Re: 17 oh progesterone
From: Andrew Folley (agfolley@hotmail.com)
Fri Jun 8 11:01:21 2007
Lynn
Thank you for detailed suggestions. andy
>From: "Lynn Montgomery" <apgar10@thebirthcentermt.com>
>Reply-To: ob-gyn-l@obgyn.net
>To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
>Subject: RE: 17 oh progesterone
>Date: Fri, 8 Jun 2007 10:49:09 -0500
>
>I have 3 ladies I am considering starting on 17 OH P at 20 weeks.
>
>#1 had an incompetent cervix in first pregnacy with rescue cerclage at
>24 weeks and preterm deliviery at 29 weeks.
>
>[Lynn] In this patient, I would be more inclined to follow serial
>cervical lengths from 16 through 24 weeks gestational age. If there is
>a dynamic change noted during this surveillance, I would place a
>cervical cerclage at that point. In a patient requiring a rescue
>cerclage, I would certainly not argue with empirically placing a
>cerclage at 12-14 weeks and forgo the serial measurements. I do not
>feel that this is a good patient for progesterone.
>
>#2 developed severe preeclampsia and and was induced and delivered early
>at 28 weeks.
>
>[Lynn]In this patient, given the history of severe preeclampsia at 28
>weeks gestational age, she has at least a 50% chance of recurrence.
>Progesterone has certainly not been shown to lessen the recurrence risk
>of preeclampsia. I would consider starting low-dose aspirin (81mg/day)
>early and continuing to 36 weeks. I know the large ASA study did not
>show a significant benefit, however, the study included a large number
>of randomly chosen primigravidas and there wasn't a decreased incidence
>when compared to controls. If a there was an early predictor of who was
>"at risk" to develop preeclampsia in those same groups and only the "at
>risk" primigravidas where randomized to ASA and no ASA, there may indeed
>be a benefit. Unfortunately, we do not have that early marker - yet...
>I always check those early, "atypical" preeclamptics for
>antiphospholipid antibodies as well - ASA definitely will benefit that
>group.
>
>Finally #3 more delivered second baby at 34 weeks following PROM.
>
>[Lynn]In PPROM, it is currently thought that the primary etiology is an
>ascending bacteria that infects the membrane, weakens it, leading to
>rupture. As to why this occurs in some, it may be due to shortening of
>the cervix or other unknown factors. In this case, if shortening is the
>result of uterine contractions, then progesterone can be argued for.
>There have been good studies demonstrating that in patients with a
>history of PPROM, by placing them on nightly antibiotic therapy
>(erythromycin) throughout the pregnancy, you lessen the recurrence rate
>of PPROM compared to controls. This likely works by lessening the
>bacterial load in the vagina, therefore lessening the risk of an
>ascending infection. I have been doing this for several years and use
>PCE 500 (well tolerated erythromycin formulation).
>
>Lynn
>
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