PROMISE: first-trimester progesterone therapy in women with a history of unexplained recurrent miscarriages – a randomised, double-blind, placebo-controlled, international multicentre trial and economic evaluation

Health Technology Assessment

Yacoub Khalaf¹  Marjory MacLean²  Siobhan Quenby³  Ayman Ewies⁴  Rachel Small⁵  Pratima Gupta⁵  Mark David Kilby⁶  Justin Chu⁷  Abey Eapen⁷  Ewa Truchanowicz⁷  Arri Coomarasamy⁷  Helen Williams⁷  Dominic Trépel⁸  Steve Parrott⁸  Holly Essex⁸  Mariëtte Goddijn⁹  Carolien A Koks^1,10  Judith Moore^1,11  Eugenie M Kaaijk^1,12  Kitty WM Bloemenkamp^1,13  Annemieke Hoek^1,14  Yvonne E Koot^1,15  Paul T Seed^1,16  Annette Briley^1,17  Jackie A Ross^1,18  Roy G Farquharson^1,19  Feroza Dawood^1,19  Nirmala Vaithilingam^2,20  Tin-Chiu Li^2,21  Jane Stewart^2,22  Ruth Bender Atik^2,23  Ben W Mol^2,24  Ying C Cheong^2,25  Lesley Regan^2,26  Rebecca Cavallaro^2,26  Lisa Sharpe^2,26  Rebecca Brady^2,26  Rajendra Rai^2,26 

[1] Assisted Conception Unit, Guy’s and St Thomas’ NHS Foundation Trust, London, UK;Ayrshire Maternity Unit, University Hospital of Crosshouse, Kilmarnock, UK;Biomedical Research Unit in Reproductive Health, University of Warwick, Coventry, UK;Birmingham City Hospital, Sandwell and West Birmingham Hospitals NHS Teaching Trust, Birmingham, UK;Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK;Centre for Women’s and Children’s Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK;College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK;Department of Health Sciences, University of York, York, UK;Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Academic Medical Centre, Amsterdam, the Netherlands;Department of Obstetrics and Gynaecology, Maxima Medical Centre Veldhoven, Veldhoven, the Netherlands;Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK;Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands;Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands;Department of Reproductive Medicine and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands;Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands;Department of Women’s Health, King’s College London and King’s Health Partners, St Thomas’ Hospital, London, UK;Department of Women’s Health, King’s Health Partners, St Thomas’ Hospital, London, UK;Early Pregnancy and Gynaecology Assessment Unit, King’s College Hospital NHS Foundation Trust, London, UK;Liverpool Women’s Hospital, Liverpool Women’s NHS Foundation Trust, Liverpool, UK;Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK;Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK;Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK;The Miscarriage Association, Wakefield, UK;The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, SA, Australia;University of Southampton Faculty of Medicine, Princess Anne Hospital, Southampton University Hospital NHS Trust, Southampton, UK;Women’s Health Research Centre, Imperial College at St Mary’s Hospital Campus, London, UK;

关键词: promise trial;    recurrent miscarriage;    randomised placebo-controlled trial;    economic evaluation;    progesterone;   

DOI  :  10.3310/hta20410

来源: DOAJ

【 摘 要 】

Background and objectives: Progesterone is essential to maintain a healthy pregnancy. Guidance from the Royal College of Obstetricians and Gynaecologists and a Cochrane review called for a definitive trial to test whether or not progesterone therapy in the first trimester could reduce the risk of miscarriage in women with a history of unexplained recurrent miscarriage (RM). The PROMISE trial was conducted to answer this question. A concurrent cost-effectiveness analysis was conducted. Design and setting: A randomised, double-blind, placebo-controlled, international multicentre study, with economic evaluation, conducted in hospital settings across the UK (36 sites) and in the Netherlands (nine sites). Participants and interventions: Women with unexplained RM (three or more first-trimester losses), aged between 18 and 39 years at randomisation, conceiving naturally and giving informed consent, received either micronised progesterone (Utrogestan®, Besins Healthcare) at a dose of 400 mg (two vaginal capsules of 200 mg) or placebo vaginal capsules twice daily, administered vaginally from soon after a positive urinary pregnancy test (and no later than 6 weeks of gestation) until 12 completed weeks of gestation (or earlier if the pregnancy ended before 12 weeks). Main outcome measures: Live birth beyond 24 completed weeks of gestation (primary outcome), clinical pregnancy at 6–8 weeks, ongoing pregnancy at 12 weeks, miscarriage, gestation at delivery, neonatal survival at 28 days of life, congenital abnormalities and resource use. Methods: Participants were randomised after confirmation of pregnancy. Randomisation was performed online via a secure internet facility. Data were collected on four occasions of outcome assessment after randomisation, up to 28 days after birth. Results: A total of 1568 participants were screened for eligibility. Of the 836 women randomised between 2010 and 2013, 404 received progesterone and 432 received placebo. The baseline data (age, body mass index, maternal ethnicity, smoking status and parity) of the participants were comparable in the two arms of the trial. The follow-up rate to primary outcome was 826 out of 836 (98.8%). The live birth rate in the progesterone group was 65.8% (262/398) and in the placebo group it was 63.3% (271/428), giving a relative risk of 1.04 (95% confidence interval 0.94 to 1.15; p = 0.45). There was no evidence of a significant difference between the groups for any of the secondary outcomes. Economic analysis suggested a favourable incremental cost-effectiveness ratio for decision-making but wide confidence intervals indicated a high level of uncertainty in the health benefits. Additional sensitivity analysis suggested the probability that progesterone would fall within the National Institute for Health and Care Excellence’s threshold of £20,000–30,000 per quality-adjusted life-year as between 0.7145 and 0.7341. Conclusions: There is no evidence that first-trimester progesterone therapy improves outcomes in women with a history of unexplained RM. Limitations: This study did not explore the effect of treatment with other progesterone preparations or treatment during the luteal phase of the menstrual cycle. Future work: Future research could explore the efficacy of progesterone supplementation administered during the luteal phase of the menstrual cycle in women attempting natural conception despite a history of RM. Trial registration: Current Controlled Trials ISRCTN92644181; EudraCT 2009-011208-42; Research Ethics Committee 09/H1208/44. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 41. See the NIHR Journals Library website for further project information.

【 授权许可】

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