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Manuck TA, Gyamfi-Bannerman C, Saade G. What now? A critical evaluation of over 20 years of clinical and research experience with 17-alpha hydroxyprogesterone caproate for recurrent preterm birth prevention. Am J Obstet Gynecol MFM 2023; 5:101108. [PMID: 37527737 PMCID: PMC10591827 DOI: 10.1016/j.ajogmf.2023.101108] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/08/2023] [Accepted: 07/14/2023] [Indexed: 08/03/2023]
Abstract
Spontaneous preterm birth is multifactorial, and underlying etiologies remain incompletely understood. Supplementation with progestogens, including 17-alpha hydroxyprogesterone caproate has been a mainstay of prematurity prevention strategies in the United States in the last 2 decades. Following a recent negative confirmatory trial, 17-alpha hydroxyprogesterone caproate was withdrawn from the US market and is currently available only through clinical research studies. This expert review summarized clinical and research data regarding the use of 17-alpha hydroxyprogesterone caproate in the United States from 2003 to 2023 for recurrent prematurity prevention. In 17-alpha hydroxyprogesterone caproate. The history of the use, mechanisms of action, clinical trial results, and efficacy by clinical and biologic criteria of 17-alpha hydroxyprogesterone caproate are presented. We report that disparate findings and conclusions between similarly designed rigorous studies may reflect differences in a priori risk and population incidence and extreme care should be taken in interpreting the studies and making decisions regarding efficacy of 17-alpha hydroxyprogesterone caproate for the prevention of preterm birth. The likelihood of improved obstetrical outcomes after receiving 17-alpha hydroxyprogesterone caproate may vary by clinical factors (eg, body mass index), plasma drug concentrations, and genetic factors, although the identification of individuals most likely to benefit remains imperfect. It is crucial for the medical community to recognize the importance of preserving the decades-long efforts invested in preventing recurrent preterm birth in the United States. Moreover, it is important that we thoroughly and thoughtfully evaluate 17-alpha hydroxyprogesterone caproate as a promising contender for future well-executed prematurity studies.
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Affiliation(s)
- Tracy A Manuck
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Dr Manuck); Institute for Environmental Health Solutions, Gillings School of Global Public Health, Chapel Hill, NC (Dr Manuck).
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, San Diego, CA (Dr Gyamfi-Bannerman)
| | - George Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Dr Saade)
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Megli CJ, Hauspurg A, Venkataramanan R, Caritis SN. A Possible Mechanism of Action of 17α-Hydroxyprogesterone Caproate: Enhanced IL-10 Production. Am J Perinatol 2023; 40:1585-1589. [PMID: 34784615 PMCID: PMC9879021 DOI: 10.1055/s-0041-1739354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The rate of recurrent spontaneous preterm birth (PTB) was reduced by 33% in the Maternal-Fetal Medicine Unit (MFMU) Network trial of 17α-hydroxyprogesterone caproate (17-OHPC), but the mechanism of action, 17 years later, remains elusive. The robustness of the interleukin-10 (IL-10) response to lipopolysaccharide (LPS) stimulation of leukocytes in pregnant women with a prior PTB correlates with gestational age at delivery. This study sought to determine if there is a relationship between the concentration of 17-OHPC and response to LPS stimulation. STUDY DESIGN We performed a secondary analysis of data from the Omega-3 MFMU trial which evaluated the effectiveness of omega-3 fatty acid supplementation in reducing recurrent PTB. We utilized previously characterized data from a subanalyses of the Omega-3 trial of IL-10 and tumor necrosis factor alpha (TNF-α) levels from peripheral blood mononuclear cells stimulated with LPS. Blood was obtained from enrolled women at 16 to 22 weeks' gestation (baseline) and 25 to 28 weeks' gestation (posttreatment). All women received 17-OHPC and plasma 17-OHPC concentrations were measured at 25 to 28 weeks' gestation. We analyzed these data to determine if there was a relationship between 17-OHPC concentration and cytokine production. We then performed an in vitro study to determine if 17-OHPC could directly alter cytokine production by THP-1-derived macrophages. RESULTS In the clinical samples, we found that 17-OHPC plasma concentrations were correlated with the quantity of the LPS-stimulated production of IL-10. TNF-α production after LPS stimulation was unrelated to 17-OHPC concentration. In the in vitro study, we demonstrate a 17-OHPC concentration dependent increase in IL-10 production. CONCLUSION In women receiving 17-OHPC for PTB prevention, we demonstrate a relationship between plasma 17-OHPC and LPS-stimulated IL-10 production by circulating leukocytes. We also demonstrate that, in vitro, 17-OHPC treatment affects IL-10 production by LPS-stimulated macrophages. Collectively, these findings support an immunomodulatory mechanism of action of 17-OHPC in the prevention of recurrent PTB. KEY POINTS · 17-OHPC plasma concentrations and LPS-stimulated IL-10 levels correlate in clinical samples in women at risk for recurrent preterm birth.. · 17-OHPC can modulate the response of LPS-stimulated macrophages to increase IL-10 production.. · There was no relationship between TNF-α and plasma concentration of 17-OHPC in clinical samples or in vitro..
