OBJECTIVE:

We sought to provide evidence-based guidelines for using progestogens for the prevention of preterm birth (PTB).

METHODS:

Relevant documents, in particular randomized trials, were identified using PubMed (US National Library of Medicine, 1983 through February 2012) publications, written in English, which evaluate the effectiveness of progestogens for prevention of PTB. Progestogens evaluated were, in particular, vaginal progesterone and 17-alpha-hydroxy-progesterone caproate. Additionally, the Cochrane Library, organizational guidelines, and studies identified through review of the above were utilized to identify relevant articles. Data were evaluated according to population studied, with separate analyses for singleton vs multiple gestations, prior PTB, or short transvaginal ultrasound cervical length (CL), and combinations of these factors. Consistent with US Preventive Task Force suggestions, references were evaluated for quality based on the highest level of evidence, and recommendations were graded. RESULTS AND

RECOMMENDATIONS:

Summary of randomized studies indicates that in women with singleton gestations, no prior PTB, and short CL ≤20 mm at ≤24 weeks, vaginal progesterone, either 90-mg gel or 200-mg suppository, is associated with reduction in PTB and perinatal morbidity and mortality, and can be offered in these cases. The issue of universal CL screening of singleton gestations without prior PTB for the prevention of PTB remains an object of debate. CL screening in singleton gestations without prior PTB cannot yet be universally mandated. Nonetheless, implementation of such a screening strategy can be viewed as reasonable, and can be considered by individual practitioners, following strict guidelines. In singleton gestations with prior PTB 20-36 6/7 weeks, 17-alpha-hydroxy-progesterone caproate 250 mg intramuscularly weekly, preferably starting at 16-20 weeks until 36 weeks, is recommended. In these women with prior PTB, if the transvaginal ultrasound CL shortens to <25 mm at <24 weeks, cervical cerclage may be offered. Progestogens have not been associated with prevention of PTB in women who have in the current pregnancy multiple gestations, preterm labor, or preterm premature rupture of membranes. There is insufficient evidence to recommend the use of progestogens in women with any of these risk factors, with or without a short CL.

Copyright © 2012. Published by Mosby, Inc.

METHODS: Plasma vitamin D3 and lipid concentrations were measured in 119 female cynomolgus monkeys (premenopausal, n = 49; ovariectomized, n = 70) consuming approximately 1,000 IU per day of vitamin D3. In a subset of the ovariectomized monkeys (n = 23), vitamin D3 was remeasured after 6 months. The concentrations of vitamin D3 were analyzed as a continuous variable and were divided at the median into high (≥48 ng/mL) versus low (<48 ng>/mL) groupings.

RESULTS: Among the 119 monkeys, the range of vitamin D3 concentrations was 24.0 to 95.2 ng/mL (mean ± SD, 48.5 ± 12.7 ng/mL). Plasma vitamin D3 concentration was positively associated with high-density lipoprotein cholesterol (HDL-C; P = 0.003). Monkeys in the high vitamin D3 group had a significantly greater plasma HDL-C concentration (57.9 mg/dL) than did those in the low vitamin D3 group (47.1 mg/dL; P = 0.001). Although the difference was not significant (P = 0.120), the monkeys in the high vitamin D3 group had a decreased total plasma cholesterol-to-HDL-C ratio compared with those in the low vitamin D3 group (5.4 and 6.2, respectively), potentially putting them at lower risk of atherosclerosis development.

CONCLUSIONS: Given that the monkeys all consumed a diet replete in vitamin D3, it seems that individual differences in vitamin D absorption or metabolism may have determined whether the monkeys had high or low concentrations of vitamin D3. Lower vitamin D3 was associated with a more atherogenic lipid profile, a major risk factor for progressing to coronary artery atherosclerosis in monkeys and human beings.

A pilot study showed that simulation using video and high fidelity simulators can substitute for clinical experience for teaching breech delivery with retention of skills at one and three month intervals.

STUDY DESIGN: We performed a retrospective cohort study of pregnant women treated with methadone for opiate addiction who delivered live-born neonates between 1996 and 2006. Four dose groups, on the basis of total daily methadone dose, were compared (160 mg/d). The primary outcome was treatment for NAS. Symptoms of NAS were objectively measured with the Finnegan scoring system, and treatment was initiated for a score>24 during the prior 24 hours.

