Vaginal Progesterone supplementation decreases preterm births, neonatal morbidity and mortality in women with twin gestation and short cervix: an updated meta-analysis of individual patient data

Administration of vaginal progesterone to asymptomatic women with a twin gestation and a sonographic short cervix (cervical length ≤ 25 mm) in the mid-trimester reduces the risk of preterm birth occurring at < 30 to < 35 gestational weeks, neonatal mortality and some measures of neonatal morbidity, without any demonstrable deleterious effects on childhood neurodevelopment.

The article was published online in Ultrasound in Obstetrics and Gynecology, the official journal of the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG).

The meta-analysis included the results of 6 studies, encompassing 303 women pregnant with twins, all of whom had a cervical length of 25 mm or less in the midtrimester. Of these, 159 women received vaginal progesterone and 144 received a placebo or no treatment. Women who received vaginal progesterone were 31 percent less likely to deliver before 33 weeks of pregnancy (31 percent for those receiving vaginal progesterone, compared to 43 percent for those who did not). Vaginal progesterone also reduced the rate of preterm delivery before 32 weeks and 34 weeks. All results were statistically significant.

The risk of preterm birth < 33 weeks was reduced by 31% and neonatal death by 47% and also reduced the rate of respiratory distress syndrome (RDS), birth weight < 1500 g and use of mechanical ventilation.

No significant difference in the risk of neurodevelopmental disability at 4–5 years of age between children exposed prenatally to vaginal progesterone and those exposed to placebo.

“The findings represent persuasive evidence that treatment with vaginal progesterone in women with a short cervix and a twin gestation reduces the frequency of preterm birth, neonatal complications such as respiratory distress syndrome, and importantly, neonatal death,” said the study’s first author, Roberto Romero, M.D., Chief of the Perinatology Research Branch at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD/NIH). Dr. Romero emphasized that individual patient data meta-analyses represent the “gold standard” in the hierarchy of scientific evidence to answer clinical questions.

Access the full article.

Access the press release.

The accompanying videoclip by the  ISUOG summarizes the importance of research. 

North American Menopause Society (NAMS) video series about important midlife health topics: hormone therapy for women 65+

HRT if used properly and under expert care have the potential to offer multisystem benefits at relatively low cost. But, sadly the acceptance of HRT is quite low in society because of risk of breast cancer and is frequently discontinued because of breakthrough bleeding.

The acceptance further dropped after the results of Women's Health Initiative study (WHI) in 2002 found that it actually increased a woman's risk of heart disease, stroke, dementia and breast cancer.

Within months a 50% drop was noticed in women using HRT.

But a final comprehensive report published in JAMA and took a deeper look at the WHI study and the results were broken down according to age and number of years elapsed since menopause.

The key findings were HRT is appropriate for younger women who are in early menopause because the Quality of life benefit derived will be much more as compared to the adverse effects. In older women who are 60+ the risks are entirely different and outweigh the harm.

The dilemma has since continued about initializing or extending HRT in women who are 60+ years. Some women still want to continue using hormones because of the ‘feel good factor’ or because the menopausal symptoms of hot flashes and urogenital syndrome of menopause still continue bothering her.  

The North American Menopause Society (NAMS) thinks that women should be evaluated according to circumstances and risk/benefit ratio. They should use the lowest possible dose under strict monitoring.

This latest video, Extended Hormone Therapy Use, Dr. Shapiro interviews Dr. Cynthia Stuenkel, Past President of NAMS, an internist, endocrinologist, and reproductive endocrinologist at the University of California, San Diego. Dr. Stuenkel discusses the safety and risk for hormone therapy use in women 65 years of age and older.  

                 Dr Stuenkel discusses risk and benefits of hormone therapy for women 65+

India's first donor uterine transplant successfully performed in Pune.

Courtesy:Indianexpress.com

With its first uterine transplant performed uneventfully in the city of Pune on Thursday, India joins the list of handfuls of countries around the world with successful uterine transplant surgeries.

A team of 12 doctors from Galaxy Care Laparoscopy Institute Pune carried out this feat after 9 hours of surgery, led by oncosurgeon Dr Shailesh Puntambekar.

“The surgery has been a success. The next 48 hours will be crucial and the patient will be under observation,” said Dr Puntambeker. 

"The procedure is difficult because multiple large arteries are to be joined there, and veins that are small and short. It is technically very tough." He further added.   

It was a donor transplant; the uterus being donated by mother to her daughter who had Müllerian agenesis. The organ was retrieved by laparoscopic surgery, while it was transplanted by open surgery.

The selection Criteria’s for donor and recipient of uterus transplant can be accessed here.  

The donor is doing well and the recipient will need a close watch in ICU for about a week. The immediate success of the surgery can only be assessed by doppler sonography which will determine successful vascularization of the transplanted organ.

Whether the transplant would be successful in terms of pregnancy and birth remains to be seen and it’s a long wait before success is seen on these fronts.  

Transplant research, as a whole, has also tended to focus on life-saving transplantation (heart, kidney, liver) with womb transplant research being rather limited especially following advances in IVF techniques.

Uterine Transplants are Unique in the sense that unlike any other transplants, they are ‘ephemeral,'” Cleveland Clinic lead researcher Andreas Tzakis said in the release. “They are not intended to last for the duration of the recipient’s life.” 

After 1-2 healthy pregnancies, the transplanted uterus is either removed or allowed to disintegrate.

In 2000, the world’s first womb transplant was performed on a 26-year-old woman in Saudi Arabia. But, the transplanted womb only lasted for 99 days.

In September 2014, Mats Brännström and colleagues report the first successful birth of a child following uterus transplantation. The recipient, a 35-year-old woman lacking a uterus (Rokitansky syndrome), received a cryopreserved embryo 1 year after transplantation, leading to a live-birth by cesarean section.

The donated uterus came from the woman’s own mother, so the baby is also the first born to a woman using the same womb from which she emerged herself.

This team has since performed a total of nine uterus transplants that have resulted in five pregnancies and four live births.

The first cadaveric uterine transplant in US was performed at Cleveland clinic in February, 2016 but it failed after 2 weeks because of a fungal infection.