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Affiliation(s)
- Christina J. Megli
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UPMC Magee-Women’s Hospital, Pittsburgh, Pennsylvania
| | - Alisse Hauspurg
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UPMC Magee-Women’s Hospital, Pittsburgh, Pennsylvania
| | - Raman Venkataramanan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UPMC Magee-Women’s Hospital, Pittsburgh, Pennsylvania
| | - Steve N. Caritis
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UPMC Magee-Women’s Hospital, Pittsburgh, Pennsylvania
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Caritis SN, Costantine MM, Clark S, Stika CS, Kiley JW, Metz TD, Chauhan SP, Venkataramanan R. Relationship between plasma concentration of 17-hydroxyprogesterone caproate and gestational age at preterm delivery. Am J Obstet Gynecol MFM 2023; 5:100980. [PMID: 37100349 PMCID: PMC10330330 DOI: 10.1016/j.ajogmf.2023.100980] [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] [Received: 01/16/2023] [Revised: 04/05/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND The effectiveness of 17-hydroxyprogesterone caproate is unclear as trials have provided conflicting results. With the absence of fundamental pharmacologic studies addressing dosing or the relationship between drug concentration and gestational age at delivery, the effectiveness of the medication cannot be evaluated. OBJECTIVE This study aimed to evaluate the relationship between plasma concentrations of 17-hydroxyprogesterone caproate and preterm birth rates and gestational age at preterm delivery and to assess the safety of the 500-mg dose. STUDY DESIGN This study recruited 2 cohorts with previous spontaneous preterm birth; 1 cohort (n=143) was randomly assigned to either 250-mg or 500-mg 17-hydroxyprogesterone caproate, and the other cohort (n=16) was receiving the 250-mg dose for routine care. Steady-state trough plasma concentrations of 17-hydroxyprogesterone caproate obtained at 26 to 30 weeks of gestation were correlated to dose, spontaneous preterm birth rates, and measures of gestational length. Furthermore, maternal and neonatal safety outcomes were evaluated according to dose. RESULTS There was a dose proportional increase in trough plasma concentrations with the 250-mg (median, 8.6 ng/m; n=66) and 500-mg (median, 16.2 ng/mL; n=55) doses. In 116 compliant participants with blood samples, drug concentration was not related to the spontaneous preterm birth rate (odds ratio, 1.00; 95% confidence interval, 0.93-1.08). However, there was a significant relationship between drug concentration and both the interval from the first administration to delivery (interval A: coefficient, 1.11; 95% confidence interval, 0.00-2.23; P=.05) and the interval from the 26- to 30-week blood draw to delivery (interval B: coefficient, 1.56; 95% confidence interval, 0.25-2.87; P=.02). The spontaneous preterm birth rate or measures of gestational length were not related to dose. Postenrollment cerclage adversely affected all pharmacodynamic assessments because it was a powerful predictor of spontaneous preterm birth (odds ratio, 4.03; 95% confidence interval, 1.24-13.19; P=.021) and both measures of gestational length (interval A [coefficient, -14.9; 95% confidence interval, -26.3 to -3.4; P=.011] and interval B [coefficient, -15.9; 95% confidence interval, -25.8 to -5.9; P=.002]). Initial cervical length was significantly related to the risk of postenrollment cerclage (odds ratio, 0.80; 95% confidence interval, 0.70-0.92; P=.001). Maternal and neonatal safety outcomes were similar in both dosing groups. CONCLUSION In this pharmacodynamic study, trough plasma 17-hydroxyprogesterone caproate concentrations were significantly associated with gestational age at preterm birth but not with the preterm birth rate. Postenrollment cerclage was a powerful predictor of spontaneous preterm birth rate and gestational length. Initial cervical length predicted the risk of postenrollment cerclage. Adverse events were similar with the 500-mg and 250-mg doses of 17-hydroxyprogesterone caproate.
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Affiliation(s)
- Steve N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Caritis).
| | - Maged M Costantine
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX (Drs Costantine and Clark); Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Houston, TX (Drs Costantine and Clark)
| | - Shannon Clark
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX (Drs Costantine and Clark); Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Houston, TX (Drs Costantine and Clark)
| | - Catherine S Stika
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Drs Stika and Kiley)
| | - Jessica W Kiley
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Drs Stika and Kiley)
| | - Torri D Metz
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah (Dr Metz)
| | - Suneet P Chauhan
- Department of Obstetrics and Gynecology, Children's Memorial Hermann Hospital, Houston, TX (Dr Chauhan)
| | - Raman Venkataramanan
- Departments of Pharmaceutical Sciences and Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA (Dr Venkataramanan)
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Recurrent Preterm Birth Reduction by 17-Hydroxyprogesterone Caproate in Dichorionic/Diamniotic Twin Gestation. Am J Perinatol 2022; 39:1183-1188. [PMID: 33321529 DOI: 10.1055/s-0040-1721713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The study aimed to evaluate the impact of 17-hydroxyprogesterone caproate (17-OHPC) on recurrent preterm birth (PTB) in women with a prior PTB and a current dichorionic/diamniotic twin gestation. STUDY DESIGN We combined individual patient-level data from two prospective randomized placebo-controlled trials of prophylactic 17-OHPC in twin gestation and compared the rates of recurrent spontaneous PTB in those women with a prior singleton PTB randomized to placebo or 17-OHPC (250 mg weekly). RESULTS Only 7.4% of women with dichorionic/diamniotic twin gestation experienced a prior PTB. Among these 66 women, spontaneous delivery prior to 34 weeks occurred significantly less often (p = 0.03) in those randomized to 17-OHPC (20.6%) than in those randomized to placebo (46.9%). However, mean gestational length was not significantly different, and there was no statistically significant difference in composite neonatal outcome. CONCLUSION 17-OHPC may be beneficial to women with a prior PTB and a current dichorionic/diamniotic twin gestation. These findings along with those reported by the Maternal Fetal Medicine Units Network in singletons suggest a common mechanism of action and a specific target population, those with a prior PTB, that may benefit from 17-OHPC treatment. A large prospective trial is needed to validate these findings. KEY POINTS · 17-OHPC reduces recurrent PTB in women with dichorionic/diamniotic twins.. · PTB risk and response to 17-OHPC may differ according to the type of twinning.. · 17-OHPC may affect a common pathway in twins and singletons with a prior PTB..
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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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Abstract
Pregnancy profoundly alters a woman's physiology. These changes alter drug absorption, distribution, metabolism, and elimination and emphasize the pharmacologic complexity of pregnancy. They also emphasize the dangers of extrapolating pharmacologic expectations from nonpregnant populations to pregnant women and their fetuses. Although concerns about fetal safety have historically limited pharmacokinetic studies during pregnancy, it is important to recognize that many medications are clinically indicated for various maternal or fetal conditions, and it is particularly important that these therapies be evidence-based with appropriate study, including short-term and long-term outcomes data.
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Affiliation(s)
- Robert M Ward
- Pediatrics, Pediatric Clinical Pharmacology, University of Utah, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108, USA.
