Role of Progesterone in Preventing Threatened & Recurrent Miscarriage

Speaker: Dr Ameet Patki, Vice President ISAR

Chairpersons: Dr Laxmi Shrikhande, Chairperson Elect ICOG and Dr Archana Baser, Vice President FOGSI 2020-21

Watch the Expert himself speak and describe the role of progesterone in preventing threatened and recurrent miscarriage. His phenomenal research work in infertility makes him the best teacher on the subject

• The problem occurs in the implantation stage, there can be problems associated with the embryo, endometrium with the interaction between embryo and endometrium and in case of ART it could be iatrogenic.

• So, when you look at pregnancy it is not only the progesterone hormone although it is the only single hormone that successively rises in all 3 trimesters and we know now it could be one of the reasons for luteal phase defect, recurrent implantation failure or even preterm labor. But it is not only the hormonal effect of progesterone, but certain progesterones have an immunomodulatory effect that is very important–cytokines & interleukins.

• 15% of spontaneously conceived pregnancies end in a miscarriage and as high as 45% when there are 3 consecutive miscarriages. To salvage the condition, many options are available like bed rest which will rarely have any benefit, uterine relaxants and anti-spasmodics have been used sporadically but Cochrane review concludes insufficient evidence for these; option of multiple small doses of HCG allow more production of progesterone but is unacceptable to patient as numerous pricks, also can lead to hyperstimulation.

• One in five pregnancies are complicated with vaginal bleeding before 20 weeks of gestation, also accompanied with cramps and back pain, sometimes intermittent spotting which may last for hours, so a per speculum examination to confirm that the cervix is closed and sonography to confirm intrauterine viable fetus to go ahead and start treatment with progesterone.

• Published studies discussed for bleeding in early pregnancy–Coomarasamy’s PRISM trial–400mg vaginal progesterone or matching placebo–no difference in live birth rates or other outcomes. Disappointing results seen for progesterone for threatened miscarriages by the PRISM trial.

• PROMISE study showed a better live birth rate–contradicting PRISM.

• Systematic review evidence favour the orally acting Dydrogesterone in threatened miscarriage, Dydrogesterone reduced the risk by half. 40mg loading dose followed by 10mg BD for a week after the bleeding stopped.

• Australian and New Zealand Guidelines discussed.

• For spontaneous recurrent miscarriage continue till 20 weeks of gestation till placentation is well established. Dydrogesterone alone was found to be better. European guidelines discussed.

• Oral Dydrogesterone is effective in preventing threatened miscarriages and recurrent spontaneous miscarriages giving you a statistically significant reduction in miscarriages.