A blueprint for the prevention of preterm birth: vaginal progesterone in women with a short cervix

Abstract

Preterm birth is the leading cause of perinatal morbidity and mortality worldwide, and is the most important challenge to modern obstetrics. A major obstacle has been that preterm birth is treated (implicitly or explicitly) as a single condition. Two-thirds of preterm births occur after the spontaneous onset of labor, and the remaining one-third after “indicated” preterm birth; however, the causes of spontaneous preterm labor and “indicated” preterm birth are different. Spontaneous preterm birth is a syndrome caused by multiple etiologies, one of which is a decline in progesterone action, which induces cervical ripening. A sonographic short cervix (identified in the midtrimester) is a powerful predictor of spontaneous preterm delivery. Randomized clinical trials and individual patient meta-analyses have shown that vaginal progesterone reduces the rate of preterm delivery at <33 weeks of gestation by 44%, along with the rate of admission to the neonatal intensive care unit, respiratory distress syndrome, requirement for mechanical ventilation, and a composite score of neonatal morbidity/mortality. There is no evidence that 17-alpha-hydroxyprogesterone caproate can reduce the rate of preterm delivery in women with a short cervix, and therefore, the compound of choice is natural progesterone (not the synthetic progestin). Routine assessment of the risk of preterm birth with cervical ultrasound coupled with vaginal progesterone for women with a short cervix is cost-effective, and implementation of such a policy is urgently needed. Vaginal progesterone is as effective as cervical cerclage in reducing the rate of preterm delivery in women with a singleton gestation, history of preterm birth, and a short cervix (<25mm).

Combinatory approaches prevent preterm birth profoundly exacerbated by gene-environment interactions

“…Extension of parturition timing but with poor neonatal outcome in LPS-treated Trp53 loxP/loxP Pgr Cre/+ females by P 4 treatment alone suggests that it can address the ovarian insufficiency of P 4 secretion but cannot overcome the adverse effects of premature decidual senescence. Indeed, there is evidence that P 4 supplementation in humans can prevent preterm delivery only in certain patient populations with specific risk factors (47)(48)(49)(50)(51).…”

Vaginal Progesterone in Asymptomatic Women with Short Cervical Length on Ultrasound: is it Beneficial?

“…Cervical shortening is one of the risk factor for preterm birth [4]. However, many women who deliver preterm do not have any known risk factors [5] Biomarkers are used for predicting preterm birth [6]. However, it is not possible to obtain biomarkers in most of the clinics; therefore, the evaluation of the cervix with ultrasonography is important.…”

Isthmicocervical insufficiency: Diagnosis and correction

“…Иногда беременные могут обра-щать внимание на ощущение давления и распирания во влагалище, ощущения дискомфорта внизу живота [2].…”

“…У пациенток группы высокого риска развития ИЦН (преждевременные роды и невынашивание беременности в анамнезе, внутриматочные вмешательства с расширени-ем цервикального канала в анамнезе) большинство отече-ственных и зарубежных авторов [1][2][3][7][8][9][10][11][12] предлагают начинать определять длину шейки матки с 16 нед бере-менности. В то же время развитие ИЦН возможно и у па-циенток без отягощенного анамнеза.…”