Publication - Advice and guidance
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.
Ensuring that a pregnancy is viable or potentially viable
Miscarriage can sometimes be diagnosed on a single ultrasound scan and treatment of a non-viable pregnancy inappropriately with progesterone can unnecessarily delay management of a miscarriage.
This means that only the following scan findings in women with threatened miscarriage and previous miscarriage would be suitable for vaginal micronised progesterone treatment:
- Normally sited pregnancy within the uterus with fetal pole and fetal heart pulsation confirmed.
- Normally sited pregnancy with a fetal pole where the CRL <7mm and no fetal heart pulsation is seen.
- Normally sited pregnancy with a gestational sac and a yolk sac but no fetal pole.
- Where there is a gestation sac (MSD <25mm) but no fetal pole and no yolk sac. However, caution should be exercised because a pseudosac can sometimes be seen in ectopic pregnancy. A gestation sac is eccentrically placed in the uterus with an obvious decidual reaction. Pseudosacs are in the midline with no decidual reaction and may have teardrop rather than smooth edges. If a pseudosac is suspected this is a pregnancy of unknown location and progesterone should not be offered at this stage.
Progesterone should not be offered:
- For women with threatened miscarriage who have no history of previous miscarriage.
- For women with a pregnancy of unknown location (PUL). These women need additional assessment with hCG measurement and repeat scanning.
- For women of previous molar/ectopic pregnancy/PUL alone with no previous miscarriage.
- For women with some clinical conditions and elements of patient history that mean that treatment with progesterone is contraindicated or relatively contraindicated even if they have a history of previous miscarriages, therefore treatment must take individual history into account.