RECURRENT MISCARRIAGE
GUIDELINES
MAJ DR AMINA AKBAR
MBBS, MCPS, FCPS
DEFINITION
A recurrent miscarriage is defined as 3
or more consecutive, spontaneous
pregnancy losses, under 20 week
gestation from the last menstrual period

Primary
recurrent
pregnancy
loss"
refers to couples that have never had a
live birth

While "secondary RPL" refers to those
who
have
had
repetitive
following a successful pregnancy
losses
TERMINOLOGY

The medical term ' abortion' should be
replaced with the term 'miscarriage'

Other names : Recurrent Pregnancy Loss (RPL),
Habitual Abortions ,
Habitual Miscarriages,
Recurrent Abortions ,
Recurrent Miscarriages.
INCIDENCE

10–15% of all clinically recognized pregnancies
end in a miscarriage

Recurrent miscarriage affects 0.5-2% of all
women -- Hence, only a proportion of women
presenting with recurrent miscarriage will have
a
persistent
underlying
pregnancy losses
cause
for
their
RISK FACTORS

Advanced maternal age adversely affects
ovarian function, giving rise to a decline in
the number of good quality oocytes, resulting
in chromosomally abnormal conceptions that
rarely develop further

Previous number of miscarriages
POSSIBLE CAUSES

Recurrent miscarriage is a heterogeneous
condition that has many possible causes;
more than one contributory factor may
underlie the recurrent pregnancy losses

Each may have had a different cause
Recurrent
Miscarriage
Explained
Genetic
factors
Un-explained
Infective
agents
Endocrine
Anatomical
factors
Body
Immune
factors
Enviromental
factors
Inhereted
Thrombophilic
defect
Bacterial
Vaginosis
Cervix
CI
APS
Paternal
Cytogenetic
karyotyping Of miscarriage
Uterine
anomalies
GENETIC FACTORS
All couples with a history of recurrent
miscarriage should have peripheral
blood karyotyping performed. The
finding of an abnormal parental
karyotype should prompt referral to a
clinical geneticist.
 3–5% of couples with recurrent miscarriage,
one of the partners carries a balanced
structural chromosomal anomaly
 5–10% chance of a pregnancy with an
unbalanced translocation.

FETAL CHROMOSOMAL ABNORMALITIES

This may be due to abnormalities in the
egg, sperm or both. The most common
chromosomal defects are:
Trisomy:

Monosomy

Polyploidy

Chromosome Testing on Fetal (Miscarriage)
Tissue

This can only be done right at the time of
miscarriage.

It is an analysis of the genetic makeup of the fetus.

It can indicate genetic problems that lead to RPL.

Many miscarriages are caused by chromosomal
abnormalities that are unlikely to repeat. To know if
the problem is likely to recur, it is necessary to study
the genetics of both parents as well.

Karyotyping of Parents

Chromosome analysis of blood of both parents.

It can show if there is a potential problem with one
of the parents that leads to miscarriage, but often
has to be done in conjunction with fetal testing to
provide answers.
ANATOMICAL FACTORS
CONGENITAL ANOMALIES

An abnormal or irregularly shaped uterus.

Sometimes the uterus has an extra wall down its
centre, which makes it look as if it is divided into
two (bicornuate or septate uterus)
a septate uterus Where as a partial septum
increases the risk to 60%-75%; a total septum
carries a risk for loss of up to 90%.
Today a relatively simple surgical procedure can
remove a uterine septum
The reported prevalence of uterine anomalies in
recurrent miscarriage populations range between
1.8% and 37.6%.
 The prevalence of uterine malformations appears to
be higher in women with late miscarriages compared
with women who suffer early miscarriages
 Untreated uterine anomalies has a term delivery rate
of only 66%.
 Open uterine surgery is associated with postoperative
infertility and carries a significant risk of uterine scar
rupture during pregnancy. Therefore treatment of
uterine anomalies in women with recurrant
miscarriage remains controversial.

FIBROIDS

If fibroids are detected on the inside of the
uterus (termed submucous fibroids) and
distort the uterine lining, they are a
significant cause of reproductive problems
and should be removed. It is less clear
whether fibroids in the wall of the uterus
cause reproductive problems
All
women
with
recurrent
miscarriage should have a pelvic
ultrasound to assess uterine
anatomy and morphology

Two
dimensional
pelvic
ultrasound
assessment of the uterine cavity with
(or without) Sonohysterography
HYSTEROSALPINGOGRAPHY
The routine use of hysterosalpingography as a
screening test for uterine anomalies in women
with recurrent miscarriage is questionable.
 It is associated with patient discomfort,
 carries a risk of pelvic infection and radiation
exposure
 and is no more sensitive than the non-invasive
two dimensional pelvic ultrasound assessment
of the uterine cavity with (or without)
Sonohysterography when performed by skilled
and experienced personnel.

