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org Letters to the Editors

to achieve a vaginal delivery, minimizing perinatal complica- 2. Rouse DJ, Owen J, Savage KG, Hauth JC. Active phase arrest: revis-
tions. While we wait for this work to be done, all clinicians who iting the 2 hour minimum. Obstet Gynecol 2001;98:550-4.
3. Henry DM, Cheng YW, Shaffer BL, Kaimal AJ, Bianco K, Caughey AB.
care for laboring women should be encouraged to exhibit pa-
Perinatal outcomes in active phase arrest and vaginal delivery. Obstet
tience during both the first and second stage of labor. We must Gynecol 2008;112:1109-15.
remind ourselves that the cesarean delivery being performed 4. Albers LL. The duration of labor in healthy women. J Perinatol 1999;
today impacts not just outcomes in the current pregnancy, but 19:114-9.
in all future pregnancies as well. f 5. Cheng YW, Hopkins LM, Caughey AB. How long is too long: is a
prolonged second stage of labor associated with worse maternal and
Aaron B. Caughey, MD, PhD neonatal outcomes? Am J Obstet Gynecol 2004;191:933-8.
Department of Obstetrics, Gynecology, and Reproductive Sciences 6. Cheng YW, Nicholson J, Shaffer B, Lyell D, Caughey AB. The second
University of California, San Francisco stage of labor and epidural use: a larger effect than previously suggested.
505 Parnassus Ave., Box 0132 Am J Obstet Gynecol 2009;201:S46-82.
San Francisco, CA 94143
abcmd@berkeley.edu © 2010 Published by Mosby, Inc. doi: 10.1016/j.ajog.2010.04.009

REFERENCES
1. Zhang J, Troendle J, Mikolajczyk R, Sundaram R, Beaver J, Fraser W.
The natural history of the normal first stage of labor. Obstet Gynecol
2010;115:705-10.

17-alpha-hydroprogesterone caproate and cervical changes


TO THE EDITORS: I read with interest the article of Durn- some antiinflammatory properties are responsible for the ter-
wald et al.1 Contrary to our prospective evaluations,2 in a ret- tiary prevention of cervical inflammation in symptomatic
rospective analysis they found that 17-alpha-hydroxyprogest- women with shortened cervix when the syndrome of preterm
erone (17P) caproate did not affect cervical length in the delivery has started. This would explain the reason that 17P
women who were enrolled in a preterm prevention clinic. caproate attenuated cervical shortening, namely in patients
Apart from population differences (⬎50% black race and with shortest cervix. On the other hand, other mechanisms of
⬎50% overweight women), the big difference between the action have to be hypothesized to explain the effectiveness of
studies was the inclusion criteria. They observed asymptomatic secondary prophylaxis of preterm delivery that is demon-
women who were at risk because of their obstetric history, strated in asymptomatic women who are at risk for recurrence
whereas we enrolled symptomatic women who had overcome because of their obstetric history. f
an episode of preterm labor. The main biologic difference was Fabio Facchinetti, MD
the length of the cervix, which was within normal ranges in Unit of Obstetrics, Mother-Infant Department
their study; it was ⱕ25 mm in ⬎50% of the women who were University of Modena and ReggioEmilia
enrolled in our small trial. This last finding means that, at ran- Via del Pozzo 71
dom assignment, our patients experienced a local activation of 41100 Modena Italy
inflammatory pathways, which was supported by cervical se- Facchi@unimore.it
cretions of proinflammatory interleukins.3 This was not sur-
REFERENCES
prising because the cervical inflammatory activation of women
1. Durnwald CP, Lynch CD, Walker H, Iams JD. The effect of treatment
in preterm labor had been discovered long ago4 and later was
with 17-alpha-hydroxyprogesterone caproate on changes in cervical
confirmed in several reports. Hence, it would be of interest to length over time. Am J Obstet Gynecol 2009;201:410.e1-5
know whether Durnwald et al could find a subpopulation of 2. Facchinetti F, Paganelli S, Comitini G, Dante G, Volpe A. Cervical length
their patients with a shortened cervix and then evaluate cervical changes during preterm cervical ripening: effects of 17-␣-hydroxypro-
changes that occurred in the no-treatment and 17P caproate– gesterone caproate. Am J Obstet Gynecol 2007;196:453.e1-4.
3. Facchinetti F, Dante G, Venturini P, Paganelli S, Volpe A. 17-alpha-
treated groups. hydroxy-progesterone effects on cervical proinflammatory agents in
Although we know little about the mechanisms that allow women at risk of preterm delivery. Am J Perinatol 2008;25:503-6.
spontaneous preterm delivery (infection and inflammatory re- 4. Rizzo G, Capponi A, Rinaldo D, Tedeschi D, Arduini D, Romanini C.
sponse remain a milestone), we ignore the mode of action by Interleukin-6 concentrations in cervical secretions identify microbial inva-
sion of the amniotic cavity in patients with preterm labor and intact mem-
which 17P caproate exerts its therapeutic role. The drug is nei-
branes. Am J Obstet Gynecol 1996;175:812-7.
ther hydrolyzed in vitro nor in vivo; it does not affect circulat- 5. Ruddock NK, Shao-Qing S, Jain S, Moore G, Hankins GDV, Romero R,
ing steroid concentrations (personal observation), and it is un- Garfield RE. Progesterone, but not 17-alpha-hydroxyprogesterone ca-
able to inhibit uterine contractility either in vivo or in vitro5 “as proate, inhibits human myometrial contractions. Am J Obstet Gynecol
apex.” Likely, a still unknown metabolite seems to be respon- 2008;199:391.e1-7.
sible for the pharmacologic actions of the drug. I suggest that © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.04.029

SEPTEMBER 2010 American Journal of Obstetrics & Gynecology e9

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