Progesterone pessaries can be safely prescribed for women who have a threatened miscarriage with bleeding—but how do you decide when to prescribe them?

Professor William Ledger, Head of Obstetrics & Gynaecology at the Royal Hospital for Women says GPs will need to interpret the guidelines according to the age of the woman and any prior miscarriages.
“A young woman who’s had one miscarriage, the likelihood is that she’ll have a good pregnancy the next time around,” said Professor Ledger, suggesting that progesterone may not be needed in these cases. Where a woman is 35 or older, or if she’s lost two or three pregnancies in a row, and is bleeding in her current pregnancy, it is generally recommended.

But there’s room for GP discretion.

Professor Ledger explained that where a woman may have had a single miscarriage and there’s a reduced chance of future pregnancy because she’s a bit older, or a woman under 35 where there’s been one miscarriage and bleeding in the second pregnancy, creating a desperate situation, the GPs can still safely prescribe it.

“Although the evidence isn’t as robust for losing one or two pregnancies, it still may help. And so lots of us, including me, still do that if the woman wants us to,” he said.

The breakthrough evidence came from two research papers published in the New England Journal of Medicine in the last five years based on large, randomised trials that showed the use of vaginal progesterone helped prevent miscarriage.

Professor Ledger said the progesterone pessaries are usually prescribed if bleeding occurs in the first trimester at around the six-week mark for about two to three weeks. In these cases, a GP should prescribe Utrogestan progesterone pessaries at 400 milligrams twice a day, Professor Ledger said, adding that it’s the only one licensed by the TGA.

“Then you would move to half the dose for a week and wean off it gently and see what happens. By then the pregnancy is usually robust and there’s no more bleeding and she has a happy pregnancy,” he said.

Professor Ledger also advised doctors to act quickly and start progesterone right away where it’s needed and to refer women to a specialist clinic such as the Early Pregnancy Assessment Clinics where they can get a range of care and work in collaboration with the primary care GP.

“If they need more specialist reproductive advice, it’s nice for primary care to know our clinics are accessible and they’re in major towns and cities,” he said.

Progesterone pessaries are routinely used in IVF and it is only covered on the pharmaceutical benefits schemes for IVF or to mothers of twins who are trying to avoid premature birth or people who are at risk of a premature birth, Professor Ledger noted. However, progesterone pessaries are not covered by the PBS for threatened miscarriage. “A private prescription is needed for miscarriage and the cost of that is about $9 a day,” he said.

Professor Ledger spoke on this topic at The Annual Women’s & Children’s Health Update 2023 in Adelaide, Brisbane, Melbourne, Sydney and Perth. Don’t miss out on Healthed’s next face-to-face seminar, find out more here.

You’ll get 8hrs of CPD in the Educational Activities category PLUS you can earn another 4hrs of CPD in the Reviewing Performance category by completing the post-seminar quizzes. Healthed will manage the CPD upload process to RACGP and ACRRM.

For more on this topic, see Dr Anneliese Perkin’s lecture available here.