Vaginal progesterone after tocolytic therapy in threatened preterm labor

Adjuvant Treatment with Oral Dydrogesterone in the Prevention of Preterm Labor: A Randomized, Double-Blinded, Placebo-Controlled Trial

We conducted a double-blind, randomized, placebo-controlled clinical trial to evaluate the efficacy of oral dydrogesterone (DG) on maternal and neonatal consequences in the treatment of preterm labor. We included 100 nulliparous mothers (24-34 weeks) with normal pregnancy who had preterm labor pain. Participants who received magnesium sulfate were randomly assigned to the investigation group (DG 30 mg/day) or placebo group. Maternal and neonatal outcomes were compared between the two groups. Recurrent uterine contraction (UC) rates (92% vs. 88%, P = 0.862) and the incidence of preterm delivery (66% vs. 58%, P = 0.834) were not different in the DG and placebo groups. No significant differences were observed in terms of gestational age at delivery (33.5 ± 3.5 vs. 34.2 ± 3.2, P = 0.281), latency period (5.53 ± 2.29 days vs. 5.59 ± 2.57 days, P = 0.622), cervical dilation (1.82 ± 0.26 cm vs. 1.84 ± 0.29 cm, P = 0.281), and effacement (53 ± 4.47% vs. 57.21 ± 6.27%, P = 0.622) between the placebo and DG groups. The percentage of neonates with a 1-min Apgar score < 7 was higher in the placebo group compared with that of the DG group (12% vs. 0%, P = 0.0001). However, both groups were similar in the frequency of a 5-min Apgar score < 7. No differences in the term of adverse effects of medications were recorded. Our results showed that DG adjuvant to magnesium sulfate could not be effective in improving the incidence of preterm labor, rate of recurrent UC, latency period, pregnancy outcomes, and maternal and neonatal outcomes when compared with the placebo group.

Progestogens for maintenance tocolysis in symptomatic women. A systematic review and meta-analysis

OBJECTIVE

Prevention of preterm birth (PTB) with progestogens after an episode of threatened preterm labour is still controversial. As different progestogens have distinct molecular structures and biological effects, we conducted a systematic review and pairwise meta-analysis to investigate the individual role played by 17-alpha-hydroxyprogesterone caproate (17-HP), vaginal progesterone (Vaginal P) and oral progesterone (Oral P).

METHODS

The search was performed in MEDLINE, ClinicalTrials.gov and the Cochrane Central Register of Controlled Trials (CENTRAL) up to 31 October 2021. Published RCTs comparing progestogens to placebo or no treatment for maintenance tocolysis were considered. We included women with singleton gestations, excluding quasi-randomized trials, studies on women with preterm premature rupture of membrane, or receiving maintenance tocolysis with other drugs. Primary outcomes were preterm birth (PTB) < 37 weeks' and < 34 weeks'. We assessed risk of bias and evaluated certainty of evidence with the GRADE approach.

RESULTS

Seventeen RCTs including 2152 women with singleton gestations were included. Twelve studies tested vaginal P, five 17-HP, and only 1 oral P. PTB < 34 weeks' did not differ among women receiving vaginal P (RR 1.21, 95%CI 0.91 to 1.61, 1077 participants, moderate certainty of evidence), or oral P (RR 0.89, 95%CI 0.38 to 2.10, 90 participants, low certainty of evidence) as opposed to placebo. Instead, 17-HP significantly reduced the outcome (RR 0.72, 95% CI 0.54 to 0.95, 450 participants, moderate certainty of evidence). PTB < 37 weeks' did not differ among women receiving vaginal P (RR 0.95, 95%CI 0.72 to 1.26, 8 studies, 1231 participants, moderate certainty of evidence) or 17-HP (RR 0.86, 95%CI 0.60 to 1.21, 450 participants, low certainty of evidence) when compared to placebo/no treatment. Instead, oral P significantly reduced the outcome (RR 0.58, 95% CI 0.36 to 0.93, 90 participants, low certainty of evidence).

CONCLUSIONS

With a moderate certainty of evidence, 17-HP prevents PTB < 34 weeks' gestation among women that remained undelivered after an episode of threatened preterm labour. However, data are insufficient to generate recommendations in clinical practice. In the same women, both 17-HP and vaginal P are ineffective in the prevention of PTB < 37 weeks'.