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B 200, Salt Lake City, UT 84132, USA
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Di Renzo GC, Cabero Roura L, Facchinetti F, Helmer H, Hubinont C, Jacobsson B, Jørgensen JS, Lamont RF, Mikhailov A, Papantoniou N, Radzinsky V, Shennan A, Ville Y, Wielgos M, Visser GHA. Preterm Labor and Birth Management: Recommendations from the European Association of Perinatal Medicine. J Matern Fetal Neonatal Med 2018; 30:2011-2030. [PMID: 28482713 DOI: 10.1080/14767058.2017.1323860] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- G C Di Renzo
- a Department of Obstetrics and Gynecology , University of Perugia , Perugia , Italy
| | - L Cabero Roura
- b Department of Obstetrics and Gynecology , Hospital Vall D'Hebron , Barcelona , Spain
| | - F Facchinetti
- c Mother-Infant Department, School of Midwifery , University of Modena and Reggio Emilia , Italy
| | - H Helmer
- d Department of Obstetrics and Gynaecology , General Hospital, University of Vienna , Vienna , Austria
| | - C Hubinont
- e Department of Obstetrics , Saint Luc University Hospital, Université de Louvain , Brussels , Belgium
| | - B Jacobsson
- f Department of Obstetrics and Gynecology , Institute of Clinical Sciences, University of Gothenburg , Gothenburg , Sweden
| | - J S Jørgensen
- g Department of Obstetrics and Gynaecology , Odense University Hospital , Odense , Denmark
| | - R F Lamont
- h Department of Gynaecology and Obstetrics , University of Southern Denmark, Odense University Hospital , Odense , Denmark.,i Division of Surgery , University College London, Northwick Park Institute of Medical Research Campus , London , UK
| | - A Mikhailov
- j Department of Obstetrics and Gynecology , 1st Maternity Hospital, State University of St. Petersburg , Russia
| | - N Papantoniou
- k Department of Obstetrics and Gynaecology , Athens University School of Medicine , Athens , Greece
| | - V Radzinsky
- l Department of Medicine , Peoples' Friendship University of Russia , Moscow , Russia
| | - A Shennan
- m St. Thomas Hospital, Kings College London , UK
| | - Y Ville
- n Service d'Obstétrique et de Médecine Foetale , Hôpital Necker Enfants Malades , Paris , France
| | - M Wielgos
- p Department of Obstetrics and Gynecology , Medical University of Warsaw , Warsaw , Poland
| | - G H A Visser
- o Department of Obstetrics , University Medical Center , Utrecht , The Netherlands
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Johnsson VL, Pedersen NG, Worda K, Krampl-Bettelheim E, Skibsted L, Hinterberger S, Strobl I, Bowman ME, Smith R, Tabor A, Rode L. Plasma progesterone, estradiol, and unconjugated estriol concentrations in twin pregnancies: Relation with cervical length and preterm delivery. Acta Obstet Gynecol Scand 2018; 98:86-94. [PMID: 30218572 DOI: 10.1111/aogs.13464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 09/09/2018] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The aim of this study was to examine the association between plasma hormone concentrations, cervical length, and preterm delivery in twin pregnancies, including the effect of progesterone treatment. MATERIAL AND METHODS This study included 191 women pregnant with twins from a randomized placebo-controlled trial. A baseline blood sample was collected at 18-24 weeks before treatment with vaginal progesterone (n = 95) or placebo pessaries (n = 96), and 167 (87.4%) women had a second sample collected after 4-8 weeks of treatment. At baseline, 155 (81.2%) women had their cervical length measured. Progesterone, estradiol, and unconjugated estriol concentration was measured, and the association between hormone concentrations, cervical length, and gestational age at delivery was examined. Hormone concentrations were compared in the placebo and progesterone group. Statistical analysis included Spearman's rho, Mann-Whitney U test, Cuzick's test for trends, and linear regression analyses. RESULTS A short cervical length was associated with preterm delivery. Cervical length and hormone concentrations were not associated (Spearman's rho; progesterone -.05, estradiol .04, estriol .08). Decreasing gestational age at delivery was associated with higher progesterone and estradiol concentrations at baseline (P trend; progesterone 0.04, estradiol 0.02) but not in the second sample or in the weekly change between samples. Progesterone treatment did not increase the progesterone concentration. CONCLUSIONS Plasma concentrations of progesterone, estradiol, and unconjugated estriol at 18-24 weeks are not associated with cervical length or preterm delivery in twin pregnancies. Vaginal progesterone treatment does not increase the circulating progesterone concentration in twin pregnancies. Cervical length, but not hormone concentration, is predictive of preterm delivery in twin gestations.
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Affiliation(s)
- Vilma L Johnsson
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, , Copenhagen, Denmark
| | - Nina G Pedersen
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, , Copenhagen, Denmark
| | - Katharina Worda
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | | | - Lillian Skibsted
- Department of Obstetrics and Gynecology, University Hospital Roskilde, Roskilde, Denmark.,Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Stefan Hinterberger
- Department of Obstetrics and Gynecology, General Hospital of Klagenfurt, Klagenfurt, Austria
| | - Isolde Strobl
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Maria E Bowman
- Mothers and Babies Research Center/Hunter Medical Research Institute, John Hunter Hospital, Faculty of Health/School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Roger Smith
- Mothers and Babies Research Center/Hunter Medical Research Institute, John Hunter Hospital, Faculty of Health/School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Ann Tabor
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, , Copenhagen, Denmark.,Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Line Rode
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, , Copenhagen, Denmark.,Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
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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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10
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Shaw JC, Palliser HK, Palazzi K, Hirst JJ. Administration of Progesterone Throughout Pregnancy Increases Maternal Steroids Without Adverse Effect on Mature Oligodendrocyte Immunostaining in the Guinea Pig. Reprod Sci 2017. [PMID: 28631553 DOI: 10.1177/1933719117715125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Progesterone is administered to pregnant women at risk of premature labor, despite systematic reviews showing conflicting outcomes regarding its use, highlighting doubt over the effectiveness of the therapy. Progesterone can be rapidly metabolized into a number of steroids, but to date, there has been a lack of investigation into the fetal steroid profiles following administration and whether this impacts fetal neurodevelopment. The objective of this study was to determine the effect of progesterone treatment on allopregnanolone and cortisol levels in the fetus and on a marker of myelination in the fetal brain. We used a guinea pig model where pregnant dams were administered vehicle (β-cyclodextrin) or progesterone orally throughout pregnancy (GA29-61). Maternal and fetal fluids and tissues were collected at both preterm (GA61) and term (GA68) ages. Maternal and fetal progesterone and cortisol were analyzed by enzyme immunoassay and allopregnanolone by radioimmunoassay. Measurement of myelination of fetal brains (hippocampus, cingulum, and subcortical white matter) at preterm and term ages was performed by immunohistochemistry staining for myelin basic protein. We found that dams receiving progesterone had significantly elevated progesterone and cortisol concentrations, but there was no effect on allopregnanolone. Interestingly, the increased cortisol concentrations were not reflected in the fetuses, and there was no effect of progesterone treatment on myelination. Therefore, we conclude that in our guinea pig model, maternal administration of progesterone has no effect on cortisol levels or markers of mature oligodendrocytes in the fetus and suggest this is potentially due to the protective cortisol barrier in the placenta.
