement of cervical length obtained at 24 or 28 weeks of gestation was significantly more predictive of preterm birth than any decrease in cervical length between these gestational ages. CONCLUSIONS Change in transvaginal sonographic cervical length over time is not a clinically useful test to predict preterm birth in women with singleton or twin gestations. A single cervical length measurement obtained between 18 and 24 weeks of gestation appears to be a better test to predict preterm birth than changes in cervical length over time.
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Affiliation(s)
- Agustin Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Department of Molecular Obstetrics and Genetics, Wayne State University, Detroit, MI.
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Ackerman WE, Summerfield TL, Mesiano S, Schatz F, Lockwood CJ, Kniss DA. Agonist-Dependent Downregulation of Progesterone Receptors in Human Cervical Stromal Fibroblasts. Reprod Sci 2015; 23:112-23. [PMID: 26243545 DOI: 10.1177/1933719115597787] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Progesterone (P(4)) maintains uterine quiescence during the majority of pregnancy, whereas diminished progesterone receptor (PR) expression and/or activity (ie, functional P(4) withdrawal) promotes parturition. To investigate the regulation of PR expression in cervical stroma, fibroblasts from premenopausal hysterectomy specimens were prepared. Greater than 99% of the cultures were vimentin positive (mesenchymal cell marker) with only occasional cytokeratin-8 positivity (epithelial cell marker) and no evidence of CD31-positive (endothelial cell marker) cells. Cells were immunolabeled with antibodies directed against PRs (PR-A and PR-B), estrogen receptor α (ER-α), and glucocorticoid receptor-α/β (GR-α/β). All cells were uniformly immunopositive for ER-α and GR-α/β but did not express PRs. Incubation of cells with 10(-8) mol/L 17β-estradiol induced a time-dependent increase in PR-A and PR-B messenger RNAs (mRNAs) by quantitative real-time polymerase chain reactions and proteins by immunoblotting and immunofluorescence. Incubation of cervical fibroblasts with PR ligands (medroxyprogesterone acetate or Org-2058) downregulated PR-A and PR-B levels. Coincubation of cells with PR ligands plus RU-486, a PR antagonist, partially abrogated agonist-induced receptor downregulation. Dexamethasone, a pure glucocorticoid, had no inhibitory effect on PR expression. These results indicate that progestins and estrogens regulate PR expression in cervical fibroblasts. We postulate that hormonal regulation of PR expression in the cervical stroma may contribute to functional P(4) withdrawal in preparation for parturition.
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Affiliation(s)
- William E Ackerman
- Division of Maternal-Fetal Medicine and Laboratory of Perinatal Research, Department of Obstetrics and Gynecology, The Ohio State University, College of Medicine and Wexner Medical Center, Columbus, OH, USA
| | - Taryn L Summerfield
- Division of Maternal-Fetal Medicine and Laboratory of Perinatal Research, Department of Obstetrics and Gynecology, The Ohio State University, College of Medicine and Wexner Medical Center, Columbus, OH, USA
| | - Sam Mesiano
- Department of Obstetrics, Gynecology and Reproductive Sciences, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - Frederick Schatz
- Division of Maternal-Fetal Medicine and Laboratory of Perinatal Research, Department of Obstetrics and Gynecology, The Ohio State University, College of Medicine and Wexner Medical Center, Columbus, OH, USA Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Charles J Lockwood
- Division of Maternal-Fetal Medicine and Laboratory of Perinatal Research, Department of Obstetrics and Gynecology, The Ohio State University, College of Medicine and Wexner Medical Center, Columbus, OH, USA Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Douglas A Kniss
- Division of Maternal-Fetal Medicine and Laboratory of Perinatal Research, Department of Obstetrics and Gynecology, The Ohio State University, College of Medicine and Wexner Medical Center, Columbus, OH, USA Department of Biomedical Engineering, College of Engineering, The Ohio State University, Columbus, OH, USA
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Predicting Preterm Labour: Current Status and Future Prospects. DISEASE MARKERS 2015; 2015:435014. [PMID: 26160993 PMCID: PMC4486247 DOI: 10.1155/2015/435014] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 06/02/2015] [Indexed: 11/24/2022]
Abstract
Preterm labour and birth are a major cause of perinatal morbidity and mortality. Despite modern advances in obstetric and neonatal management, the rate of preterm birth in the developed world is increasing. Yet even though numerous risk factors associated with preterm birth have been identified, the ability to accurately predict when labour will occur remains elusive, whether it is at a term or preterm gestation. In the latter case, this is likely due to the multifactorial aetiology of preterm labour wherein women may display different clinical presentations that lead to preterm birth. The discovery of novel biomarkers that could reliably identify women who will subsequently deliver preterm may allow for timely medical intervention and targeted therapeutic treatments aimed at improving maternal and fetal outcomes. Various body fluids including amniotic fluid, urine, saliva, blood (serum/plasma), and cervicovaginal fluid all provide a rich protein source of putative biochemical markers that may be causative or reflective of the various pathophysiological disorders of pregnancy, including preterm labour. This short review will highlight recent advances in the field of biomarker discovery and the utility of single and multiple biomarkers for the prediction of preterm birth in the absence of intra-amniotic infection.
