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The role of progestogens in threatened and idiopathic recurrent miscarriage

Hisham Arab

It is well known that progesterone plays a major role in the maintenance of pregnancy, particularly during the early stages. The management of pregnant women at risk of a threatened or idiopathic recurrent miscarriage is complex and critical. Therefore, a group of obstetricians and gynecologists practicing in Saudi Arabia gathered to update the 2014 Saudi guidelines for threatened and recurrent miscarriage management. In preparation, a literature review was conducted to explore the role of oral, vaginal, and injectable progestogens: this was used as a basis to develop position statements to guide and standardize practice across Saudi Arabia.

Position Statements Threatened Miscarriage 1. For women presenting with a clinical diagnosis of threatened miscarriage, dydrogesterone may reduce the rate of miscarriage. 2. Oral dydrogesterone should be offered. Manufacturer dosage: 40 mg loading, then 30 mg once daily until symptoms (bleeding) remit. If symptoms persist/ recur, increase dose by 10 mg three times a day. Maintain effective dose for 1 week after symptoms have ceased and then gradually reduce dose. Immediately resume treatment at effective dose, if symptoms recur.

Recurrent Miscarriage 1. Thorough investigations are warranted to rule out other causes of miscarriage. Once ruled out, a diagnosis of idiopathic recurrent miscarriage is confirmed. 2. For women presenting with a clinical diagnosis of idiopathic recurrent miscarriage (having experienced two or more), there is a reduction in the rate of miscarriage with the use of dydrogesterone. 3. Dydrogesterone should be administered as early as possible, at the diagnosis of pregnancy or during the luteal phase, in stimulated cycles. 4. Oral dydrogesterone should be offered. Manufacturer dosage: 10–20 mg daily, until the 20th week of pregnancy. Treatment should preferably start before conception. If symptoms of threatened miscarriage occur during treatment, continue treatment as stated for that indication