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ACB-CLIN-CHEM-GEN  May 2009

ACB-CLIN-CHEM-GEN May 2009

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Subject:

Re: Progesterone levels in PUL

From:

Dr Fiona Riddoch <[log in to unmask]>

Reply-To:

Dr Fiona Riddoch <[log in to unmask]>

Date:

Thu, 14 May 2009 15:46:54 +0100

Content-Type:

multipart/mixed

Parts/Attachments:

Parts/Attachments

text/plain (81 lines) , prog and PUL interp.xls (81 lines) , RCOG25 Mx early pregnancy loss.pdf (81 lines)

Hi Avril
A very late reply - I was waiting for the outcome of a meeting yesterday with 
the lead consultant in Obs & Gynae.

Last year I performed an audit of the use of progesterone testing in 
PUL/EP/miscarriage at Kingston Hospital - we use the Roche E170 too. It was 
found to be used (and abused) in all sorts of ways. We have now discussed 
the outcome with the consultant, who has thought long and hard and decided 
that the only time it helps to affect management is when there is a PUL (which 
she has also checked for), with an HCG level that is not declining, or not 
declining at the expected rate. In this situation a single progesterone level can 
then help guide her as to how often to check the HCG, ie whether she needs 
to perform 48hrly monitoring, or can leave the woman 1-2 weeks before 
checking the HCG (therefore reducing hospital visits, anxiety etc). 

In terms of interpretation, the table (XL file - attached) is the guideline given 
to me by the consultant, which follows the levels given by the RCOG guidelines 
(also attached).


She also sent me this from an internet article:
Predicting Outcomes in Pregnancies of Unknown Location: Serum Progesterone 
Levels.   
Emma Kirk 1 and Tom Bourne 1,2 
1Early Pregnancy & Gynaecology Ultrasound Unit, St George's, University of 
London, Cranmer Terrace, London, SW170RE, UK.
2Department of Obstetrics & Gynaecology, University Hospital Gasthuisberg, 
KU Leuven, Belgium
(http://www.medscape.com/viewarticle/579218_2)

Single serum progesterone levels have been used to predict the outcome of 
PULs. A serum progesterone level below 20 nmol/l has been shown to have a 
positive predictive value greater than 95% of predicting pregnancy failure.[1] 
Levels above 25 nmol/l are 'likely to indicate' and levels above 60 nmol/l 
are 'strongly associated' with pregnancies subsequently demonstrated to be 
viable.[9] However, viable IUPs have been reported with initial levels below 16 
nmol/l. Serum progesterone measurements have also been advocated as a 
diagnostic tool in the noninvasive diagnosis of ectopic pregnancy. However, a 
meta-analysis of 26 studies has demonstrated that, whilst a single serum 
progesterone measurement has a good discriminative capacity to distinguish 
between pregnancy failure and a viable IUP, a single measurement cannot 
discriminate between ectopic pregnancy and nonectopic pregnancy.[10] This 
review concluded that serum progesterone measurement can identify women 
at risk for ectopic pregnancy who need further evaluation, but its 
discriminative capacity is insufficient to diagnose ectopic pregnancy with 
certainty. Therefore, it would appear that a serum progesterone level is good 
at predicting viability, but not the location of pregnancy.
 
1 Banerjee S, Aslam N, Woelfer B, Lawrence A, Elson J, Jurkovic D: Expectant 
management of early pregnancies of unknown location: a prospective 
evaluation of methods to predict spontaneous resolution of pregnancy. BJOG 
108, 158-163 (2001).
 
9 Royal College of Obstetricians and Gynaecologists (RCOG), Green-top 
Guideline No. 25: The management of early pregnancy loss. RCOG Press, 
London, UK (2006).

10 Mol BW, Lijmer JG, Ankum W, van der Veen F, Bossuyt PMM: The accuracy 
of single serum progesterone measurement in the diagnosis of ectopic 
pregnancy: a meta-analysis. Hum. Reprod. 13, 3220-3227 (1998).




		


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