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El-refaie W, Abdelhafez MS, Badawy A. RETRACTED ARTICLE: Vaginal progesterone for prevention of
preterm labor in asymptomatic twin pregnancies with sonographic short cervix: a
randomized clinical trial of efficacy and safety. Arch Gynecol Obstet 2015; 293:61-67. [DOI: 10.1007/s00404-015-3767-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/26/2015] [Indexed: 11/24/2022]
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Feghali M, Venkataramanan R, Caritis S. Prevention of preterm delivery with 17-hydroxyprogesterone caproate: pharmacologic considerations. Semin Perinatol 2014; 38:516-22. [PMID: 25256193 PMCID: PMC4253874 DOI: 10.1053/j.semperi.2014.08.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Despite advances in neonatal care, the burden of preterm birth remains high. Preterm birth is a multifactorial problem, and strategies to identify and treat medical risk factors in early pregnancy have not been effective in reducing preterm birth rates. In a sentinel clinical trial, prophylactic therapy with 17-hydoxyprogesterone caproate (17-OHPC) reduced the risk of recurrent, spontaneous preterm birth in 34% of women. As a result, clinical practice changed and extensive research on 17-OHPC followed. The increasing body of evidence demonstrated a variable efficacy of the drug. This review will examine the plausibility, pharmacology, clinical efficacy, and safety of 17-OHPC when used in the setting of preterm birth prevention. We will also discuss pharmacokinetic and pharmacodynamics data to highlight drug metabolism and mechanism of action, which will help clarify the variability in clinical outcomes and efficacy.
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Affiliation(s)
- Maisa Feghali
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
| | - Steve Caritis
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA
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Brubaker SG, Pessel C, Zork N, Gyamfi-Bannerman C, Ananth CV. Vaginal progesterone in women with twin gestations complicated by short cervix: a retrospective cohort study. BJOG 2014; 122:712-8. [DOI: 10.1111/1471-0528.13188] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2014] [Indexed: 11/28/2022]
Affiliation(s)
- SG Brubaker
- Division of Maternal-Fetal Medicine; Columbia University; New York City NY USA
| | - C Pessel
- Division of Maternal-Fetal Medicine; Columbia University; New York City NY USA
| | - N Zork
- Division of Maternal-Fetal Medicine; Columbia University; New York City NY USA
| | - C Gyamfi-Bannerman
- Division of Maternal-Fetal Medicine; Columbia University; New York City NY USA
| | - CV Ananth
- Department of Obstetrics and Gynecology; Columbia University; New York City NY USA
- Department of Epidemiology; Columbia University; New York City NY USA
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Egerman R, Ramsey R, Istwan N, Rhea D, Stanziano G. Maternal characteristics influencing the development of gestational diabetes in obese women receiving 17-alpha-hydroxyprogesterone caproate. J Obes 2014; 2014:563243. [PMID: 25405027 PMCID: PMC4227321 DOI: 10.1155/2014/563243] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 09/22/2014] [Accepted: 10/02/2014] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Gestational diabetes (GDM) and obesity portend a high risk for subsequent type 2 diabetes. We examined maternal factors influencing the development of gestational diabetes (GDM) in obese women receiving 17-alpha-hydroxyprogesterone caproate (17OHPC) for preterm delivery prevention. MATERIALS AND METHODS Retrospectively identified were 899 singleton pregnancies with maternal prepregnancy body mass indices of ≥30 kg/m(2) enrolled for either 17OHPC weekly administration (study group) or daily uterine monitoring and nursing assessment (control group). Patients with history of diabetes type 1, 2, or GDM were excluded. Maternal characteristics were compared between groups and for women with and without development of GDM. A logistic regression model was performed on incidence of GDM, controlling for significant univariate factors. RESULTS The overall incidence of GDM in the 899 obese women studied was 11.9%. The incidence of GDM in the study group (n = 491) was 13.8% versus 9.6% in the control group (n = 408) (P = 0.048). Aside from earlier initiation of 17OHP and advanced maternal age, other factors including African American race, differing degrees of obesity, and use of tocolysis were not significant risks for the development of GDM. CONCLUSION In obese women with age greater than 35 years, earlier initiation of 17OHPC may increase the risk for GDM.
