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      Did the NICE guideline for progesterone treatment of threatened miscarriage get it right?

      research-article
      1 ,
      Reproduction & Fertility
      Bioscientifica Ltd
      luteal support, gestation, pessary, bleeding, pregnancy

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          Abstract

          In November 2021, NICE updated its clinical guideline that covers the management of threatened miscarriage in the first trimester. They recommended offering vaginal micronised progesterone twice daily until 16 completed weeks of pregnancy in those with a previous miscarriage. However, the duration of treatment is not evidence based. In the major clinical trial that informed the guideline, there was no benefit in starting progesterone after 9 weeks and the full effect of progesterone was present at 12 weeks of pregnancy. There are theoretical risks impacting offspring health in later life after maternal pharmaceutical progesterone treatment. As the effect of progesterone seems to be complete by 12 weeks of gestation, we should consider carefully whether to follow the guidance and treat up to 16 weeks of pregnancy.

          Lay summary

          In November 2021, new guidelines were published about the management of bleeding in early pregnancy. If someone who has had a previous miscarriage starts bleeding, they should now be treated with progesterone as this slightly reduces the chance of miscarriage. The guideline says progesterone should be given if the pregnancy is in the womb, and potentially normal, until 16 weeks of pregnancy. However, in the big studies looking at progesterone’s effect in reducing miscarriage the beneficial effects of progesterone were complete by 12 weeks of pregnancy. At that stage, it is the placenta and not the mother’s ovary that makes the progesterone to support the pregnancy. We do not know the long-term effects of giving extra progesterone during pregnancy on the offspring. Some research has raised the possibility that there might be some adverse effects if progesterone is given for too long. Maybe the guidance should have suggested stopping at 12 weeks rather than 16 weeks of pregnancy.

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          Most cited references8

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          Endocrine-disrupting chemicals: an Endocrine Society scientific statement.

          There is growing interest in the possible health threat posed by endocrine-disrupting chemicals (EDCs), which are substances in our environment, food, and consumer products that interfere with hormone biosynthesis, metabolism, or action resulting in a deviation from normal homeostatic control or reproduction. In this first Scientific Statement of The Endocrine Society, we present the evidence that endocrine disruptors have effects on male and female reproduction, breast development and cancer, prostate cancer, neuroendocrinology, thyroid, metabolism and obesity, and cardiovascular endocrinology. Results from animal models, human clinical observations, and epidemiological studies converge to implicate EDCs as a significant concern to public health. The mechanisms of EDCs involve divergent pathways including (but not limited to) estrogenic, antiandrogenic, thyroid, peroxisome proliferator-activated receptor gamma, retinoid, and actions through other nuclear receptors; steroidogenic enzymes; neurotransmitter receptors and systems; and many other pathways that are highly conserved in wildlife and humans, and which can be modeled in laboratory in vitro and in vivo models. Furthermore, EDCs represent a broad class of molecules such as organochlorinated pesticides and industrial chemicals, plastics and plasticizers, fuels, and many other chemicals that are present in the environment or are in widespread use. We make a number of recommendations to increase understanding of effects of EDCs, including enhancing increased basic and clinical research, invoking the precautionary principle, and advocating involvement of individual and scientific society stakeholders in communicating and implementing changes in public policy and awareness.
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            A Randomized Trial of Progesterone in Women with Bleeding in Early Pregnancy

            Bleeding in early pregnancy is strongly associated with pregnancy loss. Progesterone is essential for the maintenance of pregnancy. Several small trials have suggested that progesterone therapy may improve pregnancy outcomes in women who have bleeding in early pregnancy.
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              A Randomized Trial of Progesterone in Women with Recurrent Miscarriages.

              Progesterone is essential for the maintenance of pregnancy. However, whether progesterone supplementation in the first trimester of pregnancy would increase the rate of live births among women with a history of unexplained recurrent miscarriages is uncertain.
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                Author and article information

                Journal
                Reprod Fertil
                Reprod Fertil
                raf
                Reproduction & Fertility
                Bioscientifica Ltd (Bristol )
                2633-8386
                07 April 2022
                01 April 2022
                : 3
                : 2
                : C4-C6
                Affiliations
                [1 ]MRC Centre for Reproductive Health , The University of Edinburgh, Queen’s Medical Research Institute, Edinburgh, UK
                Author notes
                Correspondence should be addressed to W C Duncan: W.C.Duncan@ 123456ed.ac.uk
                Author information
                http://orcid.org/0000-0002-7170-5740
                Article
                RAF-21-0122
                10.1530/RAF-21-0122
                9066946
                35514538
                b98c04cc-e802-4524-aa72-cedd85c225ac
                © The authors

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                History
                : 01 April 2022
                : 07 April 2022
                Categories
                Commentary

                luteal support,gestation,pessary,bleeding,pregnancy
                luteal support, gestation, pessary, bleeding, pregnancy

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