Vaginal progesterone for prevention of preterm birth in women with a history of preterm birth regardless of cervical length: an argument against use

Abstract

Preterm birth, defined as birth before 37 weeks of gestation, has a significant public health effect as the most frequent cause of neonatal-related death and the second most frequent cause of infant-related death at the age of <5 years. Given the unclear and likely multifactorial etiologic nature of preterm birth, interventions to address this condition remain elusive. Progesterone supplementation was once considered a promising strategy for reducing preterm birth among patients with a history of previous preterm birth. However, more recent data suggesting limited efficacy led the United States Food and Drug Administration to revoke approval of 17-alpha hydroxyprogesterone caproate. Vaginal progesterone supplementation remains controversial. Recently published meta-analyses evaluating large, preregistered randomized controlled trials with low risk of bias and selective outcome reporting have found that recurrent preterm birth rates are not significantly reduced by vaginal progesterone supplementation in patients with a singleton pregnancy and previous history of spontaneous preterm birth. Furthermore, studies reporting any benefit from vaginal progesterone in this patient population are noted to have smaller sample sizes, higher risk of bias and selective outcome reporting, and low external validity. Therefore, our study argues against the universal use of vaginal progesterone supplementation for the prevention of recurrent preterm birth.