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Affiliation(s)
- Robert Egerman
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, 1600 SW Archer Road, P.O. Box 100294, Gainesville, FL 32610-0294, USA
| | - Risa Ramsey
- University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Niki Istwan
- Department of Clinical Research, Alere, Women's & Children's Health, Atlanta, GA 30339, USA
| | - Debbie Rhea
- Department of Clinical Research, Alere, Women's & Children's Health, Atlanta, GA 30339, USA
| | - Gary Stanziano
- Department of Clinical Research, Alere, Women's & Children's Health, Atlanta, GA 30339, USA
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Haram K, Mortensen JH, Morrison JC. Cerclage, progesterone andα-hydroxyprogeterone caproate treatment in women at risk for preterm delivery. J Matern Fetal Neonatal Med 2014; 27:1710-5. [DOI: 10.3109/14767058.2013.876003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hernandez-Andrade E, Romero R, Korzeniewski SJ, Ahn H, Aurioles-Garibay A, Garcia M, Schwartz AG, Yeo L, Chaiworapongsa T, Hassan SS. Cervical strain determined by ultrasound elastography and its association with spontaneous preterm delivery. J Perinat Med 2014; 42:159-69. [PMID: 24356388 PMCID: PMC4183449 DOI: 10.1515/jpm-2013-0277] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 11/25/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine if there is an association between cervical strain, evaluated using ultrasound elastography, and spontaneous preterm delivery (sPTD) <37 weeks of gestation. METHODS One hundred and eighty nine (189) women at 16-24 weeks of gestation were evaluated. Ultrasound elastography was used to estimate cervical strain in three anatomical planes: one mid-sagittal in the same plane used for cervical length measurement, and two cross sectional images: one at the level of the internal cervical os, and the other at the level of the external cervical os. In each plane, two regions of interest (endocervix and entire cervix) were examined; a total of six regions of interest were evaluated. RESULTS The prevalence of sPTD was 11% (21/189). Strain values from each of the six cervical regions correlated weakly with cervical length (from r=-0.24, P<0.001 to r=-0.03, P=0.69). Strain measurements obtained in a cross sectional view of the internal cervical os were significantly associated with sPTD. Women with strain values ≤25th centile in the endocervical canal (0.19) and in the entire cervix (0.14) were 80% less likely to have a sPTD than women with strain values >25th centile [endocervical: odds ratio (OR) 0.2; 95% confidence interval (CI), 0.03-0.96; entire cervix: OR 0.17; 95% CI, 0.03-0.9]. Additional adjustment for gestational age, race, smoking status, parity, maternal age, pre-pregnancy body mass index, and previous preterm delivery did not appreciably alter the magnitude or statistical significance of these associations. Strain values obtained from the external cervical os and from the sagittal view were not associated with sPTD. CONCLUSION Low strain values in the internal cervical os were associated with a significantly lower risk of spontaneous preterm delivery <37 weeks of gestation.