RESULTS: A total of 330 women treated with methadone and their 388 offspring were included. Average methadone dose at delivery was 117+/-50 mg/d (range, 20-340 mg/d). Overall, 68% of infants were treated for NAS. Of infants exposed to methadone doses160 mg/d, treatment for NAS was initiated for 68%, 63%, 70%, and 73% of neonates, respectively (P=.48). The rate of maternal illicit opiate abuse at delivery was 26%, 28%, 19%, and 11%, respectively (P=.04).

CONCLUSION: No correlation was found between maternal methadone dose and rate of NAS. However, higher doses of methadone were associated with decreased illicit opiate abuse at delivery.

More selective indications for cervical cerclage based on recent randomized studies were associated with decreased cerclage placement.

The decrease in incidence of history-indicated cerclage may be due to the fact that more women with prior PTB are being followed by transvaginal cervical length measurements.

The decrease in incidence of ultrasound-indicated cerclage may be due to the use of 17-hydroxy progesterone caproate in women with PTB.

Among women with a cerclage, pre-pregnancy BMI was not a significant predictor of SPTB <35 weeks.

There was a non-significant trend toward increased rates of SPTB at all gestational age cutoffs.

Morbidly obese women consistently had worse outcomes than obese and normal/overweight women.

Compared to normal/overweight, GA at delivery decreases by 1 week for obese and 2 weeks for morbidly obese women.

Duration of HPV infection was not a significant risk factor for spontaneous PTB <37 weeks.

Cervical HPV DNA and HPV serology may further delineate the relationship between HPV infection and SPTB <37 weeks.

A larger sample size may be necessary to show a difference.

The 3.5x higher rate of fetal death > 23 weeks in our study (compared to fetal death > 20 weeks in the U.S.) needs further investigation.

Traditionally, these wounds have been closed using split-thickness skin grafts with or without the use of the VAC device.

Our case study demonstrates good outcomes using the VAC device alone to achieve complete closure when applied immediately following debridement with frequent VAC changes.

STUDY DESIGN: This was a retrospective cohort study of infants treated for NAS during 2000-2006 whose mothers were on methadone maintenance at delivery. Mixed-effects linear regression was used to examine the interaction of maternal and neonatal variables with length of treatment.

RESULTS: Of 204 neonates born to methadone exposed mothers, the average dose at delivery was 127 mg daily (25-340 mg) with median length of treatment 32 days (1-122 days). Trimester of initial exposure (P = .33), methadone dose at delivery (P = .198), body mass index (P = .31), antidepressant use (P = .40), cigarette use (P = .76), race (P = .78), and maternal age (P = .84) did not predict length of treatment. In the multivariate analysis, gestational age at delivery and benzodiazepine use were significant predictors of length of treatment.

CONCLUSION: Later gestational age and concomitant benzodiazepine use were associated with longer treatment.

Conclusion: Biopsy of suspected cervical lesions can be safely deferred until after pregnancy because there were no significant changes between antepartum and postpartum CC and no missed cases of cervical cancer were detected.

Conclusions: 17P does not appear to have an effect on preterm birth <35 weeks in women with a history-indicated cerclage.

Conclusions: Among women with a prior spontaneous PTB and current UIC for CL<25mm, 17P did not reduce the rate of PTB <35 weeks.

Conclusion: Prolonged monitoring beyond 120 min is not associated with increased rate of delivery secondary to NRFS or worse neonatal outcome measured by the 5 minute Apgar score. Monitoring after a deceleration on outpatient NST may be limited to less than 120 minutes. Larger studies are needed to confirm this finding.

The purpose of this study was to review the American College of Obstetricians and Gynecologists practices bulletins to quantify the type of recommendations and references and determining whether there are any differences between obstetric and gynecologic bulletins.

Study design

All practice bulletins published from June 1998 to December 2004 were reviewed. Odds ratios and 95% confidence intervals were calculated.

Results

The 55 practice bulletins contained 438 recommendations of which 29% are level A, 33% level B, and 38% level C. The 55 bulletins cite 3953 references of which 17% are level I, 46% level II, 34% level III, and 3% others. Level A recommendations were significantly more likely among the 23 gynecologic than 32 obstetric bulletins (37% versus 23%, odds ratios 1.95, 95% confidence intervals 1.28, 2.96). The study types referenced in obstetric and gynecologic bulletins were similar (P > .05 for comparison of levels I, II, and III and meta-analysis references).

Conclusion

Only 29% of the American College of Obstetricians and Gynecologists recommendations are level A, based on good and consistent scientific evidence.