Recurrent Miscarriage Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Investigation and management of patients presenting with recurrent miscarriages in accordance with the identified referral criteria

This guidance does not cover:

  • Women who have had less than three consecutive miscarriages with the same biological partner unless additional referral criteria have been met (see referral section)

Assessment

Definition

  • A miscarriage is defined as a spontaneous loss of any pregnancy before the stage of viability (24+0). This excludes termination of pregnancies (TOPs).
  • Recurrent miscarriage is defined as a consecutive loss of three of more pregnancies and affects 1% of couples
  • Recurrent miscarriage may be primary with no previous live births or secondary following birth
  • Women with unexplained recurrent miscarriage have an excellent prognosis for future pregnancy outcome without pharmacological intervention if offered supportive care alone in the setting of a dedicated early pregnancy assessment unit

Aetiology

Age
  • Maternal age and previous number of miscarriages are independent risk factors for further miscarriage.
  • Advancing maternal age is associated with decline in oocyte quality. Many miscarriages are related to sporadic/spontaneous fetal chromosome abnormality. This is why the quality of the oocyte declines with age.
  • The age related risk in recognised pregnancies is:
    • 12% in women under 30
    • 15% in women between 30-35
    • 25% in women over 35
    • 50% in women between 40-45
  • Advanced paternal age e.g. above 40 is also a risk factor
  • Maternal BMI - linear increase in sporadic miscarriage:
    • One and a half times more likely with BMI above 35
    • Two times more likely with BMI above 40
Endocrine
  • Uncontrolled diabetes mellitus is a risk factor but not if well controlled
  • Thyroid dysfunction and the presence of anti-thyroid antibodies are NOT increased in women with recurrent miscarriage compared to the general population
Luteal phase deficiency is controversial
  • Its association remains inconclusive and its putative demonstration with low progesterone levels may be the result of rather than the cause of miscarriage,
  • The effectiveness of treatment with exogenous progesterone or progestins in early pregnancy has yet to be validated. This is in spite of several studies which show no benefit.
Polycystic Ovary Syndrome (PCOS)
  • Prevalence of PCOS in women with recurrent miscarriage has been reported to be as high as 40.7%
  • The mechanism is unknown but may be related to hyperinsulinaemia or hyperandrogenism
  • Pharmacological/hormonal intervention has not been shown to be of benefit
Environmental agents
  • Because toxic exposures are usually not recurrent, they are unlikely to be the sole cause of recurrent miscarriage in an individual
  • The exceptions are as follows (there is an association but unproven link with recurrent miscarriages. These toxins carry risk for overall outcome of pregnancy NOT specifically for recurrent miscarriage):
    • chronic smoking - risk is greatest among heavy smokers
    • excessive alcohol
    • excessive caffeine
    • cocaine use
    • prolonged occupational exposures
Immunological
  • No clear evidence to support hypotheses of human leucocyte antigen incapability; hence testing should not be routinely offered
  • No clear evidence of association with peripheral natural killer (NK) cells; hence testing should not be routinely offered
  • Paternal cell immunisation, third party donor leucocytes, IV immunoglobulin does not improve the live birth rate
  • The following does have evidence and treatment that reduces the risk of further miscarriage:
    • Antiphospholipid syndrome - acquired thrombophilia ·
    • Inherited thrombophilia
Maternal factors − acquired, inherited, structural
  • Uterine anatomic malformations:
    • Most occur sporadically
    • Most frequent in the second trimester
    • It is mostly dependent on type of anomal − most common include septate, bicornuate, and didelphic uterus
    • Minor variations do not cause miscarriage
Myomas (also called Fibroids)
  • It remains speculative whether myomas are a cause of recurrent miscarriage
  • It is thought that large or multiple myomas located in the submucosal area may affect implantation and thus may increase the risk of miscarriage
  • It is known that the presence of myomas/fibroids increase the risk of miscarriage however the risk does not reduce if they are removed.
Collagen deficits
  • Types IV and V collagen, of the cervical tissue have been noted to have a role in miscarriages
Chromosomal and single gene disorders
  • In studies, on products of conception, approximately 70% of miscarriages are associated with chromosomal abnormalities
  • Fetal chromosomal abnormalities
    • 1/3 - 1/2 of further miscarriages will be of a chromosomally abnormal fetus increasing with maternal age
  • Parental balanced translocation 4%
  • Alpha thalassemia major
  • X-linked male lethal conditions
Infective agents
  • Bacterial vaginosis in the first trimester has been reported as a risk factor for second trimester miscarriage and pre termed delivery but the evidence for association with first trimester with miscarriage is inconsistent