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Affiliation(s)
- Edgar Hernandez-Andrade
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, Michigan, and Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, Michigan, and Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
| | - Steven J. Korzeniewski
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, Michigan, and Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Hyunyoung Ahn
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, Michigan, and Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Alma Aurioles-Garibay
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, Michigan, and Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Maynor Garcia
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, Michigan, and Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Alyse G. Schwartz
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, Michigan, and Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Lami Yeo
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, Michigan, and Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, Michigan, and Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sonia S. Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, Michigan, and Bethesda, Maryland, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
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O'Brien JM. Medication safety is still an issue in obstetrics 50 years after the Kefauver-Harris amendments: the case of progestogens. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:247-253. [PMID: 23495199 DOI: 10.1002/uog.12456] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 01/27/2013] [Accepted: 02/13/2013] [Indexed: 06/01/2023]
Affiliation(s)
- J M O'Brien
- Maternal Fetal Medicine, University of Kentucky, Lexington, KY, USA.
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Dodd JM, Jones L, Flenady V, Cincotta R, Crowther CA. Prenatal administration of progesterone for preventing preterm birth in women considered to be at risk of preterm birth. Cochrane Database Syst Rev 2013; 2013:CD004947. [PMID: 23903965 PMCID: PMC11035916 DOI: 10.1002/14651858.cd004947.pub3] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Preterm birth is a major complication of pregnancy associated with perinatal mortality and morbidity. Progesterone for the prevention of preterm labour has been advocated. OBJECTIVES To assess the benefits and harms of progesterone for the prevention of preterm birth for women considered to be at increased risk of preterm birth and their infants. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (14 January 2013) and reviewed the reference list of all articles. SELECTION CRITERIA Randomised controlled trials, in which progesterone was given for preventing preterm birth. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated trials for methodological quality and extracted data. MAIN RESULTS Thirty-six randomised controlled trials (8523 women and 12,515 infants) were included. Progesterone versus placebo for women with a past history of spontaneous preterm birth Progesterone was associated with a statistically significant reduction in the risk of perinatal mortality (six studies; 1453 women; risk ratio (RR) 0.50, 95% confidence interval (CI) 0.33 to 0.75), preterm birth less than 34 weeks (five studies; 602 women; average RR 0.31, 95% CI 0.14 to 0.69), infant birthweight less than 2500 g (four studies; 692 infants; RR 0.58, 95% CI 0.42 to 0.79), use of assisted ventilation (three studies; 633 women; RR 0.40, 95% CI 0.18 to 0.90), necrotising enterocolitis (three studies; 1170 women; RR 0.30, 95% CI 0.10 to 0.89), neonatal death (six studies; 1453 women; RR 0.45, 95% CI 0.27 to 0.76), admission to neonatal intensive care unit (three studies; 389 women; RR 0.24, 95% CI 0.14 to 0.40), preterm birth less than 37 weeks (10 studies; 1750 women; average RR 0.55, 95% CI 0.42 to 0.74) and a statistically significant increase in pregnancy prolongation in weeks (one study; 148 women; mean difference (MD) 4.47, 95% CI 2.15 to 6.79). No differential effects in terms of route of administration, time of commencing therapy and dose of progesterone were observed for the majority of outcomes examined. Progesterone versus placebo for women with a short cervix identified on ultrasound Progesterone was associated with a statistically significant reduction in the risk of preterm birth less than 34 weeks (two studies; 438 women; RR 0.64, 95% CI 0.45 to 0.90), preterm birth at less than 28 weeks' gestation (two studies; 1115 women; RR 0.59, 95% CI 0.37 to 0.93) and increased risk of urticaria in women when compared with placebo (one study; 654 women; RR 5.03, 95% CI 1.11 to 22.78). It was not possible to assess the effect of route of progesterone administration, gestational age at commencing therapy, or total cumulative dose of medication. Progesterone versus placebo for women with a multiple pregnancy Progesterone was associated with no statistically significant differences for the reported outcomes. Progesterone versus no treatment/placebo for women following presentation with threatened preterm labour Progesterone, was associated with a statistically significant reduction in the risk of infant birthweight less than 2500 g (one study; 70 infants; RR 0.52, 95% CI 0.28 to 0.98). Progesterone versus placebo for women with 'other' risk factors for preterm birth Progesterone, was associated with a statistically significant reduction in the risk of infant birthweight less than 2500 g (three studies; 482 infants; RR 0.48, 95% CI 0.25 to 0.91). AUTHORS' CONCLUSIONS The use of progesterone is associated with benefits in infant health following administration in women considered to be at increased risk of preterm birth due either to a prior preterm birth or where a short cervix has been identified on ultrasound examination. However, there is limited information available relating to longer-term infant and childhood outcomes, the assessment of which remains a priority.Further trials are required to assess the optimal timing, mode of administration and dose of administration of progesterone therapy when given to women considered to be at increased risk of early birth.
