Role of Progesterone In threatened and recurrent miscarriage Dr. Eeson Sinthamoney MD (Mal), MRCOG (London), DFFP (UK) Fellowship in Reproductive Medicine (UK/Singapore) Consultant Obstetrician, Gynaecologist & Fertility Specialist Pantai Hospital Kuala Lumpur

Parameters Recurrent miscarriages – definition, causes and role of progesterone Threatened miscarriages – definition, prognosis and role of progesterone Immunological basis – progesterone role Summary & conclusion

Ultimately………… Is there or isn’t there a role for progesterone therapy in patients with recurrent miscarriage and threatened miscarriage?

Managing women with recurrent losses: a never ending controversy……. Up to 50% of them will have no identifiable reason The need to be evidence-based in investigation and management Evidence is a moving target! In the unexplained group, up to 75% have a term live birth with TLC alone

Defining recurrence Three or more consecutive pregnancy losses occurring before 24 weeks of gestation Royal College of Obstetricians and Gynaecologists Guideline 17 – The investigation and treatment of couples with recurrent miscarriage. May 2003 ASRM 2008 definition

≥ 2 or ≥ 3 ? Based on the assumption that prevalence of possible causes will be different in those with 2 compared to those with ≥3 miscarriages No such difference found! However, this increases scale of the problem from 1% to 5% of couples trying to conceive Habayeb Om, Konje JC. The one-stop recurrent miscarriage clinic: an evaluation of its effectiveness and outcome. Human Reproduction 2004;19:2952-8 Hogge WA et al. the clinical use of karyotyping spontaneous abortions. Am J Obstet Gynaecol 2003;189:397-400 Jaslow CR et al. Diagnostic factors identified in 1020 women with two versus three or more recurrent pregnancy losses. Fertil Steril. 2009

What causes recurrent losses ?

Causes Cause n Prothrombotic state 54 Chromosomal anomaly 11 Uterine anomaly 53 Polycystic ovaries 13 Retarded endometrium Unexplained 188 Unknown 79 Total 452 Li TC et al. Pattern of pregnancy loss in women with recurrent miscarriages after referral, according to diagnostic criteria. Fertility and Sterility.2002;78(5):1100-1106

Causes Osama M.H.Habayeb and Justin C.Konje. The one-stop recurrent miscarriage clinic: an evaluation of its effectiveness and outcome. Human Reproduction Vol.19, No.12 pp. 2952–2958, 2004

Evidence based investigation and treatment TORCHES Diabetes Thyroid disorders Autoimmune disorders ✖ Genetic factors Anatomical factors Polycystic ovarian syndrome Bacterial vaginosis Antiphopholipid antibody syndrome Progestrone Aspirin Heparin Steroids hCG ? ✔

Issues Do we assess all couples for genetic causes? How do we prepare PCO patients pre- conceptually? In patients without APL antibodies, does empherical aspirin or heparin help? What about other thrombophilias? How do we assess for anatomical defects? Finding and treating BV

Progesterone LPD was first described by Jones in 1949 as a clinical entity, it has been poorly characterised conflicting evidence on LPD exogenous progesterone supplementation remains a common intervention for both threatened and idiopathic recurrent miscarriages

Progesterone: current evidence No evidence to support the routine use of progesterone in the first trimester to prevent miscarriage However, subgroup analysis of women with RM showed a statistically significant decrease in miscarriage rate compared to placebo or no treatment The route of treatment did not influence the results Haas DM et al. Progestogen for preventing miscarriage. Cochrane Database Syst Rev. 2008

Conclusion Give progesterone in recurrent miss-carriers especially in idiopathic cases However, no evidence to support routine use in first trimester to prevent miscarriage Role in threatened miscarriage?