Vaginal Progesterone Supplementation in the Management of Preterm Labor: A Randomized Controlled Trial

OBJECTIVES

The primary objective in this study was to evaluate the effects of vaginal progesterone supplementation for the prolongation of the latency period in preterm labor. The secondary objectives were to evaluate gestational age at delivery, rates of preterm birth less than 34 and 37 weeks, obstetric outcomes, maternal compliance with medication use, and side effects.

METHODS

A randomized controlled, unblinded trial was performed. Ninety women with preterm labor occurring at 24 to 34 weeks were either randomized to a vaginal progesterone group (44 women) receiving tocolytic and antenatal corticosteroids treatment combined with vaginal micronized progesterone (400 mg everyday) or to the no-progesterone group (46 women) receiving tocolytic and antenatal corticosteroids treatment only.

RESULTS

Latency periods were more prolonged in the vaginal progesterone group than in the no-progesterone group (32.8 ± 18.7 vs. 25.8 ± 22.7 days, p = 0.045). Gestational age at delivery in the vaginal progesterone group was also higher than in the no-progesterone group (37 vs. 35 weeks, p = 0.027). There were significant reduction rates of preterm birth less than 34 weeks (13.6% vs. 39.1%, p = 0.012), low birth weight (29.5% vs. 50%, p = 0.048), neonatal respiratory distress syndrome (13.6% vs. 37%, p = 0.021), and neonatal intensive care unit admission (6.8% vs. 28.3%, p = 0.017).

CONCLUSIONS

Combined treatment with vaginal progesterone 400 mg could prolong the latency period in preterm labor when compared with no progesterone.

Oral dydrogesterone as an adjunctive therapy in the management of preterm labor: a randomized, double blinded, placebo-controlled trial

BACKGROUND

Preterm birth is a major challenge in obstetric and perinatal care. It is the leading cause of neonatal death. The primary aim of this study was to evaluate the efficacy of oral dydrogesterone on latency period in managing preterm labor. The secondary aims were to evaluate the gestational age at delivery, percentage of preterm delivery before 34 weeks and 37 weeks, time to recurrent uterine contraction, pregnancy outcomes, neonatal outcomes, compliance and side effects.

METHODS

This was a randomized, double blinded, placebo-controlled trial. Forty-eight pregnant women with preterm labor, singleton pregnancy, and gestational age of 24-34 weeks were enrolled into the study. The study group received 10 mg of oral dydrogesterone three times per day and the control group received placebo. All pregnant women received standard treatment with tocolytic and antenatal corticosteroids.

RESULTS

The median latency periods were not significantly different between the dydrogesterone group (27.5 days) and placebo group (34 days, p = 0.45). Additionally, there were no differences in the gestational age at delivery, percentage of preterm delivery before 34 weeks and 37 weeks, pregnancy outcomes, neonatal outcomes, compliance and side effects. However, the time to the recurrence of uterine contractions in participants that had recurrent preterm labor was longer in the dydrogesterone group than in the placebo group (30.6 ± 12.3 vs 13.7 ± 5.0 days, p = 0.01).

CONCLUSIONS

Adjunctive treatment with 30 mg of oral dydrogesterone could not prolong latency period in preterm labor when compared to placebo.

TRIAL REGISTRATION

ClinicalTrials.gov (Clinical trials registration: NCT03935152 , registered on May 2,2019).

Efficacy of daily rectal micronized progesterone for prevention of preterm delivery: a randomized clinical trial

