Recurrent Miscarriage

Question 1

recurrent miscarriage definition

Answer 1

3 or more first trimester miscarriages

Question 2

recurrent miscarriage rate

Answer 2

1%

Question 3

greatest determinant of the incidence of recurrent miscarriage

Answer 3

age

Question 4

risk factors for recurrent miscarriage

Answer 4

age (mum>dad), previous miscarriages, black, smoking, alcohol, caffeine, BMI<19 or >25

Question 5

age relates miscarriage risk 12-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45 plus

Answer 5

13, 11, 12, 15, 25, 51, 93

Question 6

what testing should be offered to women with recurrent miscarriage

Answer 6

acquired thrombophilia, lupus anticoagulant, anticardiolipin antibodies

Question 7

women with second trimester miscarriage should be offered testing for

Answer 7

Factor V Leiden, prothrombin gene mutation and protein S deficiency

Question 8

define antiphospholipid syndrome

Answer 8

Association between antiphospholipid antibodies (lupus anticoagulant, anticardiolipin) and anti-beta-2-glycoprotein-I antibodies, and adverse pregnancy outcomes or vascular thrombosis

Question 9

most frequent chromosome anomalies causing miscarriage

Answer 9

trisomy (51.9%); polyploidy (18.8%); monosomy (15.2%); structural anomalies (6.5%); and others (7.6%)

Question 10

aneuploidy rate in recurrent miscarriage

Answer 10

only 40%

Question 11

When cytogenetic analysis should be offered

Answer 11

pregnancy tissue of the third and subsequent miscarriage(s) and in any second trimester miscarriage

Question 12

what to offer when tissue reports an unbalanced structural chromosomal abnormality or there is unsuccessful or no pregnancy tissue available for testing.

Answer 12

Parental peripheral blood karyotyping

Question 13

what are the adverse pregnancy outcomes that meet the criteria for APS?

Answer 13

one of:
3 or more consecutive miscarriages before 10 weeks of gestation

at least one morphologically normal miscarriage after 10 weeks

preterm birth before 34 weeks due to placental disease

Question 14

how many tests are needed to diagnose APS

Answer 14

at least two positive tests 12 weeks apart - and at least 6 weeks post miscarriage

Question 15

percentage of transloaction present in parents after one miscarriage, after two miscarriages and after three miscarriages

Answer 15

translocation is present in 2.2% parents after one, 4.8% after two, 5.7% after three miscarriagesch

Question 16

chances of parents with a balanced structural chromosome abnormality having a healthy child

Answer 16

83%, similar to controls but the abnormality group had a higher chance of subsequent miscarriage

Question 17

miscarriage rates for parents with reciprocal translocations

Answer 17

54%

Question 18

miscarriage rates for parents with inversions

Answer 18

49%

Question 19

miscarriage rates for parents with Robertsonian translocations

Answer 19

34%

Question 20

women with recurrent miscarriage should be offered assessment for congenital uterine anomalies using what ideally

Answer 20

3D ultrasound is first line - most accurate method for diagnosing congenital uterine anomalies, following by saline-infusion ultrasound then hyserosalpingography and 2D ultrasound

Question 21

cannot reach diagnosis with 3D ultrasound what do you use

Answer 21

MRI and endoscopic evaluation for complex anomalies

Question 22

commonest uterine anomaly across all populations

Answer 22

canalisation defects e.g. septate variety followed by the unification defects e.g. bicornuate and unicornuate variety

Question 23

The risk of sporadic first trimester miscarriage was not significantly increased in women with which uterine anomalies

Answer 23

arcuate, didelphys, unicornuate uteri - same for second trimester excpept arcuate

Question 24

do myomas increase the risk of miscarriage

Answer 24

no increase in risk of miscarriage

Question 25

which endocrine tests should women with recurrent miscarriage be offered

Answer 25

thyroid function test and assessment for thyroid peroxidase (TPO) antibodies.

Question 26

should women with recurrent miscarriage be offered routine immunological screening e.g. HLA, cytokine and natural killer cell tests, infection screening or sperm DNA testing?

Answer 26

NO

Question 27

Diabetes associated with recurrent miscarriage?

Answer 27

not well controlled diabetes, or treated thyroid dysfunction

Question 28

lifestyle factors for women with recurrent miscarriage

Answer 28

maintain a BMI between 19 and 25, smoking cessation, limit alcohol consumption and limit caffeine to less than 200mg/day

Question 29

is PCOS linked to increased risk of miscarriage

Answer 29

yes - exact mechanism unclear, elevated LH or testosterone do not predict an increased risk of future pregnancy loss

Question 30

Likelihood of miscarriage in women with no, one, two, three, four or five previous miscarriages (%)

Answer 30

11.3%, 17.0%, 28.0%, 39.6%, 47.2% and 63.9% for women with no, one, two or three, four, five and six previous miscarriages

Question 31

treatment for women diagnosed with APS

Answer 31

low dose aspirin and LMWH offered from a positive test until at least 34 weeks of gestation, following discussion of potential benefits vs. risks

Question 32

when should progestogen supplementation be considered

Answer 32

recurrent miscarriage who present with bleeding in early pregnancy
e.g. 400mg micronised vaginal progesterone twice daily at the time of bleeding until 16 weeks gestation

Question 33

should progesterone be used routinely for asymptomatic unexplained recurrent miscarriage?

Answer 33

lack of evidence showing benefits - PROMISE trial showed routine progesterone did not improve outcome

Question 34

when should subclinical hypothyroidism be treated for women with recurrent miscarriage

Answer 34

when TSH more than 4 irrespective of TPO status

Question 35

in TPO or SCH when should you check TSH

Answer 35

regular TSH measurement from 7-9 weeks gestation is recommended

Question 36

what is the medical management of miscarriage

Answer 36

vaginal misoprostol for missed or incomplete miscarriage. oral is acceptable alternative if womans preference

Question 37

dose of misoprostol for women with a missed miscarriage

Answer 37

800 micrograms

Question 38

dose of misoprostol for incomplete miscarriage

Answer 38

single dose of 600 micrograms of misoprostol