1. 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

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

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

4. 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

5. 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

6. ≥ 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:
Jaslow CR et al. Diagnostic factors identified in 1020 women with two versus three or more recurrent pregnancy losses. Fertil Steril. 2009

7. What causes recurrent losses ?

8. 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):

9. 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

10. 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 ? ✔

11. 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

12. 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

13. 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

14. 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?

15. 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

16. 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

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

18. 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.

19. 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.

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

21. 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

22. 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

23. 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.

24. 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:

25. 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.

26. 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.

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

28. Progesterone ?

29. 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)

30. 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:

31. Progesterone Receptors10 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 Dec;16(3):239-47

32. 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

33. 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

34. 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 Apr;53(4):166-71

35. 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

36. progestogens

37. 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)

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

39. 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

40. 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!

41. Thank you