Dr. Sunita Chandra , of Lucknow presented at a webinar in the month of May 2020

1. DR. SUNITA CHANDRA
M.D.
 Chairperson & Director, Rajendra Nagar Hospital & IVF Centre
 Director, Morpheus Lucknow Fertility Centre
 Fellowship IVF, Germany

2. Hydroxyprogesterone Caproate
In Pre-term Birth
Dr. SUNITA CHANDRA

3. Andrew Weil
•As any doctor can tell you, the most crucial step
toward healing is having the right earlier
diagnosis by appropriate screening test.
• If the disease is precisely identified, a good
resolution is far more likely. Conversely, a late
diagnosis usually means a bad outcome, no matter
how skilled the physician.

4. Introduction
• WHO defines preterm birth as all births before 37
completed weeks of gestation, or fewer than 259
days from the first date of a woman's last
menstrual period
• Preterm labor is responsible for about 75% of
neonatal mortality
Indian Obstetrics & Gynecology. 2014; 4(2): 16-23
Emerg (Tehran). 2017; 5(1): e3.

5. Classification of PTB
• Spontaneous:
• Approximately 40-50% are due to spontaneous preterm
labor with intact membranes and 25-40% due to
preterm premature rupture of the membranes (PPROM)
• Indicated:
• Deliberate intervention for variety of maternal or
obstetric indications 20-30%.

6. Epidemiology
• Worldwide, 11.1% of infants are born preterm
every year
• PTB is the leading cause of perinatal morbidity and
mortality
• It the 2nd most common cause of death, after
pneumonia, in children under 5 years of age
Phillips C et al. BMJ Open 2017;7:e015402.

7. ETIOLOGY
In about 50 % , the cause of preterm labour is not
known, often it is multi factorial.
Following are however related with increased
incidence of preterm labour.
HIGH RISK FACTORS
1. Previous history of induced or spontaneous abortion or
preterm delivery.

9. 2. Pregnancy following ART:
• Multiple gestations
• Microbial colonization of the upper genital tract
• Increased stress among infertile couple
• Side effects of super ovulation
• Increased rate of birth defects have been proposed.
3. Asymptomatic bacteriuria or recurrent urinary tract
infections.
4. Smoking habits
5. Low socio economic and nutritional status.
6. Maternal stress
Contd . . .

10. Contd . . .
7. Complications in present preg
8. Uterine anamolies
9. Cervical factors
10. Med and surgical illness
11. Genital tract infections
12. Fetal factors
13. Placental factors
14. Itarogenic
15. Idiopathic

11. Pathophysiology

12. Question -
• Who is at risk ?
• Risk factors for preterm birth

13. Who Is At Risk?
• Reproductive history -Previous pre term birth,
history of ART.
• Ante partum bleeding, cervical excision treatment
for dysplasia, uterine anomalies.
• Fetal factors – multi-fetal gestations,
polyhydramnios.
• Infection
• Lifestyle issues – drug abuse, cigarette smoking.
• Biological variation
• Response to inflammatory mediators
Guzman ER. Ultrasound Obstet Gynecol. 2001;18:195-199.
Obstet Gynecol Sci. 2017 Sep;60(5):405-420
Emerg (Tehran). 2017; 5(1): e3.

14. Prevention Strategies In PTB
Frontiers In Immunology. REVIEW ARTICLE published: 19 November 2014. doi: 10.3389/fimmu.2014.00584

15. Cervical Length
• Cervical length measurement can be used to
identify increased risk of preterm birth in
asymptomatic women at < 24 weeks

16. Question -
• What is the best time to measure cervical length

17. Cervical Ultrasonography And The
Prediction Of Preterm Birth
• Strong inverse relationship between cervical length and
likelihood of spontaneous pre term birth before 35
weeks*
• Cervical length is stable in the first & second trimester
• Mid trimester evaluation of the cervix is important
N Eng J Med 1996; 334:567-72

18. Cervical Cerclage – In which
patients?
• In patients with
• History of preterm births, classically recurrent and
painless second trimester losses
• Shortening of the cervix on ultrasound imaging
• Short or dilated cervix on physical examination
Frontiers In Immunology. REVIEW ARTICLE published: 19 November 2014. doi: 10.3389/fimmu.2014.00584

