John O'Brien

Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double‐blind, placebo‐controlled trial

Women with a sonographic short cervix in the mid‐trimester are at increased risk for preterm delivery. This study was undertaken to determine the efficacy and safety of using micronized vaginal progesterone gel to reduce the risk of preterm birth and associated neonatal complications in women with a sonographic short cervix.

The management of placenta percreta: Conservative and operative strategies

OBJECTIVE Our purpose was to assess preferences for the management of placenta percreta and identify aspects of care related to an improved outcome. STUDY DESIGN Both an analysis of a questionnaire issued to members of the Society of Perinatal Obstetricians and a retrospective study at our institution were used to obtain case histories of women with placenta percreta during a recent 3-year period. RESULTS Fifty-five of the 109 cases (50%) reported by members of the Society of Perinatal Obstetricians were suspected ante partum. Complications associated with this disorder included uterine rupture (3 cases), transfusion of > 10 units (44 cases, 40%), ureteral ligation or fistula formation (5 cases each, 5%), infection (31 cases, 28%), perinatal death (10 cases, 9%), and maternal death (8 cases, 7%). Management options included surgical removal of the uterus and involved tissues (101 cases, 93%) and conservative treatment with the placenta left in situ after delivery (8 cases, 7%). More members of the Society of Perinatal Obstetricians responding to our survey opted for conservative management if adjacent tissues were involved (69% with extension into the bladder or gastrointestinal tract) compared with 31% when the percreta was confined to the uterus, p < 0.001. Conservative therapy was also associated with less blood loss in reported cases (median units red blood cells transfused, 0 vs 7, p = 0.003). Two of the three cases of placenta percreta at our institution were identified ante partum. The third case represents the first reported with antepartum identification of percreta followed by deliberate conservative treatment. CONCLUSIONS With greater involvement of surrounding tissues, conservative treatment was preferred in hemodynamically stable patients. If surgical excision of the placenta is attempted or necessary, physicians experienced in pelvic dissection must be involved because of the frequency of maternal morbidity and mortality.

Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and metaanalysis of individual patient data

OBJECTIVE To determine whether the use of vaginal progesterone in asymptomatic women with a sonographic short cervix (≤ 25 mm) in the midtrimester reduces the risk of preterm birth and improves neonatal morbidity and mortality. STUDY DESIGN Individual patient data metaanalysis of randomized controlled trials. RESULTS Five trials of high quality were included with a total of 775 women and 827 infants. Treatment with vaginal progesterone was associated with a significant reduction in the rate of preterm birth <33 weeks (relative risk [RR], 0.58; 95% confidence interval [CI], 0.42-0.80), <35 weeks (RR, 0.69; 95% CI, 0.55-0.88), and <28 weeks (RR, 0.50; 95% CI, 0.30-0.81); respiratory distress syndrome (RR, 0.48; 95% CI, 0.30-0.76); composite neonatal morbidity and mortality (RR, 0.57; 95% CI, 0.40-0.81); birthweight <1500 g (RR, 0.55; 95% CI, 0.38-0.80); admission to neonatal intensive care unit (RR, 0.75; 95% CI, 0.59-0.94); and requirement for mechanical ventilation (RR, 0.66; 95% CI, 0.44-0.98). There were no significant differences between the vaginal progesterone and placebo groups in the rate of adverse maternal events or congenital anomalies. CONCLUSION Vaginal progesterone administration to asymptomatic women with a sonographic short cervix reduces the risk of preterm birth and neonatal morbidity and mortality.

Progesterone vaginal gel for the reduction of recurrent preterm birth: primary results from a randomized, double‐blind, placebo‐controlled trial

Preterm birth is the leading cause of perinatal morbidity and mortality worldwide. Treatment of preterm labor with tocolysis has not been successful in improving infant outcome. The administration of progesterone and related compounds has been proposed as a strategy to prevent preterm birth. The objective of this trial was to determine whether prophylactic administration of vaginal progesterone reduces the risk of preterm birth in women with a history of spontaneous preterm birth.

Vaginal progesterone is associated with a decrease in risk for early preterm birth and improved neonatal outcome in women with a short cervix: A secondary analysis from a randomized, double-blind, placebo-controlled trial

To investigate the efficacy of vaginal progesterone to prevent early preterm birth in women with sonographic evidence of a short cervical length in the midtrimester.