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Affiliation(s)
- Julia C Shaw
- 1 School of Biomedical Sciences and Pharmacy, University of Newcastle, New South Wales, Australia.,2 Mothers and Babies Research Centre, Hunter Medical Research Institute, New South Wales, Australia
| | - Hannah K Palliser
- 1 School of Biomedical Sciences and Pharmacy, University of Newcastle, New South Wales, Australia.,2 Mothers and Babies Research Centre, Hunter Medical Research Institute, New South Wales, Australia
| | - Kerrin Palazzi
- 3 Clinical Research Design, Information Technology and Statistical Support, Hunter Medical Research Institute, New South Wales, Australia
| | - Jonathan J Hirst
- 1 School of Biomedical Sciences and Pharmacy, University of Newcastle, New South Wales, Australia.,2 Mothers and Babies Research Centre, Hunter Medical Research Institute, New South Wales, Australia
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11
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Dodd JM, Grivell RM, OBrien CM, Deussen AR. Prenatal administration of progestogens for preventing spontaneous preterm birth in women with a singleton pregnancy. Hippokratia 2017. [DOI: 10.1002/14651858.cd012531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Jodie M Dodd
- The University of Adelaide, Women's and Children's Hospital; School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology; 72 King William Road Adelaide South Australia Australia 5006
| | - Rosalie M Grivell
- Flinders University and Flinders Medical Centre; Department of Obstetrics and Gynaecology; Bedford Park South Australia Australia SA 5042
| | - Cecelia M OBrien
- Robinson Research Institute, The University of Adelaide; Women's and Babies Division, Discipline of Obstetrics and Gynaecology; Brougham Place North Adelaide SA Australia 5006
| | - Andrea R Deussen
- The University of Adelaide, Women's and Children's Hospital; School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology; 72 King William Road Adelaide South Australia Australia 5006
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12
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Ahn KH, Bae NY, Hong SC, Lee JS, Lee EH, Jee HJ, Cho GJ, Oh MJ, Kim HJ. The safety of progestogen in the prevention of preterm birth: meta-analysis of neonatal mortality. J Perinat Med 2017; 45:11-20. [PMID: 27124668 DOI: 10.1515/jpm-2015-0317] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 03/16/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND The safety of preventive progestogen therapy for preterm birth remains to be established. This meta-analysis aimed to evaluate the effects of preventive progestogen therapy on neonatal mortality. METHODS Randomized controlled trials (RCTs) on the preventive use of progestogen therapy, published between October 1971 and November 2015, were identified by searching MEDLINE/PubMed, EMBASE, Scopus, ClinicalTrials.gov, Cochrane Library databases, CINAHL, POPLINE, and LILACS using "progesterone" and "preterm birth" as key terms. We conducted separate analyses according to the type of progestogen administered and plurality of the pregnancy. RESULTS Twenty-two RCTs provided data on 11,188 neonates. Preventive progestogen treatment in women with a history of preterm birth or short cervical length was not associated with increased risk of neonatal death compared to placebo in all analyzed progestogen types and pregnancy conditions. The pooled relative risks (95% confidence interval) of neonatal mortality were 0.69 (0.31-1.54) for vaginal progestogen in singleton pregnancies, 0.6 (0.33-1.09) for intramuscular progestogen in singleton pregnancies, 0.96 (0.51-1.8) for vaginal progestogen in multiple pregnancies, and 0.96 (0.49-1.9) for intramuscular progestogen in multiple pregnancies. CONCLUSIONS The results of this meta-analysis suggest that administration of preventive progestogen treatment to women at risk for preterm birth does not appear to negatively affect neonatal mortality in single or multiple pregnancies regardless of the route of administration.
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13
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Caritis SN, Feghali MN, Grobman WA, Rouse DJ. What we have learned about the role of 17-alpha-hydroxyprogesterone caproate in the prevention of preterm birth. Semin Perinatol 2016; 40:273-80. [PMID: 27105940 PMCID: PMC4983195 DOI: 10.1053/j.semperi.2016.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Despite major advances in neonatal care, the burden of preterm birth remains high. This is not unexpected since strategies to identify and treat risk factors in early pregnancy have not been very effective in reducing the preterm birth rate. Initial studies suggested a potential benefit for 17-alpha-hydroxyprogesterone caproate (17-OHPC) in decreasing the risk of recurrent preterm birth women with a singleton gestation. However, the use of 17-OHPC has not conferred benefit for other categories of women at high risk for preterm delivery (twins, triplets, and short cervical length). The increasing body of evidence suggests that preterm birth is a complex condition with variable mechanisms of disease and significant individual heterogeneity. This review will examine the plausibility of 17-OHPC in preventing preterm birth and the investigation of its clinical efficacy. We will also highlight factors to explain variations in clinical trial outcomes and outline the trajectory needed for future investigations.
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Affiliation(s)
- Steve N Caritis
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Maisa N Feghali
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - William A Grobman
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Dwight J Rouse
- Department of Obstetrics and Gynecology, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI
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14
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Di Tommaso M, Seravalli V, Arduino S, Bossotti C, Sisti G, Todros T. Arabin cervical pessary to prevent preterm birth in twin pregnancies with short cervix. J OBSTET GYNAECOL 2016; 36:715-718. [PMID: 27013088 DOI: 10.3109/01443615.2016.1148127] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A retrospective study was conducted to evaluate the effect of Arabin cervical pessary in twin pregnancies with cervical length (CL) <25 mm between 21 and 31 weeks. Forty patients receiving pessary were matched with 40 controls without pessary. They were matched for gestational age (GA) at admission and CL. GA at delivery, delivery before 36, 34 and 32 weeks, latency between detection of short cervix and delivery, and duration of hospital admission were compared between groups. Women with the pessary delivered at higher GA compared to controls (35 vs. 33 weeks, p = 0.02). Cervical pessary significantly reduced the incidence of delivery <36 and < 34 weeks (p < 0.05), but not before 32 weeks. Interval between detection of short cervix and delivery was longer in the pessary group and duration of hospital admission was shorter (p = 0.03) compared to women without pessary.
