Recurrent miscarriage is defined as 3 or more consecutive spontaneous pregnancy losses under 20 weeks gestation. It affects 1% of women and can be caused by many potential genetic, anatomical, hormonal, and immunological factors. Evaluation involves testing the parents' chromosomes through karyotyping of their blood, testing the chromosomes of miscarried fetal tissue when possible, and examining the uterus and fallopian tubes through ultrasound, hysterosalpingogram, hysteroscopy, or laparoscopy to check for anatomical abnormalities. Finding the cause helps guide treatment such as surgery to remove uterine anomalies which may improve future pregnancy outcomes.

1. Recurrent MiscarriageRecurrent Miscarriage
GuidelinesGuidelines
Dr Muhammad El HennawyDr Muhammad El Hennawy
Ob/gyn ConsultantOb/gyn Consultant
Rass el barr central hospital andRass el barr central hospital and
dumyat specialised hospitaldumyat specialised hospital
DumyattDumyatt –– EGYPTEGYPT
www. mmhennawywww. mmhennawy .co.nr.co.nr

2. DefinitionDefinition
A recurrent miscarriage isA recurrent miscarriage is 3 or more3 or more
consecutive, spontaneousconsecutive, spontaneous
pregnancy lossespregnancy losses , under 20 week, under 20 week
gestation from the last menstrual periodgestation from the last menstrual period
, by the same partner., by the same partner.

3. Primary recurrent pregnancy lossPrimary recurrent pregnancy loss""
refers to couples that have never had arefers to couples that have never had a
live birth,live birth,
whilewhile "secondary RPL""secondary RPL" refers to thoserefers to those
who have had repetitive losseswho have had repetitive losses
following a successful pregnancyfollowing a successful pregnancy

4. a woman who had aa woman who had a
miscarriage,instead of getting sympathymiscarriage,instead of getting sympathy
and support, is made to feel that it isand support, is made to feel that it is
somehow her faultsomehow her fault
It is all too common to find recurrentIt is all too common to find recurrent
miscarriges leading to divorcemiscarriges leading to divorce

5. TerminologyTerminology
 The medical term 'spontaneous abortion'The medical term 'spontaneous abortion'
should be replaced with the termshould be replaced with the term
'miscarriage''miscarriage'
 Other names : recurrent pregnancy loss (RPL),Other names : recurrent pregnancy loss (RPL),
habitual abortions ,habitual abortions ,
habitual miscarriages,habitual miscarriages,
recurrent abortions ,recurrent abortions ,
recurrent miscarriages.recurrent miscarriages.

6. IncidenceIncidence
 1010––15%15% of all clinically recognised pregnanciesof all clinically recognised pregnancies
end in a miscarriageend in a miscarriage
 the theoretical risk of three consecutivethe theoretical risk of three consecutive
pregnancy losses that expected by chancepregnancy losses that expected by chance
alone isalone is 0.34%.0.34%.
 This incidence is greater than that expected byThis incidence is greater than that expected by
chance alone---Recurrent miscarriage affectschance alone---Recurrent miscarriage affects
1%1% of all women ---Hence, only a proportion ofof all women ---Hence, only a proportion of
women presenting with recurrent miscarriagewomen presenting with recurrent miscarriage
will have a persistent underlying cause for theirwill have a persistent underlying cause for their
pregnancy lossespregnancy losses

7. Risk factorsRisk factors
Advanced maternal ageAdvanced maternal age
adversely affects ovarian function, giving rise toadversely affects ovarian function, giving rise to
a decline in the number of good qualitya decline in the number of good quality
oocytes, resulting in chromosomally abnormaloocytes, resulting in chromosomally abnormal
conceptions that rarely develop further.conceptions that rarely develop further.
.. previous number of miscarriagesprevious number of miscarriages

8. possible causespossible causes
Recurrent miscarriage is a heterogeneousRecurrent miscarriage is a heterogeneous
condition that has many possible causes;condition that has many possible causes;
more than onemore than one contributory factor maycontributory factor may
underlie the recurrent pregnancy losses.underlie the recurrent pregnancy losses.
each may have hadeach may have had a differenta different cause.cause.

9. Genetic
factors
Anatomical
factors
Endocrine
Infective
agents
Immune
factors
Inhereted
Thrombophilic
defect
Explained Un-explained
Recurent
Miscarriage
Enviromental
factors
Body Cervix
Paternal
karyotyping
Cytogenetic
Of miscarriage
C I
Uterine
anomalies
APS
Bacterial
Vaginosis

10. Investigations and treatmentsInvestigations and treatments
Recent information indicates that women should look into RPL testingRecent information indicates that women should look into RPL testing
after two losses when it used to be common to wait until three. This isafter two losses when it used to be common to wait until three. This is
especially important for women in their 30s and 40sespecially important for women in their 30s and 40s

