17-Hydroxyprogesterone Caproate for the Prevention of Recurrent Preterm Birth – A Systematic Review and Meta-analysis Taking into Account the PROLONG Trial

Abstract

Background Prior spontaneous preterm birth is a strong risk factor for the recurrence of spontaneous preterm birth in a subsequent pregnancy and has been evaluated in prevention studies using progesterone (natural progesterone administered orally or vaginally, and 17-hydroxyprogesterone caproate [17-OHPC]) as a selection criterion. Based on the findings of a randomized, placebo-controlled study, 17-OHPC was approved for use in 2011 by the Food and Drug Administration in the USA for the prevention of recurrent preterm birth. The approval was granted with qualification that a subsequent confirmatory study would need to be carried out, the results of which have just been published (PROLONG trial). Method A systematic literature search for the period from 1970 to April 2020 using the search terms “preterm birth” and “17-OHPC” or “progesterone” was carried out. Only randomized, placebo-controlled studies of women with singleton pregnancies who received 17-OHPC to prevent recurrent preterm birth were included in the subsequent meta-analysis. The relative risk and associated 95% confidence intervals were calculated. The heterogeneity between studies was evaluated with I2 statistics. Results In addition to the original study used for the approval and the PROLONG trial, only one other study was found which met the inclusion criteria (total number of patients: 2221). With considerable heterogeneity between the studies, particularly with respect to the risk factors for preterm birth, the comparison between 17-OHPC and placebo showed no significant reduction in preterm birth rates before 37, 35 and 32 weeks of gestation and no significant differences with regard to the prevalence of miscarriage before 20 weeks of gestation or fetal deaths (antepartum or intrapartum) after 20 weeks of gestation and neonatal morbidity. Conclusion Based on the currently available data, 17-OHPC cannot be recommended for the prevention of recurrent preterm birth. Further randomized, placebo-controlled studies with clearly defined, comparable risk factors are required to identify the group of pregnant women which could benefit from the use of 17-OHPC to prevent preterm birth.

Progesterone in Pregnancy: Evidence-Based Strategies to Reduce Miscarriage and Enhance Assisted Reproductive Technology

“…There have been 2 recent studies on the use of 17-hydroxyprogesterone caproate (17-OHPC) by injection for women with recurrent pregnancy loss [ 21 , 42 ]. In 2021, a meta-analysis that included these 2 studies showed that 17-OHPC injection was not recommended to prevent pregnancy loss or recurrent miscarriage [ 43 ]. A 2016 study enrolled pregnant women at risk of premature birth and randomized them to receive intramuscular 17-OHPC or vaginal micronized progesterone [ 44 ], showing no significant difference between intramuscular 17-OHPC or vaginal micronized progesterone (RR=1.31; 95% CI 0.47–3.66; P =0.59) [ 44 ].…”

Desafios na prevenção do parto pré-termo associado à insuficiência cervical

“…Existem poucos estudos que avaliam alternativas à via vaginal para administração da progesterona 1 . Kuon et al 57 realizaram revisão sistemática e metanálise que incluiu o PROLONG Study (Estudo duplo cego, placebo controlado e randomizado, multicêntrico, que avaliou o efeito do 17-OHPC na redução do parto pré-termo recorrente e da morbidade neonatal em gestação única com parto pré-termo prévio), concluindo que o 17-OHPC não pode ser recomendado para a prevenção de partos pré-termos recorrentes, sendo necessários mais estudos randomizados, controlados por placebo, com fatores de risco claramente definidos e comparáveis, para identificar o grupo de mulheres grávidas que poderia se beneficiar do uso de 17-OHPC 57 .…”

Preventing Spontaneous Preterm Birth: Insights from Genomics

“…Initial reports and experience with progesterone or 17-alpha hydroxyprogesterone caproate supplementation for women with a high risk of preterm birth (previous preterm birth or short cervix) suggested potential therapeutic benefit (for example, (Epppic Group, 2021;Meis et al, 2003). Other evidence, though, has called these earlier findings into question and has also revealed potential adverse consequences of progesterone treatment such as the risk for cancer in the offspring of treated pregnancies (Kuon, Berger, & Rath, 2021;Murphy, Cirillo, Krigbaum, & Cohn, 2022;Norman et al, 2016).…”