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Affiliation(s)
- Jodie M Dodd
- School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide,Australia.
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Romero R, Stanczyk FZ. Progesterone is not the same as 17α-hydroxyprogesterone caproate: implications for obstetrical practice. Am J Obstet Gynecol 2013; 208:421-6. [PMID: 23643669 DOI: 10.1016/j.ajog.2013.04.027] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 04/22/2013] [Indexed: 11/29/2022]
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Short cervix syndrome: current knowledge from etiology to the control. Arch Gynecol Obstet 2013; 287:621-8. [PMID: 23389247 DOI: 10.1007/s00404-013-2740-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 01/22/2013] [Indexed: 01/09/2023]
Abstract
BACKGROUND Preterm delivery is one of the most serious public health problems and is the most important factor relating to neonatal morbidity and mortality. The strategies for preventing it include understanding the risk factors, with specific interventions. Recently, uterine cervix measurements using ultrasonography and vaginal administration of progesterone have gained importance in predicting and secondarily preventing spontaneous preterm delivery. OBJECTIVE To describe the short cervix syndrome, including its etiology, diagnosis, and possible therapies. METHODS Research in ISI, Pubmed, and Scielo database using the words short cervix, preterm delivery, sludge, cervical funneling, cervical gland area, progesterone, cerclage, and pessary. RESULTS We found a lot of articles about this topic, including randomized controlled trials. The etiology is multifactorial, being the diagnosis based in a cervix shortening at 20-24 weeks. The history and measurement of cervix length by transvaginal ultrasound have been shown to be effective to select the high risk pregnancies. The progesterone, cervical cerclage, and cervical pessary showed to be effective to reduce the preterm delivery in pregnant women with short cervix. CONCLUSION The successful management of pregnant women presenting a short cervix depends on the understanding that cervical shortening is the final common path for several causes of preterm delivery. The best approach should be individualized to each patient.
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Conde-Agudelo A, Romero R, Nicolaides K, Chaiworapongsa T, O'Brien JM, Cetingoz E, da Fonseca E, Creasy G, Soma-Pillay P, Fusey S, Cam C, Alfirevic Z, Hassan SS. Vaginal progesterone vs. cervical cerclage for the prevention of preterm birth in women with a sonographic short cervix, previous preterm birth, and singleton gestation: a systematic review and indirect comparison metaanalysis. Am J Obstet Gynecol 2013; 208:42.e1-42.e18. [PMID: 23157855 PMCID: PMC3529767 DOI: 10.1016/j.ajog.2012.10.877] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 10/12/2012] [Accepted: 10/17/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE No randomized controlled trial has compared vaginal progesterone and cervical cerclage directly for the prevention of preterm birth in women with a sonographic short cervix in the mid trimester, singleton gestation, and previous spontaneous preterm birth. We performed an indirect comparison of vaginal progesterone vs cerclage using placebo/no cerclage as the common comparator. STUDY DESIGN Adjusted indirect metaanalysis of randomized controlled trials. RESULTS Four studies that evaluated vaginal progesterone vs placebo (158 patients) and 5 studies that evaluated cerclage vs no cerclage (504 patients) were included. Both interventions were associated with a statistically significant reduction in the risk of preterm birth at <32 weeks of gestation and composite perinatal morbidity and mortality compared with placebo/no cerclage. Adjusted indirect metaanalyses did not show statistically significant differences between vaginal progesterone and cerclage in the reduction of preterm birth or adverse perinatal outcomes. CONCLUSION Based on state-of-the-art methods for indirect comparisons, either vaginal progesterone or cerclage are equally efficacious in the prevention of preterm birth in women with a sonographic short cervix in the mid trimester, singleton gestation, and previous preterm birth. Selection of the optimal treatment needs to consider adverse events, cost and patient/clinician preferences.
