General Category => Pregnancy Complications: PPROM, preeclampsia, gestational diabetes, and more => Topic started by: Charlotte on June 12, 2018 at 11:22 PM

Title: Questions about progesterone pessaries
Post by: Charlotte on June 12, 2018 at 11:22 PM
Hi all.

My doctor has just prescribed progesterone pessaries (100mg) to use every night, due to an initially funnelling, now dynamic cervix. I'm 28+3.

I didn't think to ask at my appointment yesterday so I just googled now and came across all sorts of information talking about how progesterone shouldn't be used past the first trimester... Any thoughts? The leaflet that came with the pessaries just said to let the doctor know if you're pregnant and weigh up advantages and disadvantages with the doctor. Pretty standard really.

I also noticed some side effects already after one night's use. Mainly insomnia and a mild nausea that started at night already and has been coming and going all day. Both these were listed as a possible side effect. Anyone else experience any side effects? Do they eventually subside?

Many thanks in advance.

Title: Re: Questions about progesterone pessaries
Post by: OBmom on June 13, 2018 at 12:14 PM
Hi Charlotte.

First of all, congrats on making it past 28 weeks, you've already overcome the hardest part.
Progesterone is one of the mainstays in treating insufficient cervix, so please don't worry about using it in the 2nd or 3rd trimester. I have some scientific literature on how vaginal progesterone is effective and safe in preventing preterm birth. If you want I can send it to you.
Also, the side effects tend to be very limited because it is absorbed locally. You wouldn't expect systemic effects (side effects affecting your whole body) as you would if you were to take it orally. Keep in mind that insomnia and nausea are common when you're pregnant, and they're likely to worsen if you're anxious.
I took progesterone from 23 to 36 weeks, and it helped a lot. Most moms here will tell you that on the days they take progesterone they feel less pelvic pressure and contractions. Just don't push it past 36 weeks because it can affect your liver by then, and maybe trigger pregnancy cholestasis.

Best of luck to you!
Title: Re: Questions about progesterone pessaries
Post by: Charlotte on June 13, 2018 at 07:23 PM
Many thanks for your answer Obmom. And thank you, that's comforting to hear.

That's actually another thing I was a little concerned about and seeing as you are an OB (or is this an incorrect assumption? 😃) you might be able to shed some light. So my mum had cholestasis with both her pregnancies and her ASTs and ALTs absolutely sky-rocketed with the first because it wasn't caught until she was overdue (then promptly induced and I came along). I'm being closely monitored due to this family history and whilst my bile acids have all been normal so far (5 tests over 10 weeks) my ASTs and ALTs were above the reference ranges for the first time last week. Only slightly but they have been creeping up slowly so I'm not actually thinking they'll stop there. To me this is an indication that something is happening with my liver, and given that progesterone is processed in the liver I was wondering if it's not such a good option for me. Or am I overthinking things? In the leaflet that came with the pessaries it says to let your doctor know if you have liver disease, but that's not exactly the case either because both with mum and me our livers are fine when we're not pregnant. Any thoughts on this?

Title: Re: Questions about progesterone pessaries
Post by: SilentStorm on June 13, 2018 at 08:57 PM
Great reply by OBMOM. I have also been prescribed progesterone pills to insert vaginally each night. Part of the confusion at the pharmacy and at the patient level is because this is essentially an “off label” use of a medication normally prescribed for other reasons. Upon further reasearch (of the available reasearch so far), the success rate of avoiding pre-term birth is really remarkable, compared to he placebo groups studied.
Bottom line, though, in the high-risk OB world, this is becoming a standard of care.
I won’t tell you not to worry, but hope this does help put your mind at ease. :)
Title: Re: Questions about progesterone pessaries
Post by: Charlotte on June 13, 2018 at 10:57 PM
Thanks for your input SilentStorm. I'm grateful for any thoughts and ideas re this and every reassuring word helps. :)
Title: Re: Questions about progesterone pessaries
Post by: OBmom on June 16, 2018 at 04:50 PM
Hi Charlotte.

Your assumption is spot-on, it's all in the screen name really :) I'm an OB in a high-risk big MFM center, biggest L&D in Portugal.

Cholestasis does tend to be hereditary, but that doesn't mean you'll get it for sure. Even in normal pregnancy, AST and ALT levels can suffer a slight rise without causing concern. With your family history however I'd keep an eye on things weekly. In pregnant women with cholestasis, we usually tolerate rises up to 3-4 times the normal upper limit (i.e. up to 200-300) - this is a marker of how you're doing, and has no relation to the baby's outcome.

As I said before, progesterone is more likely to trigger cholestasis at late preterm (34-37w), so everything balances on how far along you are. However, the benefits for PTB are so extensive I would recommend keep going at least until 34 weeks. Definitely keep an eye out for any signs and symptoms - abnormal itching that usually affects your palms and the soles of your feet but may spread to your abdomen and chest, especially if it gets worse in the evening. Pregnancy cholestasis is mainly a clinical diagnosis but normally also presents with high levels of bile acids. If you do get diagnosed, most experts believe in induction at around 37 weeks, because of the increased (and unpredictable) risk of fetal demise in utero. --> Please don't freak out about this, nowadays it's EXTREMELY rare because it's easy to recognize and treat. In my recent experience, in 5 years and 80 cases, no baby has ever been compromised, just some short NICU stays <--

Hope this helps. Keep us posted!
Title: Re: Questions about progesterone pessaries
Post by: Charlotte on June 16, 2018 at 08:07 PM
Thanks OBmom. Yes we've been keeping an eye on both bile acids every second week and now liver functions once they started rising. I get my most recent results from the blood test I did yesterday on Tuesday. Hanging out to see what they are and also the status of the cervix.

What does the progesterone actually do to the cervix? Can I expect to see it become more stable in the week I've been on them or even lengthen it? I'm on 100 mg daily. I'm not on bed rest, because my measurements have never been that bad (Initially funnelling with a total length of 3.7 cm funnelling part measuring 0.7 cm. Then up to 4.5 cm a week later after rather strict resting. Then down to 3 cm another week later.) but I'm not supposed to stand for long periods of time and do lots household chores. I'm off work for the remainder of my pregnancy and I'm allowed a 10 minute walk each day at this stage. Would you agree with what my doctor currently has me doing? I'm 29 weeks today.

Just one more question, since starting on the pessaries five days ago I have noticed an increased shortness of breath, especially after I've eaten but not every time after a meal... Would you say this is due to the pessaries or just a pregnancy coincidence. I went in to L&D because I also had leg pain in my right leg and they did an ultrasound to rule out any blood clots. Which was negative. I guess I just panicked because the side effects listed talked about blood clots and having to present immediately if those types of symptoms occurred...

Ever so grateful for your thoughts OBmom.