he primary outcomes of OPPTHvIUM were unique in that both immediate obstetrical and childhood outcomes were examined. These were fetal death or birth <34 weeks; a composite of death, brain injury, or bronchopulmonary dysplasia; and a standardized cognitive score at 2 years of age. Contrary to earlier reports, vaginal progesterone was not associated with a lower risk of preterm birth or composite neonatal adverse outcomes. In children at 2 years of age, vaginal progesterone also had no long-term benefit or harm.
hus, evidence is conflicting as to the eicacy of progestogens across the spectrum of the various specific indications. Some have attempted to resolve these issues through systematic review and metaanalysis (Prior, 2017; Romero, 2016, 2017). s outlined in this entire section, virtually all evidence supporting use of progestogens for a specific indication can be challenged in some way. We agree with the conclusions from the OPPTIMUM trial (Norman, 2016) that the results of recent studies should prompt a major review of progesterone use for preterm birth prophylaxis, a search to identiy specific women who might specifically benefit, and a redoubling of eforts to find alternative strategies to prevent preterm birth in women at risk.
TABLE 42-8. Comparison of 17-0HP-C versus Placebo to Prevent Preterm Birth at
Preterm birth <37 wk:
Cervical length, mm
Preterm birth <34 wk:
Cervical length, mm ap value for Breslow-Day interaction term.
Data are presented as n/N (%).
CI = confidence interval; RR = relative risk; 17-0HP-C = 17-hydroxyprogesterone caproate. Data from Grobman, 201n2.
FIGURE 42-8 Percentage of births before 37 weeks' gestation at Parkland Hospital from 1988 to 2006 compared with that in the United States from 1996 to 2002. Analysis in both cohorts was limited to singleton liveborn infants �500 g who received prenatal care. (Reproduced with permission from with permission from Leveno J, Mcintire DO, Bloom SL, et al: Decreased preterm births in an innercity public hospital, Obstet Gynecol. 2009 Mar;1o13(3):578-584.)
Awell-organized prenatal system lowers the preterm birth rate in high-risk indigent populations (Creasy, 1980). One example is the Parkland Hospital prenatal clinic system (Leveno, 2009). As shown in Figure 42-8, the declining preterm birth rate between 1988 and 2006 coincided with a substantial rise in prenatal care attendance. In the early 1990s, a concerted efort was made to improve access to prenatal care by creating seamless care that began with antenatal enrollment and extended through delivery and the puerperium. Prenatal clinics were placed strategically throughout Dallas County to provide convenient access for our patients. Prenatal protocols are used by nurse practitioners at all clinic sites to guarantee homogeneous care. Women with highrisk pregnancy complications are referred to our hospital-based central clinic system. Here, Maternal-Fetal Medicine clinics operate each weekday and are stafed by residents and midwives and supervised by fellows and faculty.
hus, prenatl care is considered one component of a comprehensive and orchestrated public health-care system that is community-based. We believethat the drop in preterm births experienced at our inner-city hospitl is at least partially attributable to a geographically based public health-care program specifically targeting minority populations ofpregnant women. A similar obstetrical care system for indigent women at the University of Alabama at Birmingham has also produced salutary results (Tita, 2011).