11. Diagnosis and investigationDiagnosis and investigation
 EPAUs should use and develop diagnostic andEPAUs should use and develop diagnostic and
therapeutic algorithms of care.therapeutic algorithms of care.
In particular, these should include management ofIn particular, these should include management of
'suspected ectopic pregnancy' (including serum hCG)'suspected ectopic pregnancy' (including serum hCG)
and the 'indeterminate' ultrasound scan.and the 'indeterminate' ultrasound scan.
 EPAUs should have access to transvaginalEPAUs should have access to transvaginal
ultrasound with staff appropriately trained in its use.ultrasound with staff appropriately trained in its use.
 Non-sensitised rhesus (Rh) negative women shouldNon-sensitised rhesus (Rh) negative women should
receive anti-D immunoglobulin in the followingreceive anti-D immunoglobulin in the following
situations: ectopic pregnancy, all miscarriages oversituations: ectopic pregnancy, all miscarriages over
12 weeks (including threatened), all miscarriages12 weeks (including threatened), all miscarriages
where the uterus is evacuated, and for threatenedwhere the uterus is evacuated, and for threatened
miscarriages under 12 weeks when bleeding is heavymiscarriages under 12 weeks when bleeding is heavy
or associated with pain.or associated with pain.

12. Genetic factorsGenetic factors

13. All couples with a history of recurrentAll couples with a history of recurrent
miscarriage should have peripheralmiscarriage should have peripheral
blood karyotyping performed. Theblood karyotyping performed. The
finding of an abnormal parentalfinding of an abnormal parental
karyotype should prompt referral to akaryotype should prompt referral to a
clinical geneticist.clinical geneticist.
33––5% of couples with recurrent miscarriage,5% of couples with recurrent miscarriage,
one of the partners carries a balancedone of the partners carries a balanced
structural chromosomal anomalystructural chromosomal anomaly
55––10% chance of a pregnancy with an10% chance of a pregnancy with an
unbalanced translocation.unbalanced translocation.

14.  In all couples with a history of recurrent
miscarriage cytogenetic analysis of the
products of conception should be
performed if the next pregnancy fails.
 an abnormal embryo, which is incompatible with
life, e.g. chromosomal abnormalities or structurallife, e.g. chromosomal abnormalities or structural
malformations.malformations.
 If the karyotype of the miscarried pregnancy isIf the karyotype of the miscarried pregnancy is
abnormal, there is a better prognosis in the nextabnormal, there is a better prognosis in the next
pregnancypregnancy
 Cytogenetic testing is an expensive tool and
should be reserved for patients who have
undergone treatment in the index pregnancy or
have been participants in a research trial

15. Fetal chromosomal abnormalitiesFetal chromosomal abnormalities
This may be due to abnormalities in theThis may be due to abnormalities in the
egg, sperm or both. Theegg, sperm or both. The most commonmost common
chromosomal defects arechromosomal defects are
Trisomy:Trisomy:
Monosomy:Monosomy:
Polyploidy:Polyploidy:

16.  Chromosome Testing on Fetal (Miscarriage)Chromosome Testing on Fetal (Miscarriage)
TissueTissue
 This can only be done right at the time of miscarriage.This can only be done right at the time of miscarriage.
 It is an analysis of the genetic makeup of the fetus.It is an analysis of the genetic makeup of the fetus.
 It can indicate genetic problems that lead to RPL.It can indicate genetic problems that lead to RPL.
 Many miscarriages are caused by chromosomalMany miscarriages are caused by chromosomal
abnormalities that are unlikely to repeat. To know ifabnormalities that are unlikely to repeat. To know if
the problem is likely to recur, it is necessary to studythe problem is likely to recur, it is necessary to study
the genetics of both parents as well.the genetics of both parents as well.
 Karyotyping of ParentsKaryotyping of Parents
 each Chromosome analysis of blood of both parents.each Chromosome analysis of blood of both parents.
 It can show if there is a potential problem with one ofIt can show if there is a potential problem with one of
the parents that leads to miscarriage, but often has tothe parents that leads to miscarriage, but often has to
be done in conjunction with fetal testing to providebe done in conjunction with fetal testing to provide
answers.answers.
 These tests help rule out the 3% or so of partners thatThese tests help rule out the 3% or so of partners that
carry a "hidden" chromosomal problem called acarry a "hidden" chromosomal problem called a
balanced translocation.balanced translocation.

17. KARYOTYPING , HOWKARYOTYPING , HOW??
 It is A display of an individualIt is A display of an individual’’s chromosome pairs.s chromosome pairs.
 Process : Sample of cells is taken, usually blood cells.Process : Sample of cells is taken, usually blood cells.
Cells are chemically stimulated to undergo mitosis.Cells are chemically stimulated to undergo mitosis.
Mitosis is stopped atMitosis is stopped at metaphasemetaphase..
Chromosomes are separated out,Chromosomes are separated out,
viewed with a microscopeviewed with a microscope
and photographed.and photographed.
The photograph is then rearranged to show the pairedThe photograph is then rearranged to show the paired
chromosomes.chromosomes. SizeSize,, shapeshape andand banding patternbanding pattern areare
used to pair up the chromosomesused to pair up the chromosomes..

