Evaluation and Treatment for Recurrent Miscarriage
Recurrent miscarriage, defined as the loss of three or more consecutive pregnancies before 24 weeks, affects 1% of women and requires a systematic evaluation of genetic, structural, endocrine, immune, thrombophilic, and other potential causes to improve outcomes. 1
Essential Diagnostic Evaluations
Medical History Assessment
- Reproductive history: Previous pregnancy outcomes, pattern of losses
- Family history: Thrombophilia, genetic disorders
- Medical conditions: Autoimmune diseases, chronic hypertension, diabetes
- Medication use: Review current medications for teratogenic potential
- Lifestyle factors: BMI, smoking, alcohol consumption
Laboratory Testing
- Antiphospholipid antibody screening (lupus anticoagulant, anticardiolipin antibodies) 1, 2
- Thyroid function tests (TSH, free T4) 2
- Complete blood count
- Blood type and screen
- Thrombophilia testing in selected cases (particularly with family history of VTE)
- Genetic testing (parental karyotyping) when indicated by history
Imaging Studies
- Transvaginal ultrasound to evaluate uterine anatomy 2
- Sonohysterography (SIS) to assess the uterine cavity for polyps, fibroids, adhesions 1
- Hysterosalpingography or 3D ultrasound to evaluate for uterine anomalies in selected cases
Treatment Recommendations Based on Etiology
Antiphospholipid Syndrome (APS)
- For women with APS and recurrent pregnancy loss: Low-dose aspirin plus prophylactic-dose heparin during pregnancy 1, 2
- Begin treatment preconception (aspirin) and add heparin immediately post-conception
Thyroid Disorders
- Levothyroxine for women with subclinical hypothyroidism 2
- Target TSH within normal pregnancy range
Hormonal Support
- First trimester progesterone supplementation should be considered 2
Uterine Abnormalities
- Surgical correction of significant uterine septum or other structural abnormalities
- Hysteroscopic removal of submucosal fibroids or polyps if implicated
Unexplained Recurrent Miscarriage
- Approximately 50% of cases remain unexplained despite thorough evaluation
- Reassurance that approximately 70% of women with unexplained recurrent miscarriage will have a successful pregnancy with supportive care 3
Special Considerations
Thrombophilia Testing
- Not routinely recommended for all women with recurrent pregnancy loss 1
- Consider in women with personal or family history of VTE
- When identified, management depends on specific thrombophilia and risk profile
Lifestyle Modifications
- Achieve healthy pre-pregnancy weight (BMI 19.8-26.0 kg/m²) 1
- Smoking cessation
- Limit alcohol consumption
- Daily multivitamin with folic acid
Follow-up Care in Subsequent Pregnancies
- Early ultrasound confirmation of pregnancy
- Regular monitoring with serial ultrasonography in first trimester
- Psychological support and counseling
- Assessment for other pregnancy complications (preterm birth, fetal growth restriction)
- Mental health screening and support
Common Pitfalls to Avoid
Overdiagnosis of thrombophilia: Routine testing for inherited thrombophilia in all women with recurrent pregnancy loss is not recommended unless there is a personal or family history of VTE 1
Unproven treatments: Avoid empiric treatments without scientific basis
Delayed evaluation: Consider evaluation after two consecutive losses, especially in women over 35
Neglecting mental health: Recurrent miscarriage significantly impacts psychological wellbeing and requires appropriate support
Missing associated risks: Women with recurrent miscarriage have increased risk for other obstetric complications in future pregnancies
By following this systematic approach to evaluation and treatment, approximately 70% of women with recurrent miscarriage can achieve successful pregnancy outcomes, even when a specific cause cannot be identified.