Prednisolone Administration in Patients With Unexplained REcurrent MIscarriages

Recurrent miscarriages (RM) affects 3% of all fertile couples, but remains unexplained in most cases, limiting therapeutic options. Possibly the maternal immune system plays a role in recurrent miscarriage. Prednisolone suppresses the immune system and might enable development of normal pregnancy.In this randomized controlled clinical trial the investigators will study the effect of prednisolone on the live birth rate in patients with RM. Secondary, the tolerability and safety for mother and child and the cost-effectiveness is investigated.In the study one group of pregnant women with RM and gestational age <7 weeks will receive prednisolone, the other group will receive a placebo. Total use of the medicine during this study is 8 weeks, further care during the study is routinely antenatal care. Subjects will be asked to fill in 4 short questionnaires and will have contact with a research nurse at different time points to gain information on the course of the pregnancy and possible side effects.Results of the study will be implemented in (inter) national guidelines, to effect everyday practice.

Inclusion Criteria:In order to be eligible to participate in this study, a subject must meet all of the following criteria:Unexplained recurrent pregnancy loss: defined as the loss of ≥2 pregnancies, without any known cause for RM (parental chromosomal abnormalities, uterine anomalies, acquired or hereditary thrombophilia, endocrine diseases (such as hypothyroidism or diabetes)).The miscarriages include:all consecutive or non-consecutive pregnancy losses before the 24th week of gestation verified by ultrasonography or uterine curettage and histologynon-visualized pregnancies (including biochemical pregnancy losses and/or resolved and treated pregnancies of unknown location), verified by positive urine or serum hCG Ectopic and molar pregnancies are not includedAge 18 - 39 years at randomization (likelihood of miscarriages due to chromosomal aberrations is higher when age > 39 years. Such miscarriages are unlikely to be pre-vented by prednisolone therapy)Conception confirmed by urinary pregnancy test, with estimated gestational age ≤ 7weeksWilling and able to give informed consent in English or Dutch (IC)Exclusion Criteria:A potential subject who meets any of the following criteria will be excluded from participation in this study:Any of the following diagnosis for the recurrent miscarriagesAntiphospholipid syndrome (lupus anticoagulant and/ or anticardiolipin anti-bodies and/or beta-2 glycoprotein [IgG or IgM)Congenital uterine abnormalities (as assessed by 2D or 3d ultrasound, hys-terosonography, hysterosalpingogram or hysteroscopy)Abnormal parental karyotypeInstable or exacerbation of auto-immune diseases such as diabetes, thyroid disease, inflammatory bowel diseases or SLEInability to conceive within 1 year of recruitmentCurrent treatment with systemic prednisolone or other immune suppressive medication (for any indication)Previous enrolment in the PREMI trialEnrolment in any other trial that studies the effectiveness of an intervention on RMContraindications to prednisolone use:Known allergy for prednisoloneAcute bacterial infection or parasite infectionActive COVID infectionSystemic sclerosisUlcus ventriculi or ulcus duodeni in medical historyObesity with BMI >40Some drugs are known to interact with Prednisolone, and thus women on the following drugs are not eligible to take part in the PREMI trial:Enzyme inducers, such as carbamazepine, fenobarbital, fenytoïne and ri-fampicineCYP3A inhibitors, such as Cobicistat or RitonavirCyclosporineDigoxinVaccination (with inactivated virus or bacteria) during prednisolone use is possibly less effective