19. Anatomical factorsAnatomical factors
One in six to ten women with recurrentOne in six to ten women with recurrent
miscarriages has a structural defectmiscarriages has a structural defect
like uterine septum or adhesionslike uterine septum or adhesions

20. HysterosalpingogramHysterosalpingogram (HSG)(HSG)
two dimensional pelvic ultrasoundtwo dimensional pelvic ultrasound
with (or without)with (or without)
SonohysterographySonohysterography
3D3D UltrasoundUltrasound
LaparoscopyLaparoscopy
HysteroscopyHysteroscopy

21.  The reported prevalence of uterine anomalies inThe reported prevalence of uterine anomalies in
recurrent miscarriage populations range betweenrecurrent miscarriage populations range between
1.8% and 37.6%.1.8% and 37.6%.
 The prevalence of uterine malformations appears toThe prevalence of uterine malformations appears to
be higher in women withbe higher in women with late miscarriageslate miscarriages comparedcompared
with women who suffer early miscarriages but thiswith women who suffer early miscarriages but this
may be related to the cervical weakness that ismay be related to the cervical weakness that is
frequently associated with uterine malformation.frequently associated with uterine malformation.
 untreated uterine anomaliesuntreated uterine anomalies has a term delivery ratehas a term delivery rate
of only 50%.of only 50%.
 Open uterine surgeryOpen uterine surgery is associated with postoperativeis associated with postoperative
infertility and carries a significant risk of uterine scarinfertility and carries a significant risk of uterine scar
rupture during pregnancy. These complications arerupture during pregnancy. These complications are
less likely to occur after hysteroscopic surgery but noless likely to occur after hysteroscopic surgery but no
randomised trial assessing the benefits of surgicalrandomised trial assessing the benefits of surgical
correction of uterine abnormalities on pregnancycorrection of uterine abnormalities on pregnancy
outcome has been performed.outcome has been performed.

22. Congenital anomaliesCongenital anomalies
 an abnormal or irregularly shaped uterus.an abnormal or irregularly shaped uterus.
 SometimesSometimes the uterus has an extra wall down its
centre, which makes it look as if it is divided intoit is divided into
two (bicornuate or septate uterus)(bicornuate or septate uterus)
a septate uterus Where as a partial septuma septate uterus Where as a partial septum
increases the risk to 60%-75%; a total septumincreases the risk to 60%-75%; a total septum
carries a risk for loss of up to 90%.carries a risk for loss of up to 90%.
Today a relatively simple surgical procedure canToday a relatively simple surgical procedure can
remove a uterine septumremove a uterine septum
or it mayor it may have only developed one half
(unicornuate uterus)(unicornuate uterus) ..
It is not clear if such problems cause recurrentIt is not clear if such problems cause recurrent
miscarriage,miscarriage,

23. fibroidsfibroids
If fibroids are detected on the inside of theIf fibroids are detected on the inside of the
uterus (termed submucous fibroids) anduterus (termed submucous fibroids) and
distort the uterine lining, they are adistort the uterine lining, they are a
significant cause of reproductive problemssignificant cause of reproductive problems
and should be removed. It is less clearand should be removed. It is less clear
whether fibroids in the wall of the uteruswhether fibroids in the wall of the uterus
cause reproductive problemscause reproductive problems

24. scar tissue in the uterusscar tissue in the uterus
scar tissue in the uterus which may hinderscar tissue in the uterus which may hinder
implantation or growth of the fetus.implantation or growth of the fetus.

25. HysterosalpingographyHysterosalpingography
The routine use of hysterosalpingography as aThe routine use of hysterosalpingography as a
screening test for uterine anomalies in womenscreening test for uterine anomalies in women
with recurrent miscarriage iswith recurrent miscarriage is questionablequestionable..
It is associated with patient discomfort,It is associated with patient discomfort,
carries a risk of pelvic infection and radiationcarries a risk of pelvic infection and radiation
exposureexposure
and is no more sensitive than the non-invasiveand is no more sensitive than the non-invasive
two dimensional pelvic ultrasound assessmenttwo dimensional pelvic ultrasound assessment
of the uterine cavity with (or without)of the uterine cavity with (or without)
Sonohysterography when performed by skilledSonohysterography when performed by skilled
and experienced personnel.and experienced personnel.

26. HysterosonographyHysterosonography
Hysterosonography provides a sensitiveHysterosonography provides a sensitive
and specific screening tool for evaluatingand specific screening tool for evaluating
the uterine cavity and it could be anthe uterine cavity and it could be an
accurate alternative to HSG in screeningaccurate alternative to HSG in screening
for uterine abnormalitiesfor uterine abnormalities

27. UltrasoundUltrasound
 It is sometimes possible to see abnormalities inside the uterus at theIt is sometimes possible to see abnormalities inside the uterus at the
time of a scan, especially atime of a scan, especially a
 vaginal scan. A scan will also enable the ovaries to be examined atvaginal scan. A scan will also enable the ovaries to be examined at
the same time. Occasionallythe same time. Occasionally
 polycystic ovariespolycystic ovaries are diagnosed by ultrasound scan (seeare diagnosed by ultrasound scan (see
above).above).
 Some units will offer a scan and an examination of the inside of theSome units will offer a scan and an examination of the inside of the
uterus at the same time -uterus at the same time - salinesaline
 installation sonography (