Recurrent miscarriage

Question 1

What is recurrent miscarriage classified as?

Answer 1

three or more consecutive miscarriages

Question 2

Describe how age affects the chances of miscarriage

Answer 2

risk of miscarriage increases with age with rate of miscarriage:

• 10% in 20-30 yrs
• 15% in 30-35 yrs
• 25% in 35-40 yrs
• 50% in 40-45 yrs

Question 3

When should investigations be initiated for recurrent miscarriage?

Answer 3

-after 3 or more first-trimester miscarriages
or
-after one or more second-trimester miscarriages

Question 4

What are the causes of recurrent miscarriage?

Answer 4

• Idiopathic (esp in older women)
• antiphospholipid syndrome
• hereditary thrombophilias
• uterine abnormalities
• genetic factors in parents
• chronic histiocytic intervillostitis (a rare but severe placental condition characterised by the presence of an inflammatory mononuclear infiltrate in the intervillous space)
• chronic diseases such as diabetes, thyroid disease and SLE

Question 5

What is antiphospholipid syndrome?

Answer 5

• disorder associated with antiphospholipid antibodies where blood becomes more prone to clotting
• results in pt being in a hyper-coagulable state
• associated with thrombosis and issues during pregnancy, particularly recurrent miscarriage

Question 6

Triad of antiphospholipid syndrome:

Answer 6

1. Recurrent miscarriage
2. VTE
3. Thrombocytopenia

Question 7

How can antiphospholipid syndrome occur?

Answer 7

-occur on its own or secondary to SLE

Question 8

How can risk of miscarriage be reduced in those with antiphospholipid syndrome?

Answer 8

• low dose aspirin
  -LMWH

- LMWH

Question 9

What are the key hereditary thrombophilias that can cause recurrent miscarriage?

Answer 9

• factor V leiden (most common)
• factor II gene mutation
• protein S defficiency

Question 10

is protein S procoagulant or anticoagulant?

Answer 10

Anticoagulant

Question 11

What uterine abnormalities can cause recurrent miscarriage?

Answer 11

• uterine septum (a partition through uterus)
• unicornuate uterus (single horned uterus)
• Bicornuate uterus (heart-shaped uterus
• didelphic uterus (double uterus)
• cervical insufficiency
• fibroids

Question 12

What is chronic histiocytic intervillositis?

Answer 12

• rare cause of recurrent miscarriage particularly in the second trimester
• histiocytes and macrophages build up in placenta leading to inflammation
• diagnosed by placental histology showing infiltrates of mononuclear cells in intervillous spaces

Question 13

What are the investigations that might be done for recurrent miscarriage?

Answer 13

1. antiphospholipid antibodies
2. testing for hereditary thrombophilias
3. pelvic US
4. genetic testing of parents and products of conception from miscarriage

Question 14

What is the management of recurrent miscarriage?

Answer 14

-management depends on the underlying cause

Question 15

Recurrent miscarriage summary

Answer 15

Question 16

which antibodies are involved in APS:

Answer 16

1. Lupus anticoagulant
2. Anti-cardiolipin antibodies

Question 17

is protein S procoagulant or anticoagulant?

Answer 17

Anticoagulant

Question 18

what are the management options for recurrent miscarriages?

Answer 18

Management of recurrent miscarriage depends on the underlying cause.

There is new evidence from the PRISM trial that suggests a benefit to using vaginal progesterone pessaries during early pregnancy for women with recurrent miscarriages presenting with bleeding. This may become part of guidelines in the future.

At present, the RCOG guidelines on recurrent miscarriage (2011) state there is insufficient evidence for progesterone supplementation.