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Nachum Z, Ganor Paz Y, Massalha M, Wated M, Harel N, Yefet E. Vaginal Progesterone for Pregnancy Prolongation After Arrested Preterm Labor: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2419894. [PMID: 38976270 PMCID: PMC11231798 DOI: 10.1001/jamanetworkopen.2024.19894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/27/2024] [Indexed: 07/09/2024] Open
Abstract
Importance Women with arrested preterm labor (APTL) are at very high risk for spontaneous preterm delivery (SPTD), the leading cause of neonatal mortality and morbidity. To date, no maintenance therapy has been found to be effective for pregnancy prolongation. A few clinical trials with considerable methodological limitations have demonstrated some efficacy for 400 mg vaginal micronized progesterone (VMP) in women with APTL. Objective To investigate the effectiveness of daily 400 mg VMP for the prolongation of pregnancy after APTL. Design, Setting, and Participants This randomized clinical trial was conducted between December 19, 2018, and February 27, 2023, in 3 university-affiliated medical centers in Israel. Participants included women with singleton and twin pregnancies after APTL following tocolysis at 24 weeks 0 days to 34 weeks 0 days' gestation. Women with a history of preterm delivery or asymptomatic cervical shortening in the current pregnancy were excluded. Interventions Participants were randomly allocated to receive VMP 200 mg twice a day or no treatment until 36 weeks 6 days' gestation. Main Outcomes and Measures The primary end points were mean number of days from study enrollment to delivery and the rate of SPTD prior to 37 weeks' gestation. Results A total of 129 participants were enrolled (65 in the VMP group and 64 in the no-treatment group). Mean (SD) age was 27.6 (5.1) years. Between the VMP and no-treatment groups, there was no difference in pregnancy prolongation (mean [SD], 40.0 [17.8] vs 37.4 [20.3] days; P = .44) and the rate of SPTD (16 [25%] vs 19 [30%]; relative risk, 0.8; 95% CI, 0.5-1.5; P = .52). In twin pregnancies, including 12 and 15 pairs in the VMP and no-treatment groups, respectively, VMP prolonged pregnancy (mean [SD], 43.7 [18.1] vs 26.1 [15.2] days; P = .02), postponed the delivery week (36.5 [1.4] vs 34.7 [2.2] weeks; P = .01), shortened the length of stay in the neonatal intensive care unit (4.9 [10.6] vs 13.2 [18.5] days; P = .03) and overall hospital stay (8.3 [9.6] vs 15.1 [17.2] days; P = .03), and was associated with a higher birth weight (2444 [528] vs 2018 [430] g; P = .01). Conclusions and Relevance These findings show that VMP given in a dosage of 200 mg twice a day following APTL is not an effective treatment to prolong pregnancy or prevent SPTD. However, VMP demonstrated beneficial effects in twin pregnancies, warranting further investigation. Trial Registration ClinicalTrials.gov Identifier: NCT02430233.
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Affiliation(s)
- Zohar Nachum
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Yael Ganor Paz
- Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel
- Department of Obstetrics and Gynecology, Samson Assuta Ashdod University Hospital, Ashdod, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Manal Massalha
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Malak Wated
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
| | - Noa Harel
- Department of Obstetrics and Gynecology, Tzafon Medical Center, Poriya, Israel
| | - Enav Yefet
- Department of Obstetrics and Gynecology, Tzafon Medical Center, Poriya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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Rath W, Kuon RJ. Progesterone - Effective for Tocolysis and Maintenance Treatment After Arrested Preterm Labour?: Critical Analysis of the Evidence. Geburtshilfe Frauenheilkd 2019; 79:834-843. [PMID: 31423018 PMCID: PMC6690738 DOI: 10.1055/a-0829-3992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/05/2019] [Accepted: 01/07/2019] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Werner Rath
- Medizinische Fakultät Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ruben-J Kuon
- Universitätsklinikum Heidelberg, Abteilung für Gynäkologische Endokrinologie und Fertilitätsstörungen, Heidelberg, Germany
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Use of progesterone supplement therapy for prevention of preterm birth: review of literatures. Obstet Gynecol Sci 2017; 60:405-420. [PMID: 28989916 PMCID: PMC5621069 DOI: 10.5468/ogs.2017.60.5.405] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/02/2017] [Accepted: 06/12/2017] [Indexed: 11/27/2022] Open
Abstract
Preterm birth (PTB) is one of the most common complications during pregnancy and it primarily accounts for neonatal mortality and numerous morbidities including long-term sequelae including cerebral palsy and developmental disability. The most effective treatment of PTB is prediction and prevention of its risks. Risk factors of PTB include history of PTB, short cervical length (CL), multiple pregnancies, ethnicity, smoking, uterine anomaly and history of curettage or cervical conization. Among these risk factors, history of PTB, and short CL are the most important predictive factors. Progesterone supplement therapy is one of the few proven effective methods to prevent PTB in women with history of spontaneous PTB and in women with short CL. There are 2 types of progesterone therapy currently used for prevention of PTB: weekly intramuscular injection of 17-alpha hydroxyprogesterone caproate and daily administration of natural micronized progesterone vaginal gel, vaginal suppository, or oral capsule. However, the efficacy of progesterone therapy to prevent PTB may vary depending on the administration route, form, dose of progesterone and indications for the treatment. This review aims to summarize the efficacy and safety of progesterone supplement therapy on prevention of PTB according to different indication, type, route, and dose of progesterone, based on the results of recent randomized trials and meta-analysis.
