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In the name of God. The effect of intramuscular progesterone on the rate of cervical shortening. Cara Pessel , MD et al American Journal of Obstetrics and Gynecology 2013.

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The effect of intramuscular progesterone on the rate of cervical shortening

The effect of intramuscular progesterone on the rateof cervical shortening

Cara Pessel, MD et al

American Journal of Obstetrics and Gynecology

2013


In the name of god

The purpose of the study was: evaluate whether17-alpha-hydroxyprogesterone caproate (17-OHPC) exposure isassociated with the rate of cervical shortening.


Introduction
Introduction

  • Cervical length measurement in

    pregnancy has proved to be a useful

    tool in the identification of women who

    Are at risk of spontaneous preterm delivery.

  • Serial assessments of the cervix

    and weekly intramuscular injections of

    17-alpha-hydroxyprogesterone caproate

    (17-OHPC)


In the name of god

cervical length decreases withadvancing gestational age and that the cervix begins to shorten physiologically after 28 weeks’ gestation, even in womenwho are destined to deliver at term


In the name of god

  • mechanism by which 17-OHPC reduces the risk of recurrent preterm delivery is not well established.

  • A previous study reported no difference in the rate of cervical shortening among women with a history of spontaneous preterm delivery according to 17-OHPC exposure.


In the name of god

aberrations in cervical remodeling may predispose women to recurrent preterm deliveries and progesterone may function by targeting these aberrations, we hypothesized that women who experience recurrent preterm delivery and were exposed to progesterone may exhibit a slower rate of cervical shortening when compared with women who were not exposed to 17-OHPC.


Materials and methods
MATERIALS AND METHODS

a retrospective study among women with history of spontaneous preterm delivery (defined as 1 spontaneous births between 16

weeks and 36 weeks 6 days’ gestation)

who underwent serial cervical length

assessments to monitor for cervical

shortening in our institution between

2009 and 2012


In the name of god

Pregnancies with

1.major fetal anomalies,

2.vaginal progesterone use at any time

in the index pregnancy,

3.<2 cervical length measurements

4.medically indicated preterm delivery, or

5.the presence or placement of an abdominal or vaginal cerclage

were excluded.


In the name of god

  • Electronic medical records were reviewed to abstract pertinent obstetric history, including the number of previous preterm deliveries, gestational age of each preterm delivery, and whether that pregnancy involved multiple gestations.

  • maternal age, race,ethnicity, prepregnancy and weight at

    delivery, type of provider (private maternal-fetal medicine specialist, private generalist obstetrician and gynecologist

    (OB/GYN), or government-insured OB/GYN low-risk clinic or high-risk maternal-fetal medicine clinic), use of in vitro fertilization, smoking status, and illicit drug use during pregnancy.


In the name of god

  • At our center, women with a history ospontaneousdelivery at <37 weeks’ gestation are offered weekly treatment with 17-OHPC starting at 16 gestational weeks.

  • Review of our electronic ultrasound database was used to record cervical length measurements (in millimeters) from 16-32 weeks’ gestation


In the name of god

  • The obstetrics ultrasound

    guidelines at Columbia University

    Medical Center require 3 measurements

    of the cervix that include at least 1

    assessment while the patient performs

    the Valsalva maneuver. The shortest of

    the 3 cervical length values is reported

    clinically; this measurement was recorded

    into our database for each visit


In the name of god

Short cervix is defined at our institution

as <25 mm, which represents the

10th percentile at 24 weeks’ gestation.

Once this is identified in our ultrasound

unit, patient treatment varies

according to practitioner and individual

patient details and may involve cerclage

placement, the initiation of vaginal

progesterone, or expectant treatment

and observation


In the name of god

the goal of our protocol was to identify

all women who may benefit from timesensitive

interventions such as antenatal

steroid and magnesium administration


Results
Results

  • Of 17,400 deliveries from 2009-2012, 376 women with a history of spontaneous preterm delivery met inclusion criteria.

  • We excluded 139 women:

    major fetal anomalies, 5 women; the presence

    of placement of a cerclage (2 abdominal

    and 78 vaginal), 80 women; exposure to

    vaginal progesterone, 32 women; indicated

    preterm delivery, 22 women.

  • This resulted in 237 women for analysis. Of the included patients, 184 (77.6%) were exposed to 17-OHPC in the current pregnancy.


In the name of god

  • Women who were exposed to 17-OHPC were, on average, 2.2 years younger None of the other characteristics, including previous uterine or cervical surgery, differed between the groups.

  • Subjects who were not exposed to 17-OHPC were more likely to have a previous preterm delivery that involved a multiple gestation

  • obstetric history of recurrent preterm delivery, gestational age at earliest preterm delivery, and history of at least 1 term delivery was similar between those who were exposed to 17-OHPC and those not.


In the name of god

The first cervical length measurements (41.6 vs 40.7 mm; P ¼.52) were similar, regardles of 17-OHPC exposure. The number of cervical length measurements was higher in women who wereexposed to 17-OHPC (median of 5 exams vs 3 in those who were not exposed to 17-OHPC; P <.01).


In the name of god

The average rates of cervical shortening per week among term deliveries were 0.9 and 0.8 mm

with and without 17-OHPC, respectively

(P ¼ .76). Among preterm deliveries,

the corresponding rates were 0.8 and

1.2 mm, respectively, among women

with and without 17-OHPC (P ¼.67).


In the name of god

Rates of spontaneous preterm delivery in the

current pregnancy on exposure to 17-OHPC did not differ based.



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