Introduction: Preterm delivery is the leading cause of neonatal morbidity and mortality and its prevention is always under serious concern.Objective: The aim of the present study was to determine the efficacy of rectal progesterone as a maintenance tocolytic after arresting preterm labor, for increasing the duration of pregnancy, and postponing preterm birth.Method: The study was performed as a double blind randomized clinical trial on women with preterm labor in whom contractions have been stopped. The eligible women were randomly divided into two groups. In the intervention group (progesterone group), progesterone was administered rectally as a dose of 200 mg daily until 36⁺⁶weeks or spontaneous delivery before that time, whichever came first; and in the placebo group, placebo was administered in a similar manner. Primary outcomes were number of deliveries before 37 weeks of gestation and time to delivery interval in two groups. Secondary outcomes were neonatal Apgar score and weight, and need for NICU admission.Results: 160 women finished the study (80 women in each group). The women of the two groups did not have significant difference according to the baseline characteristics. Frequency of preterm labor (earlier than 37 weeks) and mean gestational age at the time of delivery did not show significant difference in two groups. Also, neonatal outcome including Apgar score, birth weight, NICU admission and neonatal complications were not different between the two groups. The pregnancy length was longer in progesterone group (28.84 ± 3.36 VS 21.19 ± 4.62 days), [p = .001, CI 95%: 3.71-4.83]. The time-to-event (delivery) analysis showed a hazard ratio of 1.02 (95% CI 0.36-2.77).Conclusion: Rectal progesterone at a daily dose of 200 mg as a maintenance tocolytic agent, cannot lower the frequency of preterm delivery but was suggested to prolong pregnancy length.

Progesterone - Effective for Tocolysis and Maintenance Treatment After Arrested Preterm Labour?: Critical Analysis of the Evidence

Numerous experimental studies indicate that natural progesterone, through various mechanisms, exerts an inhibitory effect on uterine contractility and sensitises the myometrium for tocolytics. It was therefore appropriate to investigate the possible benefits of oral/vaginal progesterone and the synthetic progesterone derivative 17-α-hydroxyprogesterone caproate, applied intramuscularly, in clinical studies on primary tocolysis, additively to established tocolytics ("adjunctive tocolysis") and as maintenance treatment after successful tocolysis in cases of threatened preterm birth. Three studies with a small number of cases do not yield any sufficient evidence for recommending progesterone/17-α-hydroxyprogesterone caproate as primary tocolysis in women with preterm labour. There is also no evidence that progesterone or 17-α-hydroxyprogesterone caproate combined with commonly used tocolytics leads to a prolongation of pregnancy and a significant decrease in the rate of preterm birth. The data on the use of progesterone as maintenance treatment is controversial. While randomised, controlled studies with low quality showed promising results, studies with high quality did not reveal any significant differences with regard to the rate of preterm birth < 37 weeks of gestation, the latency period until delivery and in the neonatal outcome between progesterone/17-α-hydroxyprogesterone caproate and placebo or no treatment. Significant differences in the methodology, the inclusion and outcome criteria, the mode of application and the dosages of the substances as well as the inadequate statistical power as a result of low numbers of cases make interpretation and comparability of the studies difficult. Therefore, well-designed randomised, placebo-controlled, double-blind studies with uniform primary outcome criteria are needed in order to clarify whether progesterone and via which route of administration and at which dosage is of clinical benefit for patients with manifest preterm contractions and as maintenance treatment after arrested preterm labour.

Repeat Measurement of Cervical Length in Women with Threatened Preterm Labor

OBJECTIVE

To examine the value of a repeat measurement some days after the first cervical length measurement done at the time of preterm contractions.

STUDY DESIGN

Retrospective study involving women with singleton pregnancies who presented with preterm contractions at 24 to 33 + 6 weeks of gestation. The cervical length was measured at the time of presentation and some days afterwards.

RESULTS

The study population consisted of 17 cases with a preterm delivery within 14 days and 288 uneventful pregnancies. Univariate logistic regression analysis indicated a significant correlation between delivery within 14 days and both, the first and second cervical length measurements as well as the difference between the two measurements. Up to a false positive rate of 20 %, ROC curve analysis showed an improved detection rate for preterm delivery by inluding both measurements. At a false positive rate of 10 % - which corresponds to a first and second cervical length of 10 and 9 mm - the detection rate was 17.6 % with the first cervical length measurement, 47.0 % with the second and 52.9 % if the difference between both measurements was added.

CONCLUSION

Our results indicate that in women with symptoms of preterm labor it is worth to repeat the measurement some days later and to take into account the difference between both measurements.