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Wood S, Rabi Y, Tang S, Brant R, Ross S. Progesterone in women with arrested premature labor, a report of a randomised clinical trial and updated meta-analysis. BMC Pregnancy Childbirth 2017; 17:258. [PMID: 28768474 PMCID: PMC5541428 DOI: 10.1186/s12884-017-1400-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/02/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Progesterone may be effective in prevention of premature birth in some high risk populations. Women with arrested premature labor are at risk of recurrent labor and maintenance therapy with standard tocolytics has not been successful. METHODS Randomized double blinded clinical trial of daily treatment with 200 mg vaginal progesterone in women with arrested premature labor and an updated meta-analysis. RESULTS The clinical trial was terminated early after 41 women were enrolled. Vaginal progesterone treatment did not change the median gestational age at delivery: 36+2 weeks versus 36+4 weeks, p = .865 nor increase the mean latency to delivery: 44.5 days versus 46.6 days, p = .841. In the updated meta-analysis, progesterone treatment did reduce delivery <37 weeks gestation and increase latency to delivery, but this treatment effect was not evident in the high quality trials: (OR 1.23, 95% CI 0.91, 1.67) and (-0.95 days, 95% CI -5.54, 3.64) respectively. CONCLUSION Progesterone is not effective for preventing preterm birth following arrested preterm labor.
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Affiliation(s)
- Stephen Wood
- Department of Obstetrics and Gynaecology, University of Calgary, 4th Floor, North Tower, Foothills Medical Centre 1441 - 29th Street NW, Calgary, AB T2N 2T9 Canada
| | - Yacov Rabi
- Alberta Children’s Hospital Research Institute, Foothills Medical Centre, Room, rm C211 1403 - 29th Street NW, Calgary, AB T2N 2T9 Canada
| | - Selphee Tang
- Department of Obstetrics and Gynaecology, University of Calgary, 4th Floor, North Tower, Foothills Medical Centre 1441 - 29th Street NW, Calgary, AB T2N 2T9 Canada
| | - Rollin Brant
- Department of Statistics, University of British Columbia, ESB rm 3146, 2207 Main Mall F512-4480 Oak Street, Vancouver, BC Canada
| | - Susan Ross
- Obstetrics & Gynecology, University of Alberta, 5S141 Lois Hole Hosp/Robbins Pav/RAH, Edmonton, AB T5H 3V9 Canada
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Bafghi AST, Bahrami E, Sekhavat L. Comparative Study of Vaginal versus Intramuscular Progesterone in the Prevention of Preterm Delivery: A Randomized Clinical Trial. Electron Physician 2015; 7:1301-9. [PMID: 26516434 PMCID: PMC4623787 DOI: 10.14661/1301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 09/01/2015] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Afsar Sadat Tabatabaei Bafghi
- M.D., Obstetrician & Gynecologist, Associate Professor, Department of Obstetrics and Gynecology, Faculty of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Elham Bahrami
- M.D., Obstetrics & Gynecology Resident, Department of Obstetrics and Gynecology, Faculty of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Leila Sekhavat
- M.D., Obstetrician & Gynecologist, Associate Professor, Department of Obstetrics and Gynecology, Faculty of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Ai Y, Liu Q, Li Y, Duan T. Progesterone signaling/miR-200a/zeb2 axis regulates self-renewal of mouse embryonic stem cells. Biomed Pharmacother 2014; 68:201-8. [DOI: 10.1016/j.biopha.2013.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 12/10/2013] [Indexed: 02/01/2023] Open
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van Vliet EOG, Boormans EM, de Lange TS, Mol BW, Oudijk MA. Preterm labor: current pharmacotherapy options for tocolysis. Expert Opin Pharmacother 2014; 15:787-97. [PMID: 24533566 DOI: 10.1517/14656566.2014.889684] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION In the developed world, preterm birth is in quantity and in severity the most important issue in obstetric care. Adverse neonatal outcome is strongly related to gestational age at delivery. Since the pathophysiological mechanism of preterm birth is not yet completely unraveled, the development of successful preventive strategies is hampered. When preterm labor is actually threatening, current pharmacological therapies focus on inhibition of preterm contractions. This allows for transportation of the mother to a center with a neonatal intensive care unit and administration of corticosteroids to enhance fetal lung maturation. Globally, however, large practice variation exists. AREAS COVERED The aim of this review is to provide an overview of current pharmacological therapies for preterm labor. EXPERT OPINION For the initial tocolysis, the use of atosiban or nifedipine for 48 h is recommended based on the largest effectiveness and most favorable side effect profile. However, since data that convincingly indicate the beneficial effect of tocolytics on neonatal outcome are lacking, it might well be that tocolytics are ineffective. The role of progesterone in treatment of acute tocolysis is limited, but it might play a role in the prevention of preterm labor or as sensitizer for other tocolytic agents.