19. Transvaginal Cervical Length
• Shorter the cervical length, the greater the risk of
PTB
• Recommend TVCL to women with identified or
suspected PTL (if available)
• Consider therapeutic interventions when TVCL is <25mm

20. Fetal Fibronectin Test
• Levels ≥ 50 ng/mL at or after 22 weeks have been associated
with an increased risk of spontaneous preterm birth
• Current evidence suggest routine use of FFN alone in
women with threatened PTL is not justifiable
• Combination of CL and FFN assessment may improve
prediction of SPTB particularly in those with a CL of 15–30
mm
Moeun et al. Semin Perinatol. 2017 December ; 41(8): 445–451.

21. Question -
• DIAGNOSIS
• How do you diagnose preterm labour?

22. • Ocurrence of regular uterine contractions
• Cervical changes
• Length of cx <2.5 cm and funneling of the internal
os
• Pelvic pressure, backache, vaginal discharge and
may be some bleeding

23. Management
• Prevention of preterm labour if possible
• To arrest preterm labour if not contraindicated
• Appropriate management of labour
• Effective neonatal care

24. Management
• Admit for observation
• Consider if in-utero transfer is indicated
• Offer analgesia
• Administer corticosteroids
• Measure TVCL (if available)
• Discuss plan with women and document
• Clinical reassessments as required

25. Tocolysis
• May delay birth
and allow:
– In utero-transfer
– Corticosteroid
administration
– MgSO4
administration

26. • It is reasonable not to use tocolytic drugs, as there is no clear
evidence that they improve outcome. However, tocolysis
should be considered if the few days gained would be put to
good use, such as completing a course of corticosteroids, or in
utero transfer.
• Not associated with a clear reduction in perinatal or neonatal
mortality, or neonatal morbidity.
Most authorities do not recommend use of tocolytics at or
after 34 weeks' .
There is no consensus on a lower gestational age limit for the
use of tocolytic agents.
RCOG Guideline Grade A recommendation 2011

27. Tocolysis in multiple gestation- do not reduce the risk
of preterm delivery or improve neonatal outcome.
ACOG practice bulletin 2012

29. Tocolysis in Prevention of PTB
• Meta-analyses (Miyazaki C et al, 2016)
• No significant difference was found for the relative
effectiveness of tocolytics versus placebo
• for prolonging pregnancy in women with extremely preterm birth
(RR 1.04) or
• reducing the rate of perinatal deaths (RR 2.22)
• There is no evidence to draw conclusions on the
effectiveness of tocolytic therapy for women with
threatened extremely preterm birth, multiple gestations,
and growth-restricted babies
Miyazaki, C., Reprod Health 13, 4 (2016) doi:10.1186/s12978-015-0115-7

30. COTRAINDICATIONS TO TOCOLYSIS
Gestation more than 34 weeks
Significant vaginal bleeding
Suspected fetal asphyxia
Intra amniotic infection
IUD or lethal anomaly
Maternal indication
• Uncontrolled diabetes
• Severe anaemia
• Cardiac disease
• Severe preeclampsia or eclampsia
Imminent delivery
Maternal hypotension systolic <90 mmHg

31. Antibiotics
• Infection-related preterm birth (PTB) is more common at
early gestational ages
• The Centers for Disease Control and Prevention (CDC) do
not recommend erythromycin or coamoxiclav for the
treatment of bacterial vaginosis
• Use either metronidazole or clindamycin, orally or vaginally
• If antibiotics are to be used to prevent infection-related PTB
these should be administered early
Front. Immunol., 16 November 2015 |
https://doi.org/10.3389/fimmu.2015.00566

32. Progesterone Supplementation
• Used in prevention of PTB from decades
• Exact mechanism of action is unknown
• Two possible mechanisms of action are
• an anti-inflammatory action that may counteract the
inflammatory process that is involved in initiation of labor
• Second is a possible functional withdrawal of progesterone
through changes in progesterone receptors and their
transcriptional activity at a tissue level
Front Immunol. 2014; 5: 584.