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Slager J, Lynne S. Special Issue: Short cervix and the risk of preterm birth. Introduction. J Midwifery Womens Health 2012; 57 Suppl 1:S1-3. [PMID: 22776242 DOI: 10.1111/j.1542-2011.2012.00202.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Slager J, Lynne S. Treatment options and recommendations to reduce preterm births in women with short cervix. J Midwifery Womens Health 2012; 57 Suppl 1:S12-8. [PMID: 22776244 DOI: 10.1111/j.1542-2011.2012.00210.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Premature shortening of the cervix, or short cervix, is the most predictive risk factor for preterm birth. Results of clinical studies of interventions to prevent preterm birth have shown that identifying at-risk women on the basis of cervical length versus obstetric history alone improves the likelihood of timely interventions with cervical cerclage or progesterone supplementation, improving outcomes. Debate continues over the use of cerclage; however, results of a meta-analysis of randomized controlled trials provide evidence to support its use in women who have history of prior preterm birth and who develop short cervix before 24 weeks' gestation. Results of the recent PREGNANT trial, consistent with the earlier Fetal Medicine Foundation study, support the use of vaginal progesterone for prevention of preterm birth. In women identified by transvaginal ultrasound to have short cervix (10-20 mm) in midtrimester, daily vaginal progesterone gel reduced the risk of preterm birth before 33 weeks' gestation by 45% and before 28 weeks' gestation by 50%. Occurrence of any morbidity and mortality event also was significantly reduced by 43%, with a 61% reduction in the rate of respiratory distress syndrome in infants born to women receiving vaginal progesterone gel versus those receiving placebo. The safety profile of progesterone treatment in early pregnancy is well established, and studies of vaginal progesterone for prevention of preterm birth have identified no additional safety issues. Adverse events were comparable between women receiving progesterone and those receiving placebo. Recent guidelines issued by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine recommend vaginal progesterone in women with no prior spontaneous preterm birth and cervical length of 20 mm or less at 24 weeks' gestation or earlier. Future studies will refine strategies for prevention of preterm birth to address other risk factors and determine the role of other interventions.
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Affiliation(s)
- Joan Slager
- Bronson Women's Services in Kalamazoo, Michigan, USA
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Feltovich H, Hall TJ, Berghella V. Beyond cervical length: emerging technologies for assessing the pregnant cervix. Am J Obstet Gynecol 2012; 207:345-54. [PMID: 22717270 DOI: 10.1016/j.ajog.2012.05.015] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 05/02/2012] [Accepted: 05/21/2012] [Indexed: 12/12/2022]
Abstract
Spontaneous preterm birth is a heterogeneous phenotype. A multitude of pathophysiologic pathways culminate in the final common denominator of cervical softening, shortening, and dilation that leads to preterm birth. A precise description of specific microstructural changes to the cervix is imperative if we are to identify the causative upstream molecular processes and resultant biomechanical events that are associated with each unique pathway. Currently, however, we have no reliable clinical tools for quantitative and objective evaluation, which likely contributes to the reason the singleton spontaneous preterm birth rate has not changed appreciably in >100 years. Fortunately, promising techniques to evaluate tissue hydration, collagen structure, and/or tissue elasticity are emerging. These will add to the body of knowledge about the cervix and facilitate the coordination of molecular studies and ultimately lead to novel approaches to preterm birth prediction and, finally, prevention.