History and Examination

  • It is important to ascertain the couple's primary questions and concerns in order to mutually develop a plan to address them. Obtain detailed personal medical and pregnancy history of both partners, including:
    • Length of time trying to have a child
    • Number of pregnancies, and outcomes
    • Any pregnancies with other partners (recurrent miscarriage is consecutive. Three consecutive with the same partner).
  • Detailed pregnancy exposure histories that focus on medication, occupational/environmental exposures, and recreational drug use that may have occurred during pregnancy that ended in miscarriage
  • History of depression
  • History of alcohol or other drug use, especially a history of using alcohol or other drugs to self-medicate for depression and/or pain
  • Document family medical history: using standardised pedigree symbols, obtain first and second degree family history information

Rhesus Status

  • Routine antenatal anti-D prophylaxis is recommended as a treatment option for all pregnant women who are rhesus D (RhD)-negative and who are not known to be sensitised to the RhD antigen.
  • Administer anti-D immunoglobulin in non-sensitised Rh-negative patients in confirmed miscarriage:
    • After 12 weeks
    • Where the uterus is evacuated, either surgically or medically
    • Surgical management of ectopic pregnancy
  • Discharge documentation from the early pregnancy assessment unit should clearly state whether or not anti-D was required/given

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Miscarriage is incomplete − admission for surgical evacuation of retained products of conception has the advantage that symptoms resolves rapidly, but has the disadvantage of risks associated with an operation
  • The patient is haemodynamically unstable; or
  • Bleeding heavily
  • There is evidence of septic miscarriage

Investigations


Mandatory
  • To avoid delay in your patients care the following investigations are mandatory and must be carried out prior to referring your patient and the results must be attached to support the referral into the Recurrent Miscarriage Service:
    • Normal and up to date smear
    • Genital swabs
Suggested
  • Lupus anticoagulants
    • this test should be done when the patient is not pregnant and no sooner than six weeks after end of pregnancy/ miscarriage
    • Sample container – 2 x citrate (green) and 1 x plain (white) clotted
    • Samples to be sent to Pinderfields Hospital, where they are processed and referred onto Leeds Teaching Hospital for analysis
  • Anticardiolipin antibodies – IgG Anticardiolipin along with Beta-2-glycoprotein 1 (B2GP1)
    • This test should be done when the patient is not pregnant and no sooner than six weeks after end of pregnancy/ miscarriage
    • B2GP1 sample container – gel (brown)
    • Anticardiolipin antibodies (IgG) sample container – gel (brown)
    • Samples to be sent to Pinderfields Hospital, where they are processed and analysed in-house
  • Rubella 1gG
  • Ultrasound scan of uterus and ovaries
  • Chromosome analysis for male and female
    • This is no longer routinely done but should only be done when there is clear family history of genetic abnormality. A cytogenetics request is required for inherited conditions/karyotyping
    • Sample container – heparin (orange)
    • Samples to be sent to Pinderfields Hospital, where they are processed and referred onto Leeds Teaching Hospital for analysis.

Management

Recurrent miscarriage affects 1% of all women whereas the theoretical chance risk of three consecutive miscarriages is 0.34%. In this group, there is a higher incidence and reason other than sporadic spontaneous chance of chromosomal abnormalities. This is why testing is not done until after three miscarriages.