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Affiliation(s)
- Mariarosaria Di Tommaso
- a Department of Health Sciences , University of Florence. AOU Careggi , Florence , Italy , and
| | - Viola Seravalli
- a Department of Health Sciences , University of Florence. AOU Careggi , Florence , Italy , and
| | - Silvana Arduino
- b Department of Obstetrics and Gynecology , 2nd U. University of Turin, AO Town of Health and Science , Turin , Italy
| | - Carlotta Bossotti
- b Department of Obstetrics and Gynecology , 2nd U. University of Turin, AO Town of Health and Science , Turin , Italy
| | - Giovanni Sisti
- a Department of Health Sciences , University of Florence. AOU Careggi , Florence , Italy , and
| | - Tullia Todros
- b Department of Obstetrics and Gynecology , 2nd U. University of Turin, AO Town of Health and Science , Turin , Italy
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15
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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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16
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Combs CA, Schuit E, Caritis SN, Lim AC, Garite TJ, Maurel K, Rouse D, Thom E, Tita AT, Mol B. 17-Hydroxyprogesterone caproate in triplet pregnancy: an individual patient data meta-analysis. BJOG 2015; 123:682-90. [PMID: 26663620 DOI: 10.1111/1471-0528.13779] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Preterm birth complicates almost all triplet pregnancies and no preventive strategy has proven effective. OBJECTIVE To determine, using individual patient data (IPD) meta-analysis, whether the outcome of triplet pregnancy is affected by prophylactic administration of 17-hydroxyprogesterone caproate (17OHPc). SEARCH STRATEGY We searched literature databases, trial registries and references in published articles. SELECTION CRITERIA Randomised controlled trials (RCTs) of progestogens versus control that included women with triplet pregnancies. DATA COLLECTION AND ANALYSIS Investigators from identified RCTs collaborated on the protocol and contributed their IPD. The primary outcome was a composite measure of adverse perinatal outcome. The secondary outcome was the rate of birth before 32 weeks of gestation. Other pre-specified outcomes included randomisation-to-delivery interval and rates of birth at <24, <28 and <34 weeks of gestation. MAIN RESULTS Three RCTs of 17OHPc versus placebo included 232 mothers with triplet pregnancies and their 696 offspring. Risk-of-bias scores and between-study heterogeneity were low. Baseline characteristics were comparable between 17OHPc and placebo groups. The rate of the composite adverse perinatal outcome was similar among those treated with 17OHPc and those treated with placebo (34 and 35%, respectively; risk ratio [RR] 0.98, 95% confidence interval [95% CI] 0.79-1.2). The rate of birth at <32 weeks was also similar in the two groups (35 and 38%, respectively; RR 0.92, 95% CI 0.55-1.56). There were no significant between-group differences in perinatal mortality rate, randomisation-to-delivery interval, or other specified outcomes. CONCLUSION Prophylactic 17OHPc given to mothers with triplet pregnancies had no significant impact on perinatal outcome or pregnancy duration. TWEETABLE ABSTRACT 17-Hydroxyprogesterone caproate had no significant impact on the outcome or duration of triplet pregnancy.
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Affiliation(s)
- C A Combs
- Obstetrix Collaborative Research Network, the Center for Research, Education, and Quality, Mednax National Medical Group, Sunrise, FL, USA
| | - E Schuit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands.,Stanford Prevention Research Center, Stanford University, Stanford, CA, USA
| | - S N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA, USA
| | - A C Lim
- Department of Obstetrics and Gynaecology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - T J Garite
- Obstetrix Collaborative Research Network, the Center for Research, Education, and Quality, Mednax National Medical Group, Sunrise, FL, USA.,Department of Obstetrics and Gynecology, University of California Irvine, Irvine, CA, USA
| | - K Maurel
- Obstetrix Collaborative Research Network, the Center for Research, Education, and Quality, Mednax National Medical Group, Sunrise, FL, USA
| | - D Rouse
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Maternal-Fetal Medicine Units Network (MFMU), Bethesda, MD, USA.,Department of Obstetrics and Gynecology, Alpert Medical School, Women & Infants Hospital, Brown University, Providence, RI, USA.,Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA
| | - E Thom
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Maternal-Fetal Medicine Units Network (MFMU), Bethesda, MD, USA.,The Biostatistics Center, George Washington University, Washington, DC, USA
| | - A T Tita
- Department of Obstetrics and Gynecology, Alpert Medical School, Women & Infants Hospital, Brown University, Providence, RI, USA.,Department of Obstetrics and Gynecology and Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bwj Mol
- Department of Obstetrics and Gynaecology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands.,The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, and The South Australian Health and Medical Research Institute, Adelaide, SA, Australia
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17
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Abstract
Steroid hormones have been in use for more than a half a century as contraceptive agents, and only now are researchers elucidating the biochemical mechanisms of action and non-target effects. Progesterone and synthetic progestins, critical for women's health in the US and internationally, appear to have important effects on immune functioning and other diverse systems. Apart from the contraceptive world is a separate field that is devoted to understanding progesterone in other contexts. Based on research following a development timeline parallel to hormonal contraception, progesterone and 17-hydroxyprogesterone caproate are now administered to prevent preterm birth in high-risk pregnant women. Preterm birth researchers are similarly working to determine the precise biochemical actions and immunological effects of progesterone. Progesterone research in both areas could benefit from increased collaboration and bringing these two bodies of literature together. Progesterone, through actions on various hormone receptors, has lifelong importance in different organ systems and researchers have much to learn about this molecule from the combination of existing literatures, and from future studies that build on this combined knowledge base.
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Affiliation(s)
- Elizabeth Micks
- Department of Obstetrics and GynecologyUniversity of Washington, Box 356460, 1959 NE Pacific Street, Seattle, Washington, USADepartment of ResearchAmerican College of Obstetricians and Gynecologists, 409 12th Street SW, Washington, District of Columbia, USA
| | - Greta B Raglan
- Department of Obstetrics and GynecologyUniversity of Washington, Box 356460, 1959 NE Pacific Street, Seattle, Washington, USADepartment of ResearchAmerican College of Obstetricians and Gynecologists, 409 12th Street SW, Washington, District of Columbia, USA
| | - Jay Schulkin
- Department of Obstetrics and GynecologyUniversity of Washington, Box 356460, 1959 NE Pacific Street, Seattle, Washington, USADepartment of ResearchAmerican College of Obstetricians and Gynecologists, 409 12th Street SW, Washington, District of Columbia, USA Department of Obstetrics and GynecologyUniversity of Washington, Box 356460, 1959 NE Pacific Street, Seattle, Washington, USADepartment of ResearchAmerican College of Obstetricians and Gynecologists, 409 12th Street SW, Washington, District of Columbia, USA
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18
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O'Brien JM. Progestogen safety in multiple gestations: application of the Bradford Hill criteria. BJOG 2015; 122:610-4. [DOI: 10.1111/1471-0528.13277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2014] [Indexed: 11/29/2022]
Affiliation(s)
- JM O'Brien
- Division of Maternal Fetal Medicine; Department of Obstetrics and Gynecology; University of Kentucky; Lexington KY USA
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19
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Abstract
Pregnancy is associated with a variety of physiological changes that can alter the pharmacokinetics and pharmacodynamics of several drugs. However, limited data exists on the pharmacokinetics and pharmacodynamics of the majority of the medications used in pregnancy. In this article, we first describe basic concepts (drug absorption, bioavailability, distribution, metabolism, elimination, and transport) in pharmacokinetics. Then, we discuss several physiological changes that occur during pregnancy that theoretically affect absorption, distribution, metabolism, and elimination. Further, we provide a brief review of the literature on the clinical pharmacokinetic studies performed in pregnant women in recent years. In general, pregnancy increases the clearance of several drugs and correspondingly decreases drug exposure during pregnancy. Based on current drug exposure measurements during pregnancy, alterations in the dose or dosing regimen of certain drugs are essential during pregnancy. More pharmacological studies in pregnant women are needed to optimize drug therapy in pregnancy.