33. Question
• Actions of progesterone on myometrium

34. Actions of Progesterone on the
Myometrium
• Decreases conduction of contractions
• Increases threshold for stimulation
• Decreases spontaneous activity
• Decreases number of oxytocin receptors
• Prevents formation of gap junctions

35. RECOMMENDATIONS FOR USE
(ACOG October 2012)
• A woman with a singleton gestation and a prior
spontaneous preterm singleton birth should be offered
progesterone supplementation starting at 16–24 weeks
of gestation, regardless of transvaginal ultrasound
cervical length, to reduce the risk of recurrent
spontaneous preterm birth.
• Vaginal progesterone is recommended as a management
option to reduce the risk of preterm birth in
asymptomatic women with a singleton gestation without
a prior preterm birth with an incidentally identified very
short cervical length less than or equal to 20 mm before
or at 24 weeks of gestation.

36. • Progesterone treatment does not reduce the
incidence of preterm birth in women with twin or
triplet gestations and, therefore, is not
recommended as an intervention to prevent
preterm birth in women with multiple gestations.
• Insufficient evidence exists to assess if
progesterone and cerclage together have an
additive effect in reducing the risk of preterm birth
in women at high risk for preterm birth.

37. Prenatal Administration of Progesterone
for preventing PTB In High Risk Women
• Cochrane Systemic Review, (Dodd JM et al. 2013)
• Progesterone therapy significantly reduce the risk
of
• preterm birth <34 weeks (RR 0.31 95% CI 0.14–0.69)
• preterm birth <37weeks (RR 0.55, 95% CI 0.42–0.74)
• perinatal death (RR 0.50, 95% CI 0.33–0.75)
• Progesterone therapy significantly reduce
• Need for assisted ventilation (RR 0.40, 95% CI 0.18–0.90)
• Necrotizing Enterocolitis (RR 0.30, 95% CI 0.10–0.89),and
• Admission to neonatal intensive care(RR 0.24, 95% CI 0.14–0.40)
Dodd JM et al. Cochrane Database Syst Rev. 2013 Jul 31;(7):CD004947.

38. Question
• Options of progesterone available

39. Progesterone Supplementation
Type Route Dose (mg) Interval
17-alpha-OHPC Intramuscular injection 250 Weekly
Natural micronized
progesterone
Vaginal suppository 100, 200, 400 Daily
Vaginal gel 90 Daily
Oral capsule 200, 400 Daily
Obstet Gynecol Sci 2017;60(5):405-420

40. Available Progesterone
Vaginal Natural micronized progesterone suppositories
• Optimal dose and its efficacy in pre-term labour require further evidence
• Daily administration
• Vaginal route results in higher concentrations in the uterus but does not
reach high and constant blood levels.
Vaginal progesterone gel
• Need specific applicator
Oral Capsule
• Metabolized in liver and loses its potency
• Irregular blood concentration
• Frequent side effects
Obstet Gynecol Sci 2017;60(5):405-420

41. 17 alpha-hydroxy-progesterone
Caproate (17-OHP)
• First introduced in 1950
• Synthetic progesterone with a longer half-
life of 7 days
• Dose: 250mg/week
• Intramuscular injection
• Only US-FDA approved progestin for
prevention of pre-term birth
Progesterone
17-alpha-hydroxyprogesterone
Semin Perinatol. 2016 Aug;40(5):273-80.

42. Pharmacokinetics
Parameters
Absorption • Tmax : 4.6 (±1.7) days
• Half life: 7.8 days
Distribution • Extensively binds to plasma proteins
Metabolism • Undergoes in extensive reduction,
hydroxylation and conjugation
Excretion • Feces ~ 50%
• Urine ~ 30%

43. NICHD: MFMU Progesterone Trial
• Aim: To establish if weekly progesterone injections in
women with prior spontaneous preterm delivery (sPTD)
reduces the risk of PTD
• Design: double-masked, placebo-controlled trial
• Eligibility criteria: singleton pregnancy 16-20 wks with
documented previous sPTD
• Intervention: progesterone or placebo
• Primary outcome: delivery at < 37 weeks’
• Sample: 463 pregnant women
Meis et al. N Engl J Med. 2003 Jun 12;348(24):2379-85.

44. P<0.0001 P<0.0165 P<0.0180
17 P
17 P
17 P
Placebo
Placebo
Placebo
Meis et al. N Engl J Med. 2003 Jun 12;348(24):2379-85.

