Management strategies for the prevention of preterm birth. Part I: Update on progesterone supplementation

Abstract

Preterm birth (PTB) is the main cause of neonatal morbidity and mortality in the developed world, generating a significant public health burden. PTB is a complex disorder and it is unlikely that one generalized prevention strategy will be effective in all patients. In this review, we are concerned with the most recent status of two proposed modalities of PTB prevention: progesterone supplementation and cerclage placement. Our intention was to emphasize the differential applicability of these two interventions tailored to specific clinical presentations. Progress has been made in developing reliable prognosticators for PTB. Ultrasound cervical length measurement has emerged as the single most powerful predictor. Recent randomized trials of progesterone supplementation have indicated the relevance of this objective method of screening in the selection of patients most likely to respond to progesterone. Similarly, in studies of cerclage, cervical length has been found to perform as a tool capable of reducing unnecessary intervention. Predefined treatment strategies guiding the decision on when to proceed with medical or surgical PTB prophylaxis are still lacking. On the basis of the available evidence, we suggest a differential approach giving preferential consideration to either progesterone or cerclage based on obstetrical history, cervical surveillance, and biochemical markers of inflammation.