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Affiliation(s)
- Yang Zhao
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, 718 Salk Hall, 3501 Terrace St, Pittsburgh, PA 15261
| | - Mary F. Hebert
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA,Department of Obstetrics and Gynecology, School of Medicine University of Washington, Seattle, WA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, 718 Salk Hall, 3501 Terrace St, Pittsburgh, PA 15261; Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA; Thomas Starzl Transplantation Institute, Pittsburgh, PA; McGovern Institute for Regenerative Medicine, Pittsburgh, PA; Magee Womens Research Institute, Pittsburgh, PA.
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20
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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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21
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Awwad J, Usta IM, Ghazeeri G, Yacoub N, Succar J, Hayek S, Saasouh W, Nassar AH. A randomised controlled double-blind clinical trial of 17-hydroxyprogesterone caproate for the prevention of preterm birth in twin gestation (PROGESTWIN): evidence for reduced neonatal morbidity. BJOG 2014; 122:71-9. [PMID: 25163819 DOI: 10.1111/1471-0528.13031] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine whether 17 alpha-hydroxyprogesterone caproate (17OHPC) prolongs gestation beyond 37 weeks of gestation (primary outcome) and reduces neonatal morbidity (secondary outcome) in twin pregnancy. DESIGN Randomised controlled double-blind clinical trial. SETTING Tertiary-care university medical centre. POPULATION Unselected women with twin pregnancies. METHODS Participants received weekly injections of 250 mg 17OHPC (n = 194) or placebo (n = 94), from 16-20 to 36 weeks of gestation. Randomisation was performed using the permuted-block randomisation method. Data were analysed on an intention-to-treat basis. MAIN OUTCOME MEASURE Preterm birth (PTB) rate before 37 weeks of gestation. RESULTS There were no significant differences in the average gestational age at delivery, or in the rates of PTB before 37, 32, and 28 weeks of gestation, between the two groups. The proportion of very-low-birthweight neonates (<1500 g) was significantly lower in the 17OHPC group (7.6%) compared with placebo (14.3%) (relative risk, RR 0.5; 95% confidence interval, 95% CI 0.3-0.9; P = 0.01). Progestogen-treated neonates had a significantly lower composite neonatal morbidity (19.1%) compared with placebo (30.9%) (odds ratio, OR 0.53; 95% CI 0.31-0.90; P = 0.02), with significantly lower odds for respiratory distress syndrome (14.4 versus 23.4%; OR 0.55; 95% CI 0.31-0.98; P = 0.04), retinopathy of prematurity (1.1 versus 4.6%; OR 0.21; 95% CI 0.05-0.96; P = 0.04), and culture-confirmed sepsis (3.4 versus 12.8%; OR 0.24; 95% CI 0.10-0.57; P = 0.00). CONCLUSIONS Intramuscular 17OHPC therapy did not reduce PTB before 37 weeks of gestation in unselected twin pregnancies. Nonetheless, 17OHPC significantly reduced neonatal morbidity parameters and increased birthweight.
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Affiliation(s)
- J Awwad
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
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Schuit E, Stock S, Rode L, Rouse DJ, Lim AC, Norman JE, Nassar AH, Serra V, Combs CA, Vayssiere C, Aboulghar MM, Wood S, Çetingöz E, Briery CM, Fonseca EB, Worda K, Tabor A, Thom EA, Caritis SN, Awwad J, Usta IM, Perales A, Meseguer J, Maurel K, Garite T, Aboulghar MA, Amin YM, Ross S, Cam C, Karateke A, Morrison JC, Magann EF, Nicolaides KH, Zuithoff NPA, Groenwold RHH, Moons KGM, Kwee A, Mol BWJ. Effectiveness of progestogens to improve perinatal outcome in twin pregnancies: an individual participant data meta-analysis. BJOG 2014; 122:27-37. [PMID: 25145491 DOI: 10.1111/1471-0528.13032] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND In twin pregnancies, the rates of adverse perinatal outcome and subsequent long-term morbidity are substantial, and mainly result from preterm birth (PTB). OBJECTIVES To assess the effectiveness of progestogen treatment in the prevention of neonatal morbidity or PTB in twin pregnancies using individual participant data meta-analysis (IPDMA). SEARCH STRATEGY We searched international scientific databases, trial registration websites, and references of identified articles. SELECTION CRITERIA Randomised clinical trials (RCTs) of 17-hydroxyprogesterone caproate (17Pc) or vaginally administered natural progesterone, compared with placebo or no treatment. DATA COLLECTION AND ANALYSIS Investigators of identified RCTs were asked to share their IPD. The primary outcome was a composite of perinatal mortality and severe neonatal morbidity. Prespecified subgroup analyses were performed for chorionicity, cervical length, and prior spontaneous PTB. MAIN RESULTS Thirteen trials included 3768 women and their 7536 babies. Neither 17Pc nor vaginal progesterone reduced the incidence of adverse perinatal outcome (17Pc relative risk, RR 1.1; 95% confidence interval, 95% CI 0.97-1.4, vaginal progesterone RR 0.97; 95% CI 0.77-1.2). In a subgroup of women with a cervical length of ≤25 mm, vaginal progesterone reduced adverse perinatal outcome when cervical length was measured at randomisation (15/56 versus 22/60; RR 0.57; 95% CI 0.47-0.70) or before 24 weeks of gestation (14/52 versus 21/56; RR 0.56; 95% CI 0.42-0.75). AUTHOR'S CONCLUSIONS In unselected women with an uncomplicated twin gestation, treatment with progestogens (intramuscular 17Pc or vaginal natural progesterone) does not improve perinatal outcome. Vaginal progesterone may be effective in the reduction of adverse perinatal outcome in women with a cervical length of ≤25 mm; however, further research is warranted to confirm this finding.