45. Effectiveness of Progesterone
• 5-6 women with a previous sPTB would need to be
treated to prevent one birth <37 weeks
• 12 women with a previous sPTB birth would need
to be treated to prevent one birth <32 weeks
Meis et al. N Engl J Med. 2003 Jun 12;348(24):2379-85.

46. Progesterone Prevents Neonatal
complications
• Treatment with 17P resulted in improved neonatal outcomes
• Reduced the likelihood of several complications
Meis et al. N Engl J Med. 2003 Jun 12;348(24):2379-85.

47. Compliance & Safety
• Compliance with the weekly injections was
excellent
• 91.5% of the women received their injections at the
scheduled time
• Side effects were minor and were similar in the 17P
and placebo groups

48. Meta-analysis of 17P in pregnancy
• Meta-analysis by Keirse MJ, 1990
• 5 trials: high risk women with 17-
hydroxyprogesterone caproate injection
• Pooled analysis of results showed:
• Reduction in rates of preterm birth
Odds ratio 0.50, 95% CI: 0.30-0.85
• Reduction in rates of low birthweight
Odds ratio 0.46, 95% CI: 0.27-0.80
Keirse MJNC. Br J Obstet Gynecol 1990;97:149

49. 17-OHP in High Risk Women
• M Ibrahim et al. 2010
• N= 50 eligible women in their second trimester with a
history of previous preterm labor
• Treatment: 17-OHPC 250mg/week in 24th until the 34th
week or placebo
Middle East Fertility Society Journal. 2010; 15(1): 39-41

50. Neonatal Outcome Between Progesterone & Placebo Groups
Middle East Fertility Society Journal. 2010; 15(1): 39-41
• Delivery at <37 gestational weeks was reduced by 20% compared with the
placebo group
• Neonatal delivery, birth weight, NICU stay, and Apgar scores were more favorable
in the 17-OHCP group
• 17-OHPC was effective drug in prevention of preterm birth
PCU – pre-natal care utilization
NICU – Neonatal Intensive Care Unit

51. EFFICACY OF PROGESTERONE FOR PREVENTION OF PRETERM BIRTH
Best practices and research clinical obg and gynae sept 2018
Abstract 5-18%of preg r preterm births
This review supports the efficacy of prophylactic progesterone
SCIENCE DIRECT 2018
Preterm delivery rate was reduced from 28.5% to 13.8% with
100 mg of vaginal proges given from 24 to 34 weeks
MEDSCAPE

52. NIH
• The only preventive drug therapy is progesterone, given to
women who are at higher risk of preterm birth.
• This reduces chances of preterm birth by one third.
• Therapy starts at 16 weeks and continues to 37 weeks of
pregnancy

53. ACOG OCTOBER 2019
Clinical guidance
PROLONG STUDY:
1.Trial comparing the efficacy of 17-OHPC 250 MG im inj weekly
compared with placebo
2. Large multicentric trial randomised , controlled,double blind trial
from nov2009 tooct 2018
3.Almost 1877 women ,at 93 facilities across 9 countries
4. Women were randomised between 16-20 weeks of gestation

