17-OHPC Treatment and Prevention of Preterm Birth: Does Timing Matter?
BACKGROUND AND PURPOSE:
The current SMFM guideline recommends
250 mg 17-OHPC IM weekly starting at 16-20 weeks of gestation until 36 weeks of gestation or delivery
Ning et al. (AJOG, 2017) examined the relationship between the gestational age at 17-OHPC initiation in women with prior preterm birth
Retrospective cohort study
Women included were those who had ≥ 1 previous spontaneous preterm birth between 16 and 28 weeks with one of the following:
Spontaneous onset of contractions
Painless cervical dilation
Women were grouped based on quartiles of gestational age of initiation
Early-Start: Quartile 1 (140/7 to 161/7) + Quartile 2 (162/7 to 170/7)
Late-Start: Quartile 3 (171/7 to 186/7) + Quartile 4 (190/7 to 275/7)
Recurrent preterm birth <37 weeks’ gestation
Recurrent preterm birth <34 and <28 weeks’ gestation
Composite major neonatal morbidity (diagnosis of grade III or IV intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, necrotizing enterocolitis stage II or III, or death)
132 women met inclusion criteria
39% delivered < 37 weeks
17-OHPC was initiated at a mean 17 weeks 5 days ± 2.5 weeks
Women with Early-Start trended toward lower rates of recurrent preterm birth <37 weeks compared to Late-Start (41.3% compared to 57.7%, P= 0.65) but not statistically significant
Women with Early-Start had a later mean delivery gestational age (37.0 ± 3.1 weeks vs 35.0 ± 5.1 weeks for women with late-start 17-OHPC [P = .008])
In regression models, odds of preterm birth were increased based on
Later Initiation Quartile
Short cervical length (<25 mm) in the midtrimester
Prepregnancy BMI ≥30 kg/m2
Delivery gestational age was inversely proportional to gestational age at initiation
quartile 1, 37 weeks 4 days vs quartile 2, 36 weeks 5 days vs quartile 3, 36 weeks 1 day vs quartile 4, 34 weeks 0 days; P = .007
Early-Start had lower rates of major neonatal morbidity compared to Late-Start (1.5% vs 14.3%, P = .005)
Rates of recurrent preterm birth among women with a prior spontaneous preterm birth 16-28 weeks are high
Women beginning 17-OHPC earlier deliver later and have improved neonatal outcomes
Authors recommend initiation at 16 weeks and to study whether even earlier initiation may be appropriate for higher risk patients
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