HYSTEROSCOPY

This
investigation,
performed
under
general anaesthetic, examines the inside of
the uterus with a thin

telescope (3-5 mm in diameter) . By
inserting this telescope through the cervix
and into the uterus,

the doctor can see the shape of the uterus
and examine its lining.
CERVICAL WEAKNESS
Diagnosis of cervical incompetence is based
on history of late miscarriage preceded by
spontaneous rupture of memb or painless
cervical dilatation. Vaginal USG is helpful
in assessing early features of cervical
incompetence.
associated
Cervical
with
cerclage
potential
is
hazards
associated with surgery and risk of uterine
contractions.
ENDOCRINE FACTORS
Routine screening for occult
diabetes and thyroid disease with
oral glucose tolerance and thyroid
function tests in asymptomatic
women presenting with recurrent
miscarriage is uninformative

Well-controlled diabetes mellitus is not a risk
factor for recurrent miscarriage, nor is treated
thyroid dysfunction
There is insufficient evidence to
evaluate the effect of progesterone
supplementation in pregnancy to
prevent a miscarriage
There is insufficient evidence to
evaluate the effect of human
chorionic gonadotrophin (hCG) in
pregnancy to prevent miscarriage.

Early pregnancy hCG supplementation failed to
show any benefit in pregnancy outcome
IMMUNE FACTORS
One in ten women with recurrent miscarriages show
evidence of auto immune factors on investigation
As much as 40 percent of unexplained infertility may
be the result of immune problems. Unfortunately for
couples with immunological problems, their chances of
recurrent loss increase with each successive
pregnancy.
ANTITHYROID ANTIBODIES

Routine
screening
for
thyroid
antibodies in women with recurrent
miscarriage is not recommended.
ANTIPHOSPHOLIPID
SYNDROME
To diagnose APS it is mandatory that the
patient should have two positive tests at
least six weeks apart for either lupus
anticoagulant
or
anticardiolipin
(aCL)
antibodies of IgG and/or IgM class present in
medium or high titre.
 Adverse pregnancy outcomes include
 Three or more consecutive miscarriages before
ten weeks of gestation
 One or more morphologically normal fetal deaths
after the tenth week of gestation and
 One or more preterm births before the 34th
week of gestation due to severe pre-eclampsia,
eclampsia or placental insufficiency.

In women with a history of recurrent
miscarriage and aPL, future live birth rate is
significantly improved when a combination
therapy of aspirin plus heparin is prescribed.

Pregnancies associated with aPL treated
with aspirin and heparin remain at high risk
of complications during all three trimesters.
INHERITED THROMBOPHILIC
DEFECTS


Inherited thrombophilic defects,
Including activated protein C resistance (most
commonly
due
to
factor
V
Leiden
gene
mutation), deficiencies of protein C/S and
antithrombin III, hyperhomocysteinaemia and
prothrombin gene mutation,

Are established causes of systemic thrombosis
INFECTIVE AGENTS

Screening for and treatment of
bacterial
vaginosis
in
early
pregnancy among high risk women
with a previous history of second-
trimester
miscarriage
or
spontaneous preterm labour may
reduce the risk of recurrent late
loss and preterm birth.
ENVIRONMENTAL FACTORS

Exposture to noxious or toxic substances are
known to be associated with recurrent
miscarriage ( cigarretes,alcohol and caffeine
,anaestetic
gases,petrolium
products
)
UNEXPLAINED RECURRENT
MISCARRIAGE
In about half the women in the research studies, no
cause could be found, so no specific treatment could
be given.
However, this group responded very well to a
programme which removed as many stress factors
as possible from their lives, resulting in an 80%
success rate with the subsequent pregnancy
PSYCHOLOGICAL SUPPORT

The value of psychological support in improving pregnancy
outcome has not been tested in the form of a randomised
controlled
trial.
However,
data
from
several
non-
randomised studies86–88 have suggested that attendance
at a dedicated early pregnancy clinic has a beneficial
effect, although the mechanism is unclear

All
professionals
should
be
aware
of
the
psychological sequelae associated with miscarriage
and should provide support and follow-up, as well
as access to formal counselling when necessary.
THANK YOU