FIGO Good Practice Recommendations on the use of progesterone in the management of recurrent first-trimester miscarriage

Acute liver injury in pregnancy

A woman in her fifth month of pregnancy presented to the outpatient department with vomiting, generalised itching and yellowish discolouration of the skin for 1 week. No history of rashes, fever, pain abdomen or altered stools. In view of four pregnancy losses previously, she was evaluated to have antiphospholipid antibody syndrome and was advised low molecular weight heparin. She was a known type-II diabetic on insulin. Prophylactic oral dydrogesterone and natural micronised progesterone were started at a local hospital 2 months prior, in view of threatened abortion. Investigations revealed grossly elevated serum bilirubin and liver enzymes. Other blood investigations were unremarkable and abdominal ultrasonography was normal. The most likely diagnosis in this case, is drug-induced liver injury due to oral progestin consumption. Causality assessment by Roussel Uclaf Causality Assessment Model was used to establish the diagnosis. High doses of progestin over a prolonged period resulted in acute hepatic toxicity causing itching, jaundice and transaminitis. Cautious use of progestins in appropriate dosage is recommended during pregnancy.

Managing couples with recurrent miscarriage: A narrative review and practice recommendations

There is significant variation in practice when managing couples with recurrent miscarriage (RM), with guidelines differing on the definition of RM, recommended investigations, and treatment options. In the absence of evidence-based guidance, and following on from a paper by the authors-FIGO Good Practice Recommendations on the use of progesterone in the management of recurrent first-trimester miscarriage-this narrative review aims to propose a global holistic approach. We present graded recommendations based on best available evidence.

CPY27B1-related vitamin D deficiency contributes to the impaired function of CD4+T cells in Recurrent spontaneous miscarriage

The study aimed to explore the relationship between the expression of cytochrome P450 family 27 subfamily B member 1 (CYP27B1), vitamin D, and impaired T cell subsets in recurrent spontaneous miscarriage (RSM). A Total of 779 healthy women of childbearing age and 1031 women with a history of RSM were involved in this study. The results of flow cytometry showed that the proportion of Tregs was higher in healthy women than in the women with RSM. For cytokines, the levels of interleukin-17 (IL-17) and interferon-gamma (IFN-γ) were significantly higher in RSM patients than in healthy women, while IL-10 was notably lower in RSM patients. Furthermore, compared to healthy individuals, RSM patients had lower levels of serum 25(OH)D detected by chemiluminescence. The frequency of Tregs was negatively correlated with 25(OH)D. Specifically, for every 10 ng/ml increase in 25(OH)D, the percentage of Tregs increased by 0.58 as calculated. IL-17 and IFN-γ were inversely correlated with 25(OH)D, while the serum interleukin-10 (IL-10) level was positively correlated with 25(OH)D. CYP27B1 was found to be expressed in both cytotrophoblast and extracellular villi trophoblast cells. However, reduced expression of CYP27B1 was observed in the placenta with RSM. Notably, the level of 25(OH)D increased in the supernatant of CYP27B1 knockdown BeWo compared to normal cells, while human chorionic gonadotropin (hCG) was significantly reduced. The hCG secretion of CYP27B1 KO BeWo cells was partially restored after 1,25(OH)2D3 supplementation. In addition, 1,25(OH)2D3 treatment could induce more CD4+ T cells to convert to Foxp3+iTreg, which in turn inhibited the secretion of IL-17, IFN-γ. In summary, this research unveiled a connection between reduced CYP27B1 and vitamin D deficiency in RSM. Our study underscores the potential benefits of vitamin D treatment supplementation in the context of RSM. However, it is important to note that further research is imperative to validate these observations.

Association between the duration of progesterone supplementation treatment and premature neonates outcomes: A retrospective cohort study

Background and Aims

Preterm birth (PTB) is the leading cause of perinatal mortality and morbidity, progesterone is one of the main hormones to maintain a normal pregnancy. However, there are still conflicting results regarding using progesterone supplementation to prevent PTB and improve neonatal outcomes. The length of treatment with progesterone supplementation is also one of the challenges ahead, so the present study was conducted to investigate the relationship between the duration of progesterone supplementation treatment and neonatal outcomes.

Methods

This retrospective cohort study was conducted on pregnant women at risk of PTB and who have taken progesterone supplementation. They were asked about the length of treatment with progesterone supplements and finally, the neonatal outcomes of these women were measured.

Results

A total of 265 pregnant women who met the inclusion criteria were included in this study and the subjects were divided into two groups that received progesterone <12 weeks and received progesterone ≥12. In the group of women receiving progesterone with a treatment duration of ≥12 weeks, the rate of preterm labor, respiratory distress syndrome, low birth weight, and the need for hospitalization were significantly lower than in the group receiving progesterone with a treatment duration of ≥12 weeks.

Conclusion

Progesterone administration for longer than 12 weeks in women at risk of PTB can improve neonatal outcomes.