From the Guidelines
The workup for recurrent miscarriage should begin with a comprehensive evaluation to identify potential causes, including parental karyotyping, antiphospholipid antibody testing, and assessment of uterine anatomy via hysteroscopy, sonohysterography, or MRI. Initial testing should also include endocrine evaluation, such as thyroid function tests (TSH, free T4), hemoglobin A1c for diabetes screening, and prolactin levels 1. Additional testing may include testing for inherited thrombophilias (Factor V Leiden, prothrombin gene mutation) in selected cases, particularly with personal or family history of thrombosis.
Some key points to consider in the workup for recurrent miscarriage include:
- Parental karyotyping to detect chromosomal abnormalities
- Antiphospholipid antibody testing (including lupus anticoagulant, anticardiolipin antibodies, and anti-β2 glycoprotein-I)
- Assessment of uterine anatomy via hysteroscopy, sonohysterography, or MRI to identify structural abnormalities like septate uterus or fibroids
- Endocrine evaluation, including thyroid function tests, hemoglobin A1c, and prolactin levels
- Testing for inherited thrombophilias in selected cases
For treatment, correctable factors should be addressed, such as:
- Antiphospholipid syndrome, which may be treated with low-dose aspirin (81mg daily) plus prophylactic heparin or low molecular weight heparin during pregnancy
- Uterine anomalies, which may require surgical correction
- Endocrine disorders, which should be optimized before conception
- Progesterone supplementation (vaginal progesterone 200mg daily or intramuscular progesterone 25mg daily) starting after ovulation may benefit some patients
It's also important to note that psychological support is essential as recurrent pregnancy loss causes significant emotional distress. The prognosis remains generally favorable, with approximately 70% of couples with unexplained recurrent miscarriage ultimately achieving a successful pregnancy with supportive care alone 1.
From the FDA Drug Label
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From the Research
Workup for Recurrent Miscarriage
The workup for recurrent miscarriage involves a comprehensive evaluation of various factors that may contribute to the condition. Some of the key investigations and treatments are outlined below:
- Essential investigations:
- Measurements of lupus anticoagulant, anticardiolipin antibodies, thyroid function, and a transvaginal pelvic ultrasound scan 2
- Chromosomal analysis, Haemoglobin A1C, blood sugar, Magnetic resonance imaging, 3D-ultrasound, auto-antibodies profile, torch profile, blood vitamin D3 levels, psychological factors, Body mass index, and thrombotic factors 3
- Key treatments:
- First trimester progesterone administration, levothyroxine in women with subclinical hypothyroidism, and the combination of aspirin and heparin in women with antiphospholipid antibodies 2
- Intravenous immunoglobulin, low molecular weight heparin, low dose aspirin, levothyroxine, progesterone, folic acid, human chorionic gonadotrophin, vitamin D3, psychotherapy, and genetic counselling 3
- Other considerations:
Factors Contributing to Recurrent Miscarriage
Various factors can contribute to recurrent miscarriage, including:
- Endocrinological disorders (39%) 3
- Uterine abnormalities (5.7%) 3
- Vitamin D3 deficiency (3.5%) 3
- Psychological factors (3.2%) 3
- Infection (3.6%) 3
- Autoimmune abnormalities (1.8%) 3
- Protein S deficiency (1.8%) 3
- Idiopathic factors (40%) 3
Management of Recurrent Miscarriage
The management of recurrent miscarriage involves a multidisciplinary approach, including:
- Dedicated miscarriage clinic with thorough investigations and structured history and investigation sheets 4
- Graded model of care, with online health-care advice and support, care in a nurse or midwifery-led clinic, and care in a medical consultant-led clinic, according to clinical needs 2
- Evidence-based guidance on clinical management, with critically appraised evidence and graded recommendations 5