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Affiliation(s)
- E Schuit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Obstetrics and Gynaecology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
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Caritis SN, Venkataramanan R, Thom E, Harper M, Klebanoff MA, Sorokin Y, Thorp JM, Varner MW, Wapner RJ, Iams JD, Carpenter MW, Grobman WA, Mercer BM, Sciscione A, Rouse DJ, Ramin S. Relationship between 17-alpha hydroxyprogesterone caproate concentration and spontaneous preterm birth. Am J Obstet Gynecol 2014; 210:128.e1-6. [PMID: 24113254 PMCID: PMC3926421 DOI: 10.1016/j.ajog.2013.10.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 09/10/2013] [Accepted: 10/04/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE 17-alpha hydroxyprogesterone caproate 250 mg weekly reduces recurrent spontaneous preterm birth in women with a prior spontaneous preterm birth by 33%. The dose is not based on pharmacologic considerations. A therapeutic concentration has not been determined hampering any attempt to optimize treatment. This study evaluated the relationship between 17-alpha hydroxyprogesterone caproate plasma concentrations and the rate of spontaneous preterm birth in women with singleton gestation. STUDY DESIGN A single blood sample was obtained between 25 and 28 weeks' gestation from 315 women with a spontaneous preterm birth who participated in a placebo-controlled, prospective, randomized clinical trial evaluating the benefit of omega-3 supplementation in reducing preterm birth. All women in the parent study received 17-alpha hydroxyprogesterone caproate and 434 received omega-3 supplementation and 418 received a placebo. Plasma from 315 consenting women was analyzed for 17-alpha hydroxyprogesterone caproate concentration. RESULTS There were no differences between placebo and omega-3 supplemented groups in demographic variables, outcomes or in mean 17-alpha hydroxyprogesterone caproate concentration. Plasma concentrations of 17-alpha hydroxyprogesterone caproate ranged from 3.7-56 ng/mL. Women with plasma concentrations of 17-alpha hydroxyprogesterone caproate in the lowest quartile had a significantly higher risk of spontaneous preterm birth (P = .03) and delivered at significantly earlier gestational ages (P = .002) than did women in the second to fourth quartiles. The lowest preterm birth rates were seen when median 17-alpha hydroxyprogesterone caproate concentrations exceeded 6.4 ng/mL. CONCLUSION Low plasma 17-alpha hydroxyprogesterone caproate concentration is associated with an increased risk of spontaneous preterm birth. This finding validates efficacy of this treatment but suggests that additional studies are needed to determine the optimal dosage.
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Affiliation(s)
- Steve N Caritis
- Department of Obstetrics and Gynecology and Reproductive Sciences and Pharmaceutical Sciences, University of Pittsburgh Schools of Medicine and Pharmacy, Pittsburgh, PA
| | - Raman Venkataramanan
- Department of Obstetrics and Gynecology and Reproductive Sciences and Pharmaceutical Sciences, University of Pittsburgh Schools of Medicine and Pharmacy, Pittsburgh, PA
| | - Elizabeth Thom
- The George Washington University Biostatistics Center, Washington, DC
| | - Margaret Harper
- Department of Obstetrics and Gynecology, Wake Forest University Health Sciences, Winston-Salem, and University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mark A Klebanoff
- Maternal-Fetal Medicine Units, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI
| | - John M Thorp
- Department of Obstetrics and Gynecology, Wake Forest University Health Sciences, Winston-Salem, and University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jay D Iams
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH
| | - Marshall W Carpenter
- Department of Obstetrics and Gynecology, Women and Infants Hospital, Alpert Medical School, Brown University, Providence, RI
| | - William A Grobman
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH
| | | | - Dwight J Rouse
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Susan Ramin
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Houston, TX
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24
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Rode L, Tabor A. Prevention of preterm delivery in twin pregnancy. Best Pract Res Clin Obstet Gynaecol 2013; 28:273-83. [PMID: 24378186 DOI: 10.1016/j.bpobgyn.2013.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 11/24/2013] [Indexed: 10/25/2022]
Abstract
The incidence of twin gestation has increased markedly over the past decades, mostly because of increased use of assisted reproductive technologies. Twin pregnancies are at increased risk of preterm delivery (i.e. birth before 37 weeks of gestation). Multiple gestations therefore account for 2-3% of all pregnancies but constitute at least 10% of cases of preterm delivery. Complications from preterm birth are not limited to the neonatal period, such as in retinopathy of prematurity, intraventricular haemorrhage, necrotising enterocolitis, respiratory disorder and sepsis; they can also constitute sequelae such as abnormal neurophysiological development in early childhood and underachievement in school. Several treatment modalities have been proposed in singleton high-risk pregnancies. The mechanism of initiating labour may, however, be different in singleton and twin gestations. Therefore, it is mandatory to evaluate the proposed treatments in randomised trials of multiple gestations. In this chapter, we describe the results of trials to prevent preterm delivery in twin pregnancies.
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Affiliation(s)
- Line Rode
- Center of Fetal Medicine, Department of Obstetrics, Copenhagen University Hospital, 2100 Rigshospitalet, Denmark
| | - Ann Tabor
- Center of Fetal Medicine, Department of Obstetrics, Copenhagen University Hospital, 2100 Rigshospitalet, Denmark.
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Arabin B, Alfirevic Z. Cervical pessaries for prevention of spontaneous preterm birth: past, present and future. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:390-9. [PMID: 23775862 PMCID: PMC4282542 DOI: 10.1002/uog.12540] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 05/26/2013] [Accepted: 06/07/2013] [Indexed: 05/15/2023]
Abstract
This Review describes the rationale for the use of cervical pessaries to prevent spontaneous preterm birth and their gradual introduction into clinical practice, discusses technical aspects of the more commonly used designs and provides guidance for their use and future evaluation. Possible advantages of cervical pessaries include the easy, 'one-off' application, good side-effect profile, good patient tolerance and relatively low cost compared with current alternatives. Use of transvaginal sonography to assess cervical length in the second trimester allows much better selection of patients who may benefit from the use of a cervical pessary, but future clinical trials are needed to establish clearly the role of pessaries as a preterm birth prevention strategy worldwide.