Threatened miscarriage A threatened miscarriage is defined as vaginal bleeding, usually painless, that occurs in the first 24 weeks in a viable pregnancy without cervical dilatation. It is common, especially in the first trimester, occurring in 14%–21% of all pregnancies Important causes include chromosomal abnormalities, which occur in about 70% of the cases

Threatened miscarriage Prognosis of threatened miscarriage with expectant management: -Gestational age: 29% of foetuses presenting at 5–6 weeks, 8.2% at 7–12 weeks and 5.6% at 13–20 weeks, miscarried -Severity of bleed: those who had active fresh bleeding (excluding spotting), and a viable foetus at presentation (average gestation period was 8 weeks), the miscarriage rate was 9.3%. Basama FM, Crosfill F. The outcome of pregnancies in 182 women with threatened miscarriage. Arch Gynecol Obstet 2004; 270:86-90. Johns J, Jauniaux E. Threatened miscarriage as a predictor of obstetric outcome. Obstet Gynecol 2006; 107:845-50

Why isn’t there evidence to support the use of progesterone In treatment of threatened miscarriage?

Conclusion: Corpus luteal support with dydrogesterone has been shown to reduce the incidence of pregnancy loss in threatened abortion during the first trimester in women without a history of recurrent abortion.

Theoretical considerations What role does progesterone play in maintaining a successful pregnancy? Therefore, based on sound scientific understanding is there adequate justification to give our threatened miscarriage patients progesterone? Successful embryo implantation requires both an activated blastocyst and synchronized development of a receptive endometrium. The process of embryo implantation can be divided into three main phases: apposition, adhesion and invasion.

Successful mammalian pregnancy depends upon tolerance of a genetically incompatible fetus by the maternal immune system.

Immunology – back to basics macrophages General responce granulocytes Secondary responce Type 1/Cellular Type 2/ Humoral T cells antibodies Differentiate into Th1 and Th2 lymphocytes, which secrete different types of IL and IFN

Immunology of pregnancy Medawar’s ‘fetal allograft’ hypothesis 1953: Fetal survival was d/t anatomical separation of fetus, antigenic immaturity of fetus and immunological inertness of mother (high steroids) Medawar-shwartzman paradox

Immunology of pregnancy Tolerance is now believed to depend in part on the interactions of cytokines secreted by maternal and fetal cells at the site of implantation.

Immunology of pregnancy An inflammatory response with predominant pro- inflammatory Th1 cytokines is necessary for initial implantation with invasion of trophoblasts and induction of angioneogenesis. Keleman K, Paldi A, Tinneberg H, Torok A, Szekeres-Bartho J: AJRI 1998; 39: 351-355

Immunology of pregnancy But thereafter the potential detrimental effects of the pro-inflammatory response are counteracted by anti-inflammatory cytokines (TGF-B2) involving a Th1 to Th2 shift.

Anti versus pro-inflammatory cytokines Th-1 cytokines (TNF-, IFN-, IL-2, IL-12, Il- 18) induce several cell-mediated cytotoxic and inflammatory reactions Th-2 cytokines (IL-4, IL-5, IL-6, IL-10, IL-13) are associated with B cell antibody production Th-2 cytokines downregulate Th-1-type reactivity.

Shift towards TH-2 response, resulting in: Anti-inflammatory cytokines > pro-inflammatory cytokines “IMMUNOMODULATION”

Progesterone ?

Progesterone – role in immunology of pregnancy When antigens on trophoblast are recognized, peripheral blood lymphocytes and CD56+ cells in decidua develop specific progesterone receptors If sufficient progesterone present  these cells produce a protein called Progesterone Induced Blocking Factor (PIBF) PIBF is the pivotal mediator in progesterone dependent immunomodulation* DH Munn et al. Prevention of allogenic foetal rejection by tryptophan catabolism. Science 281 (1998) 1191-93

PIBF  anti-abortive effects of progesterone Induces increased production and predominance of Th2 cytokines. Downregulates expression of the prothrombinase fgl2. Szekeres-Bartho J, Wegmann T: J Reprod Immunol 1996; 31: 81-95.

