ImportancePreterm birth (PTB) is the leading cause of infant morbidity and mortality worldwide. It has been suggested that vaginal progesterone (VP) treatment may reduce the recurrence of PTB.ObjectiveTo evaluate the association of VP treatment with prevention of recurrent PTB among patients with a singleton pregnancy.Design, Setting, and ParticipantsThis prospective, observational cohort study, set in a public health care system for inner-city pregnant patients, enrolled patients with prior spontaneous PTB (gestational age, ≤35 weeks) receiving VP from May 15, 2017, to May 7, 2019. Patients who delivered between 1998 and 2011 served as a referent cohort matched 3:1 for obesity, race and ethnicity, and individual specific preterm birth history. Statistical analysis was performed from August 19, 2021, to September 2, 2022.ExposurePatients received 90 mg of vaginal progesterone, 8%, nightly, initiated between 16 weeks and 0 days and 20 weeks and 6 days of pregnancy until 36 weeks and 6 days of pregnancy or delivery.Main Outcomes and MeasuresThe primary outcome was overall rate of recurrent PTB at 35 weeks or less of patients given VP compared with the 3:1 matched untreated historical controls. Secondary outcomes included assessment of PTB according to adherence (≥80% completing scheduled doses), duration of pregnancy relative to index gestational age, progesterone blood levels, and outcomes for those who declined VP.ResultsA total of 417 patients (mean [SD] age, 30.4 [5.9] years; 64 Black patients [15.3%]; 272 [65.2%] with a body mass index of ≥30) received VP and were matched with 1251 controls (mean [SD] age, 28.8 [5.7] years; 192 Black patients [15.3%]; 816 [65.2%] with a body mass index of ≥30). The overall rate of recurrent PTB was 24.0% (100 of 417; 95% CI, 20.0%-28.4%) for the VP cohort compared with 16.8% (1394 of 8278) expected in the matched historical controls. Adherence was not associated with lower rates of recurrent PTB compared with nonadherence (odds ratio, 0.87 [95% CI, 0.51-1.41]). The mean difference between historical matched controls and those using VP was 0.2 weeks (95% CI, −1.4 to 1.0 weeks) without improvement in the interval of recurrent PTB after the implementation of VP (P = .73). Progesterone blood levels for patients who were adherent compared with those who were nonadherent were not significantly different at either 24 or 32 weeks (24 weeks: 99 ng/mL [95% CI, 85-121 ng/mL] vs 104 ng/mL [95% CI, 89-125 ng/mL]; P = .16; 32 weeks: 200 ng/mL [95% CI, 171-242 ng/mL] vs 196 ng/mL [95% CI, 155-271 ng/mL]; P = .69).Conclusions and RelevanceThis cohort study of patients with a current singleton pregnancy suggests that VP was not associated with a reduction in recurrent PTB.
The incidence of peripartum hysterectomy is increasing and is related to the increasing incidence of placenta accreta spectrum.
INTRODUCTION:Postpartum hypertension is observed in up to 20% of patients within 6 weeks of delivery. While blood pressure evaluation is an integral component of prenatal care, effective blood pressure follow-up postpartum is uncertain. The objective of this study was to evaluate the use of antihypertensive medications and subsequent dosage adjustments in the postpartum period.METHODS:This was a retrospective qualitative observational study of patients with hypertensive disorders of pregnancy who delivered at a single quaternary care safety net hospital from July to December 2021. Patients with at least one of the following diagnoses: chronic hypertension (cHTN), gestational hypertension (gHTN), and/or severe preeclampsia (SPE), were included. Data collected included initiation and/or titration of antihypertensives during delivery admission, postpartum visit attendance, outpatient antihypertensive dose adjustments, and emergency department visits.RESULTS:From July to December 2021, 1,232 pregnancies were complicated by hypertensive disorders: gHTN only, 577 (46.8%); both gHTN and cHTN, 34 (2.8%); both gHTN and SPE, 499 (40.5%); and all three, 122 (9.9%). Of these, 256 (20.8%) required initiation and/or titration of antihypertensives during delivery admission with over 90% of these complicated by SPE. Of the 197 (77.0%) attending at least one follow-up, medication was stopped in 26 (13%), increased in 9 (5%), decreased in 22 (11%), and continued unchanged in 140 (71%). The majority of medication adjustment occurred in the first 2 weeks postpartum.CONCLUSION:Postpartum hypertensive therapy management occurs predominantly within 2 weeks postpartum, with nearly one-fourth decreasing and only 5% requiring increased medication.
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