54. 156 | © 2019 International Federation of wileyonlinelibrary.com/journal/ijgo Int J Gynecol Obstet 2019; 147: 156–164
Gynecology and Obstetrics
Received: 9 November 2018 | Revised: 29 March 2019 | Accepted: 9 August 2019 | First published online: 28 August 2019
DOI: 10.1002/ijgo.12940
REVIEW AR TICLE
O bst e trics
A systematic review and meta-analysis of randomized controlled
trials comparing 17-alpha-hydroxyprogesterone caproate versus
placebo for the prevention of recurrent preterm birth
Rosa Fernandez-Macias1,2,†
| Raigam J. Martinez-Portilla1,3,
*,†
| Lucas Cerrillos2
|
Francesc Figueras1,4
| Montse Palacio1
1
Fetal i+D Fetal Medicine Research Center,
BCNatal - Barcelona Center for Maternal-Fetal and
Neonatal Medicine (Hospital Clínic and Hospital
Sant Joan de Deu), Institut Clínic de Ginecologia,
Obstetricia i
Neonatologia, Institut d'Investigacions Biomèdiques
August Pi i Sunyer, Universitat de Barcelona,
Barcelona, Catalonia, Spain
2Department of Genetics, Reproduction and
Maternal-Fetal Medicine, University Hospital Virgen
del Rocío, Seville, Spain
3
Maternal-Fetal Medicine and Therapy Research
Center Mexico; on behalf of the Iberoamerican
Research Network in
Translational, Molecular and Maternal-Fetal
Medicine, Mexico City, Mexico
4
Center for Biomedical Research on Rare Diseases
(CIBER-ER), Madrid, Spain
*Correspondence
Raigam J. Martinez-Portilla, Fetal i+D Fetal
Medicine Research Center, BCNatal
- Barcelona Center for Maternal-Fetal and Neonatal
Medicine (Hospital Clínic and Hospital Sant Joan de
Deu), Institut Clínic de Ginecologia, Obstetricia i
Neonatologia, Institut d'Investigacions Biomèdiques
August Pi i Sunyer, Universitat de Barcelona,
Barcelona, Catalonia, Spain.
Email: raifet@hotmail.com
†Joint first authors.
Abstract
Background: Preterm birth causes an increased risk for perinatal morbidity and
mortality.
Objective: To determine whether mid-trimester 17-alpha-hydroxyprogesterone caproate
(17-OHPC) reduces the risk of recurrent preterm birth and adverse perinatal outcomes.
Search strategy: Systematic search to identify relevant studies published in different
languages, registered after 2000, using appropriate MeSH terms.
Selection criteria: Inclusion criteria were women between 16 and 26+6
weeks of
pregnancy with history of preterm delivery in any pregnancy randomized to either 17-
OHPC or placebo/no treatment.
Data collection and analysis: The number of preterm births and adverse outcomes in
the 17-OHPC and placebo arms over the total number of patients in each randomized
group were used to calculate the risk ratio (RR) by random-effects models using the
Mantel-Haenszel method. Between-study heterogeneity was assessed using tau2
, χ2
(Cochrane Q), and I2
statistics.
Main results: Four studies were included. There was a 29% (RR 0.71; 95% CI, 0.53–
0.96; P=0.001), 26% (RR 0.74; 95% CI, 0.58–0.96; P=0.021), and 40% (RR 0.60; 95%
CI,
0.42–0.85; P=0.004) reduction in recurrent preterm birth at <37, <35, and <32 weeks,
respectively, in the 17-OHPC group compared with placebo. The reduction in neonatal
death was 68% (RR 0.32; 95% CI, 0.15–0.66; P=0.002).
Conclusions: 17-OHPC could reduce the risk of recurrent preterm birth at <37, <35, and
<28 weeks and neonatal death.
PROSPERO: CDR42017082190
KEYWORDS
17-alpha-hydroxyprogesterone caproate; Intramuscular progesterone; Meta-analysis; Preterm birth;
Recurrent preterm birth; Systematic review

55. 17-Progesterone caproate In
Prevention of Recurrent PTB
• Fernandez-Macias R et al.
2019
• Four Studies included
• The reduction in neonatal
death was 68%
Int J Gynaecol Obstet. 2019 Nov;147(2):156-164
p=0.021p=0.001
p=0.004
17-OHPC reduces the risk of
• recurrent preterm birth before 37 weeks of pregnancy,
• neonatal death, and birthweight less than 2500 g in women with non-selected cervical
length in the 2nd trimester

