Dear All:
Please see the attached article from the NEJM. It talks about the use of progesterone in the prevention of preterm delivery.
There was talk today at our meeting about waiting until viability to start the progesterone. This article supports the use of progesterone as early as 16 weeks.
As you can see, the article is from 2003. I asked if there was newer evidence supporting the use of progesterone, and I was told by an MFM from RWJ that although this article is old, it is still used amongst MFM's. It would be interesting to hear Dr Schneider's viewpoint on this matter.
Dr Encinas
WMR Replies:
Should Medicos urgently pursue 17 OH P injections for the woman at 14 weeks with a history of three prior miscarriages?
On the issue of 17 OH P, I think the data does not meet a "standard of care" due to conflicting and poorly controlled studies. In the 2003 study you sent [Meis PJ et al. Prevention of recurrent preterm delivery etc. NewEngl J Med 2003;348: 2379], there were no women who miscarrried prior to 20 weeks.
When there is a range of 16-20 weeks within the study you cited, the physician would be within protocol if injections were deferred until 20 weeks. Others have stated 24 weeks, but all of this is currently under study by several centers. When the experts disagree, country doctors can decide.
I would not criticize Medicos fellows for pursuing this treatment, but I have my doubts about effectiveness(versus efficacy) at this time. I predict that many uninsured AND MEDICAID women are unable to obtain these services for a variety of reasons. Prematurely declaring a standard of care, creates unjustified liablility.
If she miscarries at 23 weeks, would Medicos physicians be liable for failing to obtain these injections for this patient? for an uninsured woman?
Would it be better to send her to the county hospital where the next available appointment is in two months?
Is there a moral obligation for the physician to buy the medications and give them in the office regardless of reimbursement.
I would not require these injections as a standard of care until these confounders were settled in studies which had been replicated in the community. Medicos has learned that instantaneous transfer to a higher level of care is not always realistic.
As we discussed, MFM Dr Carter has a protocol on these issues and sending the patient for consultation may bring us up to date. Thank you for bringing this study to our attention.
wmr
Index--Preterm labor prevention