A randomized, double blinded, placebo controlled trial of oral dydrogesterone supplementation in the management of preterm labor

The primary aim of this study was to evaluate the effect of oral dydrogesterone on the recurrent uterine contraction in preterm labor. The secondary aims were to evaluate latency period, gestational age at delivery, pregnancy outcomes, neonatal outcomes, compliance and side effects. A randomized, double blinded, placebo controlled trial was conducted. Forty-eight pregnant women at 24-34 weeks gestation with preterm labor were either randomized to study group receiving tocolytic treatment combined with oral dydrogesterone (20 mg daily) or to placebo group receiving tocolytic treatment combined with oral placebo. Recurrent rates of uterine contraction were comparable between groups (87.5% vs 91.7%, p = 0.64). Latency periods were not different between dydrogesterone and placebo group (32.7 ± 20.2 days vs 38.2 ± 24.2 days, p = 0.39). There were also no differences in gestational age at delivery, pregnancy outcomes, neonatal outcomes, compliance and side effects. Adjuvant treatment with oral dydrogesterone 20 mg/day could not decrease the rates of recurrent uterine contraction and prolong latency period in preterm labor management when compared to placebo.

Population differences and the effect of vaginal progesterone on preterm birth in women with threatened preterm labor (.)

OBJECTIVE

Threatened preterm labor (tPTL) is a complication of pregnancy. Identification of women and clinical definition differs between countries. This study investigated differences in tPTL and effectiveness of vaginal progesterone to prevent preterm birth (PTB) between two countries.

METHODS

Secondary analysis of a randomized controlled trial (RCT) from Argentina and Switzerland comparing vaginal progesterone to placebo in women with tPTL (n = 379). Cox proportional hazards analysis was performed to compare placebo groups of both countries and to compare progesterone to placebo within each country. We adjusted for baseline differences. Iatrogenic onset of labor or pregnancy beyond gestational age of interest was censored.

RESULTS

Swiss and Argentinian women were different on baseline. Risks for delivery <14 days and PTB < 34 and < 37 weeks were increased in Argentina compared to Switzerland, HR 3.3 (95% CI 0.62-18), 54 (95% CI 5.1-569) and 3.1 (95% CI 1.1-8.4). In Switzerland, progesterone increased the risk for delivery <14 days [HR 4.4 (95% CI 1.3-15.7)] and PTB <37 weeks [HR 2.5 (95% CI 1.4-4.8)], in Argentina there was no such effect.

CONCLUSION

In women with tPTL, the effect of progesterone may vary due to population differences. Differences in populations should be considered in multicenter RCTs.

Comparative Study of Vaginal versus Intramuscular Progesterone in the Prevention of Preterm Delivery: A Randomized Clinical Trial

BACKGROUND

Preterm birth is a worldwide health concern due to its various negative consequences. Therefore, the prevention of preterm birth is a top priority for healthcare systems in all countries.

OBJECTIVE

To compare the effectiveness of vaginal versus intramuscular progesterone in the prevention of preterm delivery.

METHODS

This randomized clinical trial was conducted at Shahid Sadoughi Hospital in Yazd, Iran, from November 21, 2012 to January 20, 2015. Seventy-eight pregnant women with singleton pregnancy and one risk factor of preterm delivery were included in the study. The subjects were assigned randomly to two groups, with group one receiving Cyclogest and group two receiving 17-α hydroxyprogesterone caproate. Subsequently, we analyzed drug complications during pregnancy, delivery time, neonatal outcomes, and patients' satisfaction among the two groups. The data were analyzed using SPSS version 16. We used descriptive statistics, chi-squared, t-test, and ANOVA for the analyses of primary and secondary outcomes.

RESULTS

Among the 39 births in group one, 33.3% occurred preterm, and, among the 39 births in group two, 30.7% occurred preterm (< 37 weeks). The mean gestational ages at delivery in groups 1 and 2 were 37.07 ± 2.23 and 36.81 ± 2.77 weeks, respectively (p = 0.765). Other variables were not significantly different between the two groups, including birth weight (p = 0.745), Apgar scores for the first and fifth minutes (p = 0.574, 0.630), length of stay in the neonatal intensive care unit (NICU) when the newborns needed hospitalization (p = 0.358), and the patients' satisfaction with the drugs that were used (p = 0.615).

CONCLUSIONS

In this study, vaginal progesterone and intramuscular progesterone had the same levels of effectiveness, safety and acceptance by patients in the prevention of preterm delivery. Therefore, both can be used for this purpose in clinical practices, but more studies are needed.