Vaginal progesterone vs cervical cerclage for the prevention of preterm birth in women with a sonographic short cervix, previous preterm birth, and singleton gestation: a systematic review and indirect comparison metaanalysis

OBJECTIVE No randomized controlled trial has compared vaginal progesterone and cervical cerclage directly for the prevention of preterm birth in women with a sonographic short cervix in the mid trimester, singleton gestation, and previous spontaneous preterm birth. We performed an indirect comparison of vaginal progesterone vs cerclage using placebo/no cerclage as the common comparator. STUDY DESIGN Adjusted indirect metaanalysis of randomized controlled trials. RESULTS Four studies that evaluated vaginal progesterone vs placebo (158 patients) and 5 studies that evaluated cerclage vs no cerclage (504 patients) were included. Both interventions were associated with a statistically significant reduction in the risk of preterm birth at <32 weeks of gestation and composite perinatal morbidity and mortality compared with placebo/no cerclage. Adjusted indirect metaanalyses did not show statistically significant differences between vaginal progesterone and cerclage in the reduction of preterm birth or adverse perinatal outcomes. CONCLUSION Based on state-of-the-art methods for indirect comparisons, either vaginal progesterone or cerclage are equally efficacious in the prevention of preterm birth in women with a sonographic short cervix in the mid trimester, singleton gestation, and previous preterm birth. Selection of the optimal treatment needs to consider adverse events, cost and patient/clinician preferences.

Vaginal progesterone decreases preterm birth ≤ 34 weeks of gestation in women with a singleton pregnancy and a short cervix: an updated meta‐analysis including data from the OPPTIMUM study

To evaluate the efficacy of vaginal progesterone administration for preventing preterm birth and perinatal morbidity and mortality in asymptomatic women with a singleton gestation and a mid‐trimester sonographic cervical length (CL) ≤ 25 mm.

Effect of progesterone on cervical shortening in women at risk for preterm birth: secondary analysis from a multinational, randomized, double-blind, placebo-controlled trial

To determine whether progesterone supplementation alters cervical shortening in women at increased risk for preterm birth.

Neonatal progeroid (Wiedemann-Rautenstrauch) syndrome: Report of five new cases and review

The neonatal progeroid syndrome (NPS), or Wiedemann-Rautenstrauch, is a rare autosomal recessive disorder comprised of generalized lipoatrophy except for fat pads in the suprabuttock areas, hypotrichosis of the scalp hair, eyebrows, and eyelashes, relative macrocephaly, triangular face, natal teeth, and micrognathia. We report on 5 new patients who demonstrate phenotypic variability and who represent the single largest series of NPS reported to date. Two of the patients are from an African-American kindred, an ethnic occurrence not reported previously. The fact that there are 2 pairs of sibs among the 5 patients further supports that NPS is an autosomal recessive condition. This report also includes a review of the previously reported 16 patients and compares them with the 5 new patients. Abnormalities in endocrine and lipid metabolism were found in 3 of 5 patients. Skeletal findings in 2 of our patients demonstrated some new findings as well as the typical radiological abnormalities previously noted in NPS. It is apparent, based on the 21 cases, that mild to moderate mental retardation is common in NPS. Long term follow-up of patients with NPS should provide more information relative to their ultimate psychomotor development. NPS is usually lethal by 7 months; however, on rare occasions, patients have survived into the teens. Our 3 surviving patients range in age from 16-23 months. Variability in the phenotype of NPS is clear; however, the phenotype remains distinct enough to allow a secure diagnosis.

The effect of fetal number on the development of hypertensive conditions of pregnancy.

OBJECTIVE: To estimate the incidence and effect of pregnancy-related hypertensive conditions on multiple gestations. METHODS: Women with 1–4 fetuses enrolled in an outpatient perinatal services program at 28 or more weeks of gestation were identified. Those without a prior diagnosis of hypertension at enrollment and who delivered at more than 28 weeks of gestation were included in the analysis. The incidence of all pregnancy-related hypertensive conditions, diagnosis of severe hypertensive conditions (hemolysis, elevated liver enzymes and low platelets syndrome; disseminated intravascular coagulation; eclampsia; low platelets; renal failure; and abruption), and interventional delivery related to hypertension were estimated, and compared according to fetal number. RESULTS: Data were analyzed for 34,374 singleton, twin, triplet, and quadruplet gestations. The incidence of pregnancy-related hypertensive conditions increased with multifetal gestations as compared with singletons (12.7–19.6% for multifetal gestations compared with 6.5% for singletons, P < .001). The incidence of severe pregnancy-related hypertensive conditions was significantly increased in twin (1.6%) and triplet (3.1%) gestations as compared with singletons (0.5%, P < .001). Quadruplet pregnancies were not significantly higher than triplet gestations for these complications. The need for early delivery related to hypertension was greater with increasing fetal number through triplet gestations. By logistic regression, higher fetal number, nulliparity, and advanced maternal age were each independently associated with the development of pregnancy-related hypertensive conditions. CONCLUSION: Mild and severe pregnancy-related hypertensive disease increases progressively with advancing fetal number from singleton to triplets but is not further increased in quadruplet pregnancies. Multifetal pregnancies should be observed closely for onset of gestational hypertensive disease. LEVEL OF EVIDENCE: II-2