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Lim AC, Schuit E, Papatsonis D, van Eyck J, Porath MM, van Oirschot CM, Hummel P, Hasaart THM, Kleiverda G, de Graaf IM, van Ginkel AA, Mol BWJ, Bruinse HW. Effect of 17-alpha hydroxyprogesterone caproate on cervical length in twin pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:426-430. [PMID: 23008102 DOI: 10.1002/uog.11174] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES Previous studies on singleton pregnancies have indicated that progestogens may reduce the rate of cervical shortening during pregnancy. The aim of this study was to investigate whether treatment with 17-alpha hydroxyprogesterone caproate (17-OHPC) has an effect on cervical shortening in twin pregnancies. METHODS This was a secondary analysis of patients who had participated in a multicenter randomized clinical trial on the effectiveness of 17-OHPC in preventing preterm birth in multiple pregnancies (the AMPHIA-trial). We included all trial participants with a twin gestation who had undergone repeat cervical length measurements during pregnancy. We performed a separate analysis of women with repeat measurements in centers where this was standard protocol for multiple pregnancies. The rate of cervical shortening for both the 17-OHPC group and the placebo group was analyzed using a linear mixed model. RESULTS Of the 671 patients who participated in the trial, 282 (42%) had a twin pregnancy and underwent two or more cervical length measurements. Of these women, 140 were monitored in centers where repeat measurements were standard protocol. We observed an overall reduction of cervical length from 44.3 mm at 14-18 weeks to 30.0 mm at 30-34 weeks' gestation. In the 17-OHPC group, cervical length decreased by 1.04 mm each gestational week, while this was 1.11 mm per week for the placebo group (P = 0.6). For the overall group, each 10% decrease in cervical length led to an increase in the risk of preterm birth (hazard ratio, 1.14; 95% CI, 1.08-1.21). CONCLUSION In women with a twin pregnancy, there is progressive shortening of the cervix during pregnancy, regardless of 17-OHPC use.
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Affiliation(s)
- A C Lim
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands.
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The change in cervical length over time as a predictor of preterm delivery in asymptomatic women with twin pregnancies who have a normal mid-trimester cervical length. Twin Res Hum Genet 2012; 15:516-21. [PMID: 22854157 DOI: 10.1017/thg.2012.27] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM To determine whether or not the change in cervical length (CL) over time is valuable in predicting spontaneous preterm delivery (SPTD) in asymptomatic twin pregnancies with a normal mid-trimester CL (>25 mm). METHODS This was a prospective study including 190 consecutive asymptomatic twin gestations with a CL>25 mm at 20-24 weeks. The women underwent an initial CL measurement at the time of routine ultrasound examination between 20 and 24 weeks' gestation, followed 4-5 weeks later by a repeat CL measurement. The primary outcome measure was SPTD at <32 completed weeks' gestation. Multicollinearity was a concern in the multivariable model since change in CL and follow-up CL were highly correlated. RESULTS The rate of SPTD at <32 weeks was 4.2%. Multiple logistic regression analyses demonstrated that the change in CL and the follow-up CL were significantly associated with SPTD before 32 weeks after adjusting for baseline covariate such as in vitro fertilization. The best cut-off values for the prediction of SPTD at <32 weeks' gestation were 13% for the change in CL with a sensitivity of 87.5% and a specificity of 63.2%. There was no significant difference in the area under the receiver operating characteristic curves between the change in CL and the follow-up CL. CONCLUSIONS A greater change in CL is a good predictor of SPTD in asymptomatic twin pregnancies with a normal mid-trimester CL. However, the change in CL cannot provide data beyond the follow-up CL. In the setting of a normal mid-trimester CL, a follow-up CL measurement should be considered in asymptomatic twin pregnancies.
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Abstract
The incidence of twin gestation has increased significantly over the past 30 years. One of the most significant public health implications of this trend is the increased incidence of preterm birth (PTB). Efforts to improve neonatal outcomes must address the rate of PTB, particularly among multiple gestations, which contribute a disproportionate share to the burden of PTB and neonatal morbidity. There is evidence that sonographic cervical length assessment and fetal fibronectin testing can identify twin pregnancies at risk for PTB, but, to date, there are no proven interventions for prevention of PTB in this population. Perhaps the most promising is vaginal progesterone, which has been shown to reduce the risk of PTB in a cohort of women that included twin gestations. However, the study lacked statistical power to definitively answer this question. Identification of an appropriate treatment for twin gestations recognized to be at increased risk for prematurity will help to decrease overall rate of PTB, a significant public health problem in the United States.
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Affiliation(s)
- Sara G Brubaker
- Division of Maternal Fetal Medicine, Columbia University Medical Center, New York, NY 10032, USA.
