Women with higher order miscarriages should be seen by an experienced recurrent pregnancy loss clinician

Introduction

Women who present with a history of a high number of recurrent miscarriages are a real clinical challenge. Understandably there is a high level of emotional distress and sometimes feelings of hopelessness for the couple. Many women and their partners will be desperate for reasons as to why they are unable to continue their pregnancies. Offering them the correct set of investigations and effective counselling is important.1, 2 They may have visited a number of recurrent miscarriage clinics and offered tests and treatments that may not all be evidence based.1

It has been found that women with higher order miscarriages are more likely to have an identifiable cause for their miscarriages.3 However, in a significant proportion of women, the tests may still not provide any explanations or answers. Women with higher order miscarriages are also more likely to have subsequent pregnancies that are euploid.4

Bullet point guidance

  • Women with higher order miscarriages should be seen by an experienced recurrent pregnancy loss clinician.1
  • The minimum set of investigations for recurrent pregnancy loss should be performed. This includes measurements of full blood count, lupus anticoagulant, anticardiolipin antibodies, thyroid peroxidase antibodies, thyroid function, and a transvaginal pelvic ultrasound scan.1
  • Cytogenetic analysis should be performed on pregnancy tissue of the third and subsequent miscarriages. Where an unbalanced structural chromosomal is detected in the pregnancy tissue, parental karyotyping is advised. The finding of an abnormal parental karyotype should prompt referral to a clinical geneticist.
  • Parental karyotype should be considered for women with ³5 previous miscarriages, or ³2 miscarriages and a history of ³3 miscarriages in their siblings or parents.5
  • Couples should be advised that these tests may not provide answers about the cause of miscarriage.
  • Vaginal progesterone (Utrogestanâ or Cyclogestâ 400 mg twice daily) should be provided to those with ³4 previous miscarriages from the point of a positive pregnancy test until 16 completed weeks of gestation.3
  • Supportive ultrasound scans should be offered from 7 weeks gestation if possible.
  • Counselling and psychological support should be offered as the prevalence of mental health disorders in women with higher numbers of previous miscarriages is high.1
  • Referral to clinical research according to individual patient eligibility.
  • Referral to regional centre where standard care has been unsuccessful, especially in cases where cytogenetic testing has been normal.

References

  1. Bender Atik R, Christiansen OB, Elson J, et al. ESHRE guideline: recurrent pregnancy loss. Hum Reprod Open 2018; 2018: hoy004. 2018/04/06. DOI: 10.1093/hropen/hoy004.
  2. Quenby S, Gallos ID, Dhillon-Smith RK, et al. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet 2021; 397: 1658-1667. 2021/04/30. DOI: 10.1016/s0140-6736(21)00682-6.
  3. Coomarasamy A, Devall AJ, Brosens JJ, et al. Micronized vaginal progesterone to prevent miscarriage: a critical evaluation of randomized evidence. American Journal of Obstetrics and Gynecology 2020; 223: 167-176. 2020/02/06. DOI: 10.1016/j.ajog.2019.12.006.
  4. Sugiura-Ogasawara M, Ozaki Y, Katano K, et al. Abnormal embryonic karyotype is the most frequent cause of recurrent miscarriage. Human Reproduction 2012; 27: 2297-2303. DOI: 10.1093/humrep/des179.
  5. van den Berg MM, Goddijn M, Ankum WM, et al. Early pregnancy care over time: should we promote an early pregnancy assessment unit? Reproductive Biomedicine Online 2015; 31: 192-198. 2015/06/24. DOI: 10.1016/j.rbmo.2015.04.008.