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Recurrent Miscarriage
Nicola
Clinical Scenario
• 41 year old female
• Successful first time try son last year
• Same partner throughout
• One miscarriage 6w gestation 6m ago
• Now presenting with 1d Hx of fresh, stringy PV
loss
• “I would like some investigations please – time
is not on my side”
Epidemiology / background
• “Early loss (before 23w) of pregnancy”
• Occurred >3 times
• 1:100
• Investigations after the 3rd
RCOG Guideline No 17 (May 2003)
• 10-15% pregnancies result in miscarriage
• 1% are recurrent
• All women should have pelvic USS
• In asymptomatic women TFTs and fasting glucose is
uninformative
• Insufficient evidence about the use of progesterone
• APL – 2 positive results 6w apart / combination therapy
improves live birth rate
• Supportive ANC alone has high rates of future success
What to do?
• Communication skills:
– By definition not eligible for investigations
– Consoling / empathy
– Facts and figures
– Self-help / help groups available nationally and
locally
Causes & Investigations
1. Anatomical
• Uterine:
– bicornuate, septal,
unicornuate
– Hysterosalpingogram /
hysteroscopy / MRI /
pelvic USS
Cervical:
-Incompetence
-Hx of >14w rapid
labour & ROM
-Consider resistance
test and stitch 13-
14w
2. Chromosomal
• Translocations
• Aneuploidy
• Placental and
parental karyotyping
3. Endocrine
• Thrombophilia
• Hyperthyroidism
• DM
• Hyperprolactinaemia
• TFTs / bloods / fasting glucose / PRL
4. Immune
• Antiphospholipid
• Increased uterine NK cells
• Parental HLA sharing
• Haematological: Antithrombin III / protein C, S,
factor 5 leiden
• Placental examination
• Anticardiolipin antibodies
• Lupus anticoagulant antibodies
5. Ovarian
• Decreased ovarian reserve (poor egg quality)
• Luteal phase defect (lacking P4)
• PCOS
• Hormonal profile
– High levels of E2 reduced chance
6. Lifestyle
• Smoking
• Alcohol
• Drugs
• Age
But…..
• In patients with unexplained recurrent
miscarriage there is a 60-70% chance their
next pregnancy will be successful without
treatment
Take home
• >3 miscarriages warrant Ix
• Ix;
– HVS (BV /chlamydia)
– Bloods (TFT’s, prolactin, FBC, APL bloods, fasting
glucose, hormonal profile)
– Pelvic USS
• Comm skills
• Infertility clinic
National Support
• Miscarriage Association, Clayton Hospital,
Northgate, Wakefield 01924 200799
• www.miscarriageassociation.org.uk

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No Title

  • 2. Clinical Scenario • 41 year old female • Successful first time try son last year • Same partner throughout • One miscarriage 6w gestation 6m ago • Now presenting with 1d Hx of fresh, stringy PV loss • “I would like some investigations please – time is not on my side”
  • 3. Epidemiology / background • “Early loss (before 23w) of pregnancy” • Occurred >3 times • 1:100 • Investigations after the 3rd
  • 4. RCOG Guideline No 17 (May 2003) • 10-15% pregnancies result in miscarriage • 1% are recurrent • All women should have pelvic USS • In asymptomatic women TFTs and fasting glucose is uninformative • Insufficient evidence about the use of progesterone • APL – 2 positive results 6w apart / combination therapy improves live birth rate • Supportive ANC alone has high rates of future success
  • 5. What to do? • Communication skills: – By definition not eligible for investigations – Consoling / empathy – Facts and figures – Self-help / help groups available nationally and locally
  • 7. 1. Anatomical • Uterine: – bicornuate, septal, unicornuate – Hysterosalpingogram / hysteroscopy / MRI / pelvic USS Cervical: -Incompetence -Hx of >14w rapid labour & ROM -Consider resistance test and stitch 13- 14w
  • 8. 2. Chromosomal • Translocations • Aneuploidy • Placental and parental karyotyping
  • 9. 3. Endocrine • Thrombophilia • Hyperthyroidism • DM • Hyperprolactinaemia • TFTs / bloods / fasting glucose / PRL
  • 10. 4. Immune • Antiphospholipid • Increased uterine NK cells • Parental HLA sharing • Haematological: Antithrombin III / protein C, S, factor 5 leiden • Placental examination • Anticardiolipin antibodies • Lupus anticoagulant antibodies
  • 11. 5. Ovarian • Decreased ovarian reserve (poor egg quality) • Luteal phase defect (lacking P4) • PCOS • Hormonal profile – High levels of E2 reduced chance
  • 12. 6. Lifestyle • Smoking • Alcohol • Drugs • Age
  • 13. But….. • In patients with unexplained recurrent miscarriage there is a 60-70% chance their next pregnancy will be successful without treatment
  • 14. Take home • >3 miscarriages warrant Ix • Ix; – HVS (BV /chlamydia) – Bloods (TFT’s, prolactin, FBC, APL bloods, fasting glucose, hormonal profile) – Pelvic USS • Comm skills • Infertility clinic
  • 15. National Support • Miscarriage Association, Clayton Hospital, Northgate, Wakefield 01924 200799 • www.miscarriageassociation.org.uk