ObstetricsTier 2Disease (DEADMAN)

Recurrent miscarriages

Description

Recurrent pregnancy loss - conventionally >=2 or >=3 consecutive miscarriages (definitions vary; RCOG uses 3, other bodies increasingly use 2) before 20-24 weeks

Epidemiology

Affects ~1-2% of women trying to conceive (using the 3-loss definition); risk of a further miscarriage rises with each successive loss

Aetiopathogenesis

Antiphospholipid syndrome - most common treatable cause identified (~15% of recurrent miscarriage)
Parental balanced chromosomal translocation (~2-5%)
Uterine anomalies (septate uterus - the most significant structural cause), untreated thyroid disease, poorly controlled diabetes, obesity
Advancing maternal age - the single strongest overall risk factor (rising aneuploidy rate)
Unexplained in ~50% despite full workup

Diagnosis

Workup after 2-3 losses: antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, anti-beta2-glycoprotein I) on two occasions 12 weeks apart, parental karyotype, pelvic imaging (3D ultrasound/MRI/hysteroscopy) for uterine anomaly, thyroid function, HbA1c
Products of conception karyotype from the most recent loss, if available, guides whether further workup is warranted

Management

Antiphospholipid syndrome -> low-dose aspirin + prophylactic LMWH from confirmation of pregnancy - substantially improves live birth rate
Uterine septum - hysteroscopic resection may be offered
Balanced translocation - genetic counselling +/- IVF with pre-implantation genetic testing
No proven benefit for empirical progesterone in unexplained recurrent miscarriage without a specific indication

Associations

Antiphospholipid syndrome, thrombophilia, thyroid disease, uterine anomalies

Natural history & complications

Even after 3 losses, most women with no identified cause will have a successful subsequent pregnancy with supportive care alone - important for counselling
Live birth rate declines with the number of prior losses and with maternal age

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