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Affiliation(s)
- B Arabin
- Centre for Mother and Child of the Philipps University Marburg, Marburg, Germany; Clara Angela Foundation, Witten, Germany
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26
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Mortality related to 17-OHPC exposure is an important safety outcome. Am J Obstet Gynecol 2013; 209:282-3. [PMID: 23628265 DOI: 10.1016/j.ajog.2013.04.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 04/24/2013] [Indexed: 11/20/2022]
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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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Caritis SN, Zhao Y, Bettinger J, Venkataramanan R. Qualitative and quantitative measures of various compounded formulations of 17-alpha hydroxyprogesterone caproate. Am J Obstet Gynecol 2013; 208:470.e1-5. [PMID: 23453884 DOI: 10.1016/j.ajog.2013.02.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 01/23/2013] [Accepted: 02/18/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE 17-alpha hydroxyprogesterone caproate (17-OHPC) is available both as an Food and Drug Administration (FDA)-approved medication and as a product prepared for individual patients by compounding pharmacies. Compounding pharmacies may omit the preservative that is used in the FDA-approved formulation or use an alternate preservative and may dispense 17-OHPC in containers that differ from the FDA-approved product. The objective of this study was to assess the stability and the microbiologic and pyrogen status of 17-OHPC formulations under various compounding and dispensing conditions. STUDY DESIGN 17-OHPC was prepared by a local compounding pharmacy. The formulations that were prepared included 1 identical to the FDA-approved product with benzyl alcohol as a preservative, 1 with benzalkonium chloride as a preservative, and 1 without a preservative. These various formulations were dispensed into either single-dose 1-mL plastic syringes or glass vials or 10-mL glass vials. The concentration of 17-OHPC and microbial and pyrogen status were evaluated at various time intervals over the ensuing 19 weeks. RESULTS The concentration of 17-OHPC did not change over the duration of study, regardless of the dispensing medium that was used or the absence or presence of any preservatives. The preparations remained microbe- and pyrogen-free during the study period, regardless of the dispensing medium that was used or the absence of presence of any preservatives. CONCLUSION Products that contained 17-OHPC tested in this study were quite stable over the 19-week period of study in different dispensing containers and in the absence or presence of a different preservative. The compounded products remained sterile and pyrogen-free during the period of observation.
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Affiliation(s)
- Steve N Caritis
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Usta I, Usta J, Nassar A. 17-hydroxy progesterone caproate for preterm labor prevention: final blood levels. Am J Obstet Gynecol 2013; 208:337. [PMID: 23295976 DOI: 10.1016/j.ajog.2012.12.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 12/27/2012] [Indexed: 11/25/2022]
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Caritis SN. Reply: To PMID 23295976. Am J Obstet Gynecol 2013; 208:337-8. [PMID: 23295980 DOI: 10.1016/j.ajog.2012.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 12/27/2012] [Indexed: 10/27/2022]
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Durnwald CP. 17 OHPC for prevention of preterm birth in twins: back to the drawing board? Am J Obstet Gynecol 2013; 208:167-8. [PMID: 23433323 DOI: 10.1016/j.ajog.2013.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 01/15/2013] [Indexed: 11/30/2022]
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Senat MV, Porcher R, Winer N, Vayssière C, Deruelle P, Capelle M, Bretelle F, Perrotin F, Laurent Y, Connan L, Langer B, Mantel A, Azimi S, Rozenberg P. Prevention of preterm delivery by 17 alpha-hydroxyprogesterone caproate in asymptomatic twin pregnancies with a short cervix: a randomized controlled trial. Am J Obstet Gynecol 2013; 208:194.e1-8. [PMID: 23433324 DOI: 10.1016/j.ajog.2013.01.032] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 12/05/2012] [Accepted: 01/15/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate the use of 17 alpha-hydroxyprogesterone caproate (17P) to reduce preterm delivery in women with a twin pregnancy and short cervix. STUDY DESIGN This open-label, multicenter, randomized controlled trial included women with a twin pregnancy between 24(+0) and 31(+6) weeks of gestation who were asymptomatic and had a cervical length of 25 mm or less measured by routine transvaginal ultrasound. Women were randomized to receive (or not) 500 mg of intramuscular 17P, repeated twice weekly until 36 weeks or preterm delivery. The primary outcome was time from randomization to delivery. Analysis was performed according to the intent-to-treat principle. RESULTS The 17P and control groups did not differ significantly for median [interquartile range] time to delivery: 45 (26-62) and 51 (36-66) days, respectively. However, treatment with 17P was associated with a significant increase in the rate of preterm delivery before 32 weeks. CONCLUSION Twice-weekly injections of 17P did not prolong pregnancy significantly in asymptomatic women with a twin pregnancy and short cervix.
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Affiliation(s)
- Marie-Victoire Senat
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Paris, Hopital Bicêtre, Hopital Antoine Béclère, Université Paris Sud, Faculté de Medecine, Paris, France.
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Vidaeff AC, Belfort MA. Critical appraisal of the efficacy, safety, and patient acceptability of hydroxyprogesterone caproate injection to reduce the risk of preterm birth. Patient Prefer Adherence 2013; 7:683-91. [PMID: 23874089 PMCID: PMC3714001 DOI: 10.2147/ppa.s35612] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Prevention of preterm delivery is a major desiderate in contemporary obstetrics and a societal necessity. The means to achieve this goal remain elusive. Progesterone has been used in an attempt to prevent preterm delivery since the 1970s, but the evidence initially accumulated was fraught by mixed results and was based on mostly underpowered studies with variable eligibility criteria, including history of spontaneous abortion as an indication for treatment. More recent randomized controlled clinical trials restimulated the interest in progesterone supplementation, suggesting that progesterone may favorably influence the rate of preterm delivery. Preterm delivery is a complex disorder and consequently it is unlikely that one generalized prevention strategy will be effective in all patients. Further, an additional impediment in accepting progesterone as the "magic bullet" in the prevention of preterm delivery is that its mechanism of action is not fully understood and the optimal formulations, route of administration, and dose have yet to be established. We have concerned ourselves in this review with the most recent status of 17 alpha-hydroxyprogesterone caproate (17OH-PC) supplementation for prevention of preterm delivery. Our intention is to emphasize the efficacy, safety, and patient acceptability of this intervention, based on a comprehensive and unbiased review of the available literature. Currently there are insufficient data to suggest that 17OH-PC is superior or inferior to natural progesterone. Based on available evidence, we suggest a differential approach giving preferential consideration to either 17OH-PC or other progestins based on obstetric history and cervical surveillance. Progestin therapy for risk factors other than a history of preterm birth and/or a short cervix in the current pregnancy is not currently supported by the published evidence. The experience to date with 17OH-PC indicates that there are population subgroups that may be harmed by administration of 17OH-PC. Therefore, extending the use of 17OH-PC to unstudied populations or for indications that are not evidence-based is inadvisable outside of a research protocol.
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Affiliation(s)
- Alex C Vidaeff
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, USA
- Correspondence: Alex C Vidaeff Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children’s Hospital, 6651 Main Street, Suite F1020, Houston, TX 77030, USA, Tel +1 83 2826 3737, Fax +1 83 2825 9351, Email
| | - Michael A Belfort
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, USA
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