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Progesterone and preterm birth prevention: translating clinical trials data into clinical practice. Am J Obstet Gynecol 2012; 206:376-86. [PMID: 22542113 DOI: 10.1016/j.ajog.2012.03.010] [Citation(s) in RCA: 231] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 03/13/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We sought to provide evidence-based guidelines for using progestogens for the prevention of preterm birth (PTB). METHODS Relevant documents, in particular randomized trials, were identified using PubMed (US National Library of Medicine, 1983 through February 2012) publications, written in English, which evaluate the effectiveness of progestogens for prevention of PTB. Progestogens evaluated were, in particular, vaginal progesterone and 17-alpha-hydroxy-progesterone caproate. Additionally, the Cochrane Library, organizational guidelines, and studies identified through review of the above were utilized to identify relevant articles. Data were evaluated according to population studied, with separate analyses for singleton vs multiple gestations, prior PTB, or short transvaginal ultrasound cervical length (CL), and combinations of these factors. Consistent with US Preventive Task Force suggestions, references were evaluated for quality based on the highest level of evidence, and recommendations were graded. RESULTS AND RECOMMENDATIONS Summary of randomized studies indicates that in women with singleton gestations, no prior PTB, and short CL ≤ 20 mm at ≤ 24 weeks, vaginal progesterone, either 90-mg gel or 200-mg suppository, is associated with reduction in PTB and perinatal morbidity and mortality, and can be offered in these cases. The issue of universal CL screening of singleton gestations without prior PTB for the prevention of PTB remains an object of debate. CL screening in singleton gestations without prior PTB cannot yet be universally mandated. Nonetheless, implementation of such a screening strategy can be viewed as reasonable, and can be considered by individual practitioners, following strict guidelines. In singleton gestations with prior PTB 20-36 6/7 weeks, 17-alpha-hydroxy-progesterone caproate 250 mg intramuscularly weekly, preferably starting at 16-20 weeks until 36 weeks, is recommended. In these women with prior PTB, if the transvaginal ultrasound CL shortens to < 25 mm at < 24 weeks, cervical cerclage may be offered. Progestogens have not been associated with prevention of PTB in women who have in the current pregnancy multiple gestations, preterm labor, or preterm premature rupture of membranes. There is insufficient evidence to recommend the use of progestogens in women with any of these risk factors, with or without a short CL.
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Aboulghar MM, Aboulghar MA, Amin YM, Al-Inany HG, Mansour RT, Serour GI. The use of vaginal natural progesterone for prevention of preterm birth in IVF/ICSI pregnancies. Reprod Biomed Online 2012; 25:133-8. [PMID: 22695310 DOI: 10.1016/j.rbmo.2012.03.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 03/24/2012] [Accepted: 03/27/2012] [Indexed: 11/26/2022]
Abstract
The aim of this study was to evaluate the effect of vaginal natural progesterone on the prevention of preterm birth in IVF/intracytoplasmic sperm injection (ICSI) pregnancies. A single-centre prospective placebo-controlled randomized study was performed. A total of 313 IVF/ICSI pregnant patients were randomized into two groups for either treatment with daily 400 mg vaginal natural progesterone or placebo, starting from mid-trimester up to 37 weeks or delivery. Amongst the patients, there were 215 singleton and 91 twin pregnancies. There was no significant difference in risk of preterm birth among all patients (OR 0.672, 95% CI 0.42-1.0. There was a significantly lower preterm birth rate in singleton pregnancies in the natural progesterone arm (OR 0.53, 95% CI 0.28-0.97) and no significant difference between both arms in twin pregnancies (OR 0.735, 95% CI 0.36-2). In conclusion, the administration of 400 mg vaginal natural progesterone from mid trimester reduced the incidence of preterm birth in singleton, but not in twin, IVF/ICSI pregnancies.
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Affiliation(s)
- Mona M Aboulghar
- The Egyptian IVF Center, Maadi, Cairo, Egypt; Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt.
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Bomba-Opon DA, Kosinska-Kaczynska K, Kosinski P, Wegrzyn P, Kaczynski B, Wielgos M. Vaginal progesterone after tocolytic therapy in threatened preterm labor. J Matern Fetal Neonatal Med 2012; 25:1156-9. [DOI: 10.3109/14767058.2011.629014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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