Management of threatened miscarriage and recurrent miscarriage: guidance on use of progesterone
The Progesterone Pathway ensures that women who have had at least one previous miscarriage and present with early pregnancy bleeding are offered vaginal micronised progesterone, where it is clinically indicated, and provides guidance on asymptomatic women with four or more previous miscarriages.
Use in recurrent miscarriage
The PROMISE trial, the largest multicentre Randomised Control Trial to date, which was adequately powered and with a very low risk of bias, showed that routine progesterone supplementation did not result in a significantly higher rate of live births (progesterone 65.8% vs placebo 63.3%, difference 2.5% (95%CI -4.0-9.0)). However, the efficacy seemed to change based on number of previous miscarriages. The livebirth rate was not higher for women with a history of 3 miscarriages (RR 1.01 CI 0.89-1.14, P=0.91). However, there was a trend to a benefit for women with 4 or more miscarriages (63% vs 58%, P=0.07).
Therefore, based on the evidence from the PROMISE trial, and as per the recommendations in the Lancet miscarriage series, it is recommended that vaginal micronised progesterone treatment should be offered for asymptomatic women with recurrent miscarriage with 4 or more miscarriages.