No clear and reliable clinical criteria exist for deciding between conservative, medical and surgical management for miscarriage in non-urgent situations

Miscarriage can have both medical and psychological consequences − psychological consequences include depression and anxiety for both the woman and her partner

  • Advise patient about appropriate counselling and psychological support services
  • All professionals should be aware of the psychological impact associated with pregnancy loss and should provide:
    • Support
    • Access to formal counselling if necessary
    • Inform all relevant professionals, including the community midwife, in cases of pregnancy loss
  • Grief, anxiety and depression are common for both the woman and her partner following miscarriage
  • Grief following comparable in nature, intensity, and duration to grief reactions in people suffering other types of loss
  • Distress is commonly at its worst 4-6 weeks after a miscarriage and may last 6-12 months
  • Give the woman an opportunity to discuss any questions she has about her miscarriage

Patient support and information includes:

  • Information about the symptoms of miscarriage
  • Advise patient about treatment options
  • Advise patient about appropriate counselling and psychological support services e.g.
  • www.miscarriageassociation.org.uk
  • Advice about sex and contraception
    • Advise avoidance of sexual intercourse until miscarriage symptoms have completely settled and until after the woman's next period
    • Explain that menstruation can be expected to resume within 48 weeks of the miscarriage, but may take several cycles to re-establish a regular pattern
    • For woman who wish to become pregnant
      • advise that that they can do so as soon as they feel psychologically and physically ready
      • offer preconception advice, including advice about folic acid
  • For women who do not wish to become pregnant − advise the use of contraception immediately after the miscarriage

Rhesus Status (secondary care intervention)

  • Routine antenatal anti-D prophylaxis is recommended as a treatment option for all pregnant women who are rhesus D (RhD)-negative and who are not known to be sensitised to the RhD antigen.
  • Administer anti-D immunoglobulin in non-sensitised Rh-negative patients in confirmed miscarriage:
    • After 12 weeks
    • Where the uterus is evacuated, either surgically or medically
    • Surgical management of ectopic pregnancy
  • Discharge documentation from the early pregnancy assessment unit should clearly state whether or not anti-D was required/given

Referral

Referral Criteria

  • Please note this service is provided at all three sites; Pinderfields General Hospital, Dewsbury District Hospital and Pontefract General Infirmary.
  • This is a Recurrent Miscarriage Service only and the following conditions are treated:
    • Women with 3 consecutive 1st trimester(up to 13 weeks) miscarriages- including ectopic
      Or
    • Women with 2 consecutive miscarriages age >36 years
    • Women with at least 2 or more consecutive second trimester miscarriage or preterm labour up to 24 weeks
    • Women with 2 consecutive miscarriages with no living children and history of infertility.
    • Women with at least 2 consecutive miscarriages and associated conditions like PCOS antiphospholipid syndrome, medical disorders or history of congenital anomalies

Please Note : If your patient becomes pregnant at time of their planned outpatient appointment for recurrent miscarriage then they must cancel the appointment and return to the care of their GP.

Exclusions
  • This is a Recurrent Miscarriage Service only, therefore all other Gynaecology problems other than Recurrent Miscarriage are excluded from this service.
  • 2nd trimester or later pregnancy loss should be seen as follow up with Obstetrics
  • Please see the list in Alternative Services for further information and signposting regarding where to refer your patient.

Referral requirements

  • To avoid delay in your patients care the mandatory investigations and relevant suggested investigations must be undertaken prior to referring your patient and the results must be attached to support the referral into the Recurrent Miscarriage Service
  • For URGENT referrals please ensure that the clinical letter and supporting information is attached within 24 hours of the appointment request.
  • For ROUTINE referrals please ensure that the clinical letter and supporting information is attached within 3 working days of the appointment request
  • Please ensure that the patient demographic details are up to date and complete, including telephone number the patient can be best contacted on.
  • The referral should include previous medical history, presenting complaint and duration, and a list of medication and dosage. Details of previous treatment regimes and results of tests performed.
  • Please indicate clearly if interpreting service are required - stating language or if Sign Language (BSL) is required

Referral Instructions

  • e-consultation is available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient Information/Public Health/Self Care

Evidence/additional information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This Care Pathway was ratified by: The OSCAR Assurance Group
  • Date ratified: 12.2017
  • Publication Date: 12.2017
  • Review Date: 4.2019
  • Ref No: OG7 - 3.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk

Only the electronic version is maintained, once printed this is no longer a controlled document

 

Home > Care Pathways > Obstetrics & Gynaecology* > Recurrent Miscarriage Care Pathway