56. Objective: To investigate whether treatment with progestogens in the first trimester of pregnancy would decrease the incidence of miscarriage
in women with a history of unexplained recurrent miscarriage.
Design: Systematic review and meta-analysis.
Setting: Not applicable.
Patient(s): Women with a history of unexplained recurrent miscarriage.
Intervention(s): Randomized, controlled trials were identified by searching electronic databases. We included randomized, controlled trials
comparing supplementation with progestogens (i.e., intervention group) in the first trimester of pregnancy with control (either placebo or no
treatment) in women with a history of recurrent miscarriage. All types of progestogens, including natural P and synthetic progestins, were
analyzed.
Main Outcome Measure(s): The primary outcome was the incidence of miscarriage. The summary measures were reported as relative
risk (RR) with 95 confidence interval (CI).
Result(s): Ten trials including 1,586 women with recurrent miscarriage were analyzed. Eight studies used placebo as control and were double-
blind. Regarding the intervention, two RCTs used natural P, whereas the other eight studies used progestins: medroxyprogesterone,
cyclopentylenol ether of progesterone, dydrogesterone, or 17-hydroxyprogesterone caproate. Pooled data from the 10 trials showed that women
with a history of unexplained recurrent miscarriage who were randomized to the progestogens group in the first trimester and before 16 weeks
had a lower risk of recurrent miscarriage (RR 0.72, 95 CI 0.53–0.97) and higher live birth rate (RR 1.07, 95 CI 1.02–1.15) compared with
those who did not. No statistically significant differences were found in the other secondary outcomes, including preterm birth (RR 1.09, 95 CI
0.71–1.66), neonatal mortality (RR 1.80, 95 CI 0.44–7.34), and fetal genital abnormalities (RR 1.68, 95 CI 0.22–12.62).
Conclusion(s): Our findings provide evidence that supplementation with progestogens may reduce the incidence of recurrent miscar- riages
and seem to be safe for the fetuses. Synthetic progestogens, including weekly IM 17-hydroxyprogesterone caproate, but not natural P, were
associated with a lower risk of recurrent miscarriage. Given the limitations of the studies included in our meta- analysis, it is difficult to
recommend route and dose of progestogen therapy. Further head-to-head trials of P types, dosing, and route of administration are required.
(Fertil Steril® 2017;107:430–8. ©2016 by American Society for Reproductive Medicine.)
Key Words: Abortion, endocrinology, meta-analysis, progesterone, review
Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/ 16110-
fertility-and-sterility/posts/12828-22912
Received August 11, 2016; revised October 3, 2016; accepted October 24, 2016; published online November 22, 2016.
G.S. has nothing to disclose. C.S. has nothing to disclose. J.M.F. has nothing to disclose. R.T.S. has nothing to disclose. V.B. has nothing to disclose. Reprint requests: Vincenzo Berghella,
M.D., Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University,
833 Chestnut, Philadelphia, Pennsylvania 19107 (E-mail: vincenzo.berghella@jefferson.edu).
Fertility and Sterility® Vol. 107, No. 2, February 2017 0015-0282/$36.00
Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2016.10.031
ORIGINAL ARTICLE: EARLY PREGNANCY
Supplementation with
progestogens in the first trimester
of pregnancy to prevent
miscarriage in women with
unexplained recurrent miscarriage:
a systematic review and meta-
analysis of randomized, controlled
trials
Gabriele Saccone, M.D.,a
Corina Schoen, M.D.,b
Jason M. Franasiak, M.D.,c
Richard T. Scott, Jr., M.D., H.C.L.D.,c
and
Vincenzo Berghella, M.D.b
a
Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy; b
Division of
Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia,
Pennsylvania; and c
Reproductive Medicine Associates of New Jersey, Morristown, New Jersey
430 VOL. 107 NO. 2 / FEBRUARY2017

57. • In women with a singleton gestation and a history of prior spontaneous pre-
term birth between 20 and 36 6/7 weeks of gestation, we recommend
17OHP-C at 250 mg intramuscularly weekly, starting at 16-20 weeks of
gestation until 36 weeks of gestation or delivery, and vaginal progesterone
should not be considered a substitute for 17OHP-C in these patients
Am J Obstet Gynecol. 2017 Mar;216(3):B11-B13

58. Summary
• Pre-term birth is a major public health problem
• Pre-term is leading cause of morbidity and death of
newborn infants
• First and only agent to date approved for marketing by the
United States Food and Drug Administration (FDA) for
prevention of recurrent preterm birth
• Trials of 17-OHPC have shown consistent efficacy in
reducing pre-term delivery in women with a history of a
previous pre-term delivery

59. Cases
First case
• 38 yrs ,ist conception ivf twins
• Cervical stitch given at 18weeks
• Had PTL at 22 weeks
• And lost both babies
• 2nd pregnancy singleton
• Stich not given
• Started pain at 25 weeks and again lost the baby

60. Cases
2nd case
• 3rd gravida none alive
• 36yrs old
• All losses at 12-14 weeks
• Kept on inj progesterone
• No circlage given
• She is now 36 weeks

61. Healthy Baby …. Healthy Mother