A. Mattei

Progesterone and pregnancy.

Purpose of review Progesterone is an essential hormone in the process of reproduction. Although the pharmacokinetics and pharmacodynamics of progesterone have been well studied, its use in the pathophysiology of pregnancy remains controversial. One of these concerns is the way in which the hormone is administered. Recent findings In obstetrics the most frequent uses of progesterone are in the treatment of threatened abortion, prevention of recurrent miscarriage, or in the support of the luteal phase in assisted reproduction programmes, and in threatened preterm labour. Randomized, controlled trials showed that women who received progesterone were statistically significantly less likely to have recurrent miscarriages before 34 weeks, to have an infant with birth weight of 2.5 kg or lower, or to have an infant diagnosed with intraventricular haemorrhage. There is currently, however, insufficient information to allow recommendations regarding the optimal dose, route and timing of administration of progesterone supplementation. Summary Progesterone has shown to be efficacious when continuation of pregnancy is hampered by immunological factors, luteinic and neuroendocrine deficiencies and myometrial hypercontractility. This may explain the reduction in the incidence of preterm birth in high-risk pregnant women using high-dosage prophylactic progesterone.

The changing role of progesterone in preterm labour

Progesterone is an essential hormone in the process of reproduction. It is involved in the menstrual cycle, implantation and is essential for pregnancy maintenance. Although the pharmacokinetics and pharmacodynamics of progesterone have been well studied, and since 1935 it has been synthesised and is now available commercially, its use in the pathophysiology of pregnancy remains controversial. One of these concerns is the way in which the hormone is administered, with parenteral use proving the best way to obtain optimal plasma levels. Another concern is the paucity of randomised controlled trials and the different dosages and populations studied. As a result, the therapeutic application of progesterone in pregnancy is restricted to the prevention and treatment of threatened miscarriage, recurrent miscarriage and preterm birth. Progesterone is efficacious when continuation of pregnancy is hampered by immunological factors, luteinic and neuroendocrine deficiencies and myometrial hypercontractility. This may explain the reduction in the incidence of preterm birth in high risk pregnant women using high‐dosage prophylactic progesterone.

Use of tocolytics: what is the benefit of gaining 48 hours for the fetus?

Preterm birth remains one of the serious problems in perinatal medicine and is associated with an increased risk of neonatal complications and long‐term morbidity. Although each day that delivery is delayed between 22 and 28 weeks of gestation increases survival by 3%, since most spontaneous preterm labour occurs between 28 and 34 weeks of gestation, this is of secondary concern; the primary goal of delay is to improve the function of certain systems in the fetus and to balance the risks of a hostile intrauterine environment with the complications of extrauterine preterm life. Although there is a lack of definitive evidence that tocolytic drugs improve outcome following spontaneous preterm labour and preterm birth, there is ample evidence that tocolysis delays delivery for long enough to permit administration of a complete course of antepartum glucocorticoids and to facilitate in utero transfer to a tertiary care unit where neonatal care will be optimal. Both these measures have been associated with improved outcomes; antepartum glucocorticoids reduce the incidence of respiratory distress syndrome, intraventricular haemorrhage, periventricular leucomalacia and necrotising enterocolitis, and in utero transfer is associated with decreased morbidity and mortality and less hospital‐based intervention compared with postnatal transportation. Consequently, women who are more likely to benefit from tocolysis are those at early gestational ages, those needing transfer to a hospital that can provide neonatal intensive care and those who have not yet received a full course of antepartum glucocorticosteroids. In these cases, delaying labour for at least 48 hours with drugs such as atosiban should be considered, since it offers clear advantages for the fetus.

The role of progesterone in maternal and fetal medicine

Progesterone is an essential hormone in the process of reproduction. It has been extensively studied in the treatment of different gynecological pathologies, as a contraceptive and in assisted reproductive technologies. However, the use of progesterone in the pathophysiology of pregnancy remains controversial. Progesterone, and its synthetic form 17 α-hydroxyprogesterone caproate (17 OHP-C), offer an effective intervention when the continuation of pregnancy is at risk from immunological factors, luteinic and neuroendocrine deficiencies, and myometrial hypercontractility. Progesterone has been successfully used as prophylaxis in the prevention of spontaneous miscarriage, with treatment beginning from the first trimester of pregnancy. There is substantial evidence, too, to indicate that women with idiopathic recurrent miscarriage may benefit from the immunomodulatory properties of progesterone in early pregnancy. The use of progesterone and 17 OHP-C has been extensively studied in the prevention of preterm birth in a variety of settings. Transvaginal ultrasound measurement of cervical length in singleton pregnancies between 19 and 24 weeks’ gestation has been deemed the best way to identify women (approximately 2% of the pregnant population) who would benefit from prophylactic progesterone treatment for the prevention of spontaneous preterm birth. This paper reviews the evidence for the safety and efficacy of the use of progesterone in each of these indications.

Flecainide treatment of fetal tachycardia and hydrops fetalis in a twin pregnancy

Fetal supraventricular tachycardia (SVT) is a rarecomplication of pregnancy leading, in some cases, tocardiac failure and intrauterine fetal death. Digoxin isa safe and successful treatment for SVT and can beconsideredas thefirst-linechoicein singletonand multiplepregnancies in which one of the fetuses presents withSVT