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Affiliation(s)
- Elvira O G van Vliet
- UMC Utrecht, Department of Obstetrics and Gynaecology , WKZ, PO Box 85090, 3508 AB Utrecht , Netherlands
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Vejrazkova D, Vcelak J, Vankova M, Lukasova P, Bradnova O, Halkova T, Kancheva R, Bendlova B. Steroids and insulin resistance in pregnancy. J Steroid Biochem Mol Biol 2014. [PMID: 23202146 DOI: 10.1016/j.jsbmb.2012.11.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Metabolism of glucose during pregnancy reflects the equilibrium between lactogenic hormones stimulating insulin production and counterregulatory hormones inducing insulin resistance. In physiological pregnancies, insulin-mediated glucose uptake is substantially decreased and insulin secretion increased to maintain euglycemia. This common state of peripheral insulin resistance arises also due to steroid spectra changes. In this review article, we have focused on the role of steroid hormones (androgens, estrogens, gestagens, mineralocorticoids, glucocorticoids, as well as secosteroid vitamin D) in the impairment of glucose tolerance in pregnancy and in the pathogenesis of gestational diabetes mellitus. This article is part of a Special Issue entitled 'Pregnancy and Steroids'.
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Velez Edwards DR, Likis FE, Andrews JC, Woodworth AL, Jerome RN, Fonnesbeck CJ, Nikki McKoy J, Hartmann KE. Progestogens for preterm birth prevention: a systematic review and meta-analysis by drug route. Arch Gynecol Obstet 2013; 287:1059-66. [PMID: 23532387 DOI: 10.1007/s00404-013-2789-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 03/05/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE Progestogen has been investigated as a preventive intervention among women with increased preterm birth risk. Our objective was to systematically review the effectiveness of intramuscular (IM), vaginal, and oral progestogens for preterm birth and neonatal death prevention. METHODS We included articles published from January 1966 to January 2013 and found 27 randomized trials with data for Bayesian meta-analysis. RESULTS Across all studies, only vaginal and oral routes were effective at reducing preterm births (IM risk ratio [RR] 0.95, 95 % Bayesian credible interval [BCI]: 0.88-1.03; vaginal RR 0.87, 95 % BCI: 0.80-0.94; oral RR 0.64, 95 % BCI: 0.49-0.85). However, when analyses were limited to only single births all routes were effective at reducing preterm birth (IM RR 0.77, 95 % BCI: 0.69-0.87; vaginal RR 0.80, 95 % BCI: 0.69-0.91; oral RR 0.66, 95 % BCI: 0.47-0.84). Only IM progestogen was effective at reducing neonatal deaths (IM RR 0.78, 95 % BCI: 0.56-0.99; vaginal RR 0.75, 95 % BCI: 0.45-1.09; oral RR 0.72, 95 % BCI: 0.09-1.74). Vaginal progestogen was effective in reducing neonatal deaths when limited to singletons births. CONCLUSIONS All progestogen routes reduce preterm births but not neonatal deaths. Future studies are needed that directly compare progestogen delivery routes.
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Affiliation(s)
- Digna R Velez Edwards
- Vanderbilt Epidemiology Center, Institute for Medicine and Public Health, 2525 West End Ave., Suite 600 6th Floor, Nashville, TN 37203, USA.
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