Progesterone Receptors 10 9 3rd TRIMESTER 2nd TRIMESTER 8 7 NON PREGNANT 1st TRIMESTER PRETERM DEL. 6 ABORTION RECEPTOR + CELLS % 5 4 3 2 1 Szekeres-Bartho J et al. Lymphocytic progesterone receptors in normal and pathological human pregnancy. J Reprod Immunol. 1989 Dec;16(3):239-47

Looking for evidence 1.Does PIBF really modulate the immunological reaction towards a Th-2 bias in pregnancy? Effects of PIBF on selected type 1 and type 2 cytokines secretion from peripheral blood mononuclear cells from: 30 women with unexplained RSM 18 women undergoing PTD 11 women normal pregnancy 13 healthy non pregnant women type 2 cytokines significantly increased in pregnant groups, with Th-2 bias but did not effect non-pregnant women Raghupathy R et al. Progesterone –induced blocking factor (PIBF) modulates cytokine production by lymphocytes from women with recurrent miscarriage or preterm delivery. J reprod Immunology 80 (2009) 91-99

Evidence:2 2. PIBF and cytokine levels in normal versus threatened miss-carriers 30 women with threatened miscarriage 20 healthy pregnant women, 6-24 weeks Serum + urine PIBF, IL10, IL6, TNF, IFN measured 1. PIBF concentration in urine and serum of threatened miss-carriers significantly lower than in healthy pregnant women 2. Threatened miss-carriers significantly lower serum levels of anti-inflammatory cytokines and higher pro-inflammatory cytokines than healthy controls Hudic I et al. Progesterone-induced blocking factor (PIBF) and Th(1)/Th(2) cytokine in women with threatened spontaneous abortion. J Perinat Med. 2009;37(4):338-42

Evidence: 3 3. Does progesterone treatment make a difference on hormone profile? 27 women with threatened miscarriage treated for 10 days with dydrogesterone 16 healthy pregnant controls, no treatment Serum P4 and E2 levels and urine PIBF measured 1. Serum progesterone in controls increased as pregnancy progressed but not threatened cases 2. PIBF in threatened cases initially low, significantly increased after treatment, reaching normal healthy control levels Kalinka J et al. The impact of dydrogesterone supplementation on hormonal profile and progesterone-induced blocking factor concentrations in women with threatened abortion. Am J Reprod Immunol. 2005 Apr;53(4):166-71

Evidence: 4 Does dydrogesterone change the type of cytokines produced? 30 women with unexplained RSM Peripheral blood mononuclear cells (PBMC) from venous blood stimulated with phytohaemagglutinin (PHA) IFN-, TNF-, IL-4,IL-6,IL-10 and PIBF measured Dydrogesterone significantly inhibited the production of the Th1 cytokines IFN-,TNF- and induced an increase in the levels of the Th2 cytokines IL-4 and IL-6 resulting in a substantial shift in the ratio of Th1/Th2 cytokines Raghupathy R et al. Modulation of cytokine production by dydrogesterone in lymphocytes from women with recurrent miscarriage. BJOGAugust 2005, Vol. 112, pp. 1096–1101

progestogens

Which progestogen is best? Medroxyprogesterone Has androgenic and anabolic effects Early case report linking first trimester use to CAH in a male neonate (1969) Later and larger studies showed no association FDA – category X – contraindicated if are / may become pregnant 17-hydroxyprogesterone caproate Reports of fetal genital abnormalities and virilization (Cochrane 2003) Recent evidence – reduces PTD risk when given from 16 weeks onwards (NEJM 2003) Dydrogesterone No androgenic effects No reports of fetal abnormalities except one when used together with 17OHPC (1977)

Summary -Inhibition of NK cell activity -Asymmetric, pregnancy protecting a/b -Th2 bias

Immunological recognition of pregnancy Up-regulation of progesterone receptors on NK cells in decidua / lymphocytes amongst placental cells In presence of sufficient progesterone, activated lympocytes and decidual CD56+ cells synthesise Progesterone induced Blocking Factor (PIBF) Effect on humoral (B cell) and cellular (T cell) immune system and reduced NK cell activity* substantial anti-abortive effects *J Szekeres-Bartho et al. The role of g/d T cells in progesterone-mediated immunomodulation during pregnancy: a review. Am J Reprod Immunolo 42(1999) 44-8

Summary & conclusion Recurrent miscarriage especially idiopathic– give progesterone Important ‘immunomodulatory’ role of progesterone via PIBF in immunology of pregnancy Good evidence to support concept of progesterone deficiency in threatened / recurrent miscarriage Threatened miscarriage – consider progesterone despite lack of RCT evidence Routine use to prevent miscarriage – NO!

Thank you