Recurrent Miscarriage

Question 1

Define recurrent miscarriage.

Answer 1

The loss of 3 or more consecutive pregnancies before 24 weeks gestation with the same biological father.

Question 2

What are the possible causes of recurrent miscarriage?

Answer 2

Antiphospholipid syndrome
Parental chromosome abnormality
Endocrine abnormalities (not well-controlled) e.g. DM/thyroid
Structural abnormalities of the female reproductive tract
Infection e.g. bacterial vaginosis
Thrombophilia

Question 3

What are the chromosomal abnormalities that can contribute to recurrent miscarriage?

Answer 3

Parental chromosome rearrangements e.g. balanced reciprocal or Robertsonian translocations
Embryonic chromosomal abnormalities

Question 4

Which structural abnormalities in the female reproductive tract cause recurrent miscarriage?

Answer 4

Uterine malformations e.g. septae, bicornuate or arcuate uterus
Cervical weakness (2nd trimester miscarriage)
Acquired uterine abnormalities - adhesions (asherman’s syndrome), fibroids

Question 5

What are the risk factors for recurrent miscarriage?

Answer 5

Advancing maternal age (decline in number and quality of oocytes)
Number of previous miscarriages
Smoking
Moderate to heavy alcohol/caffeine consumption

Question 6

What investigations are done for recurrent miscarriages?

Answer 6

Blood tests
- antiphospholipid antibodies (2 positive tests 12 weeks apart)
- inherited thrombophilia screen
Karyotyping
- cytogenetic analysis of the foetal chromosomes (test products of conception)
- parental peripheral blood karyotyping to look for parental chromosomal abnormalities
Imaging
- pelvic USS to assess uterine anatomy
— if suspected - further investigation like hysteroscopy, laparoscopy and 3D pelvic USS can be performed

Question 7

What is included in an inherited thrombophilia screen?

Answer 7

Factor V Leiden
Prothrombin gene mutation
Protein S deficiency

Question 8

What is the management for genetic abnormalities being the cause of recurrent miscarriage?

Answer 8

Referral to clinical geneticist
Genetic counselling 
Familial chromosome studies
Gamete donation, adoption
Preimplantation genetic screening with IVF

Question 9

What is the management for anatomical abnormalities being the cause of recurrent miscarriage?

Answer 9

Surgical correction of UTI next abnormalities
Cervical cerclage (cervical weakness)
Cervical sonographic surveillance

Question 10

What is the management for recurrent miscarriage when inherited thrombophilia is the cause?

Answer 10

Heparin therapy during pregnancy

Question 11

What is the treatment for recurrent miscarriages when antiphospholipid syndrome is found to be the cause?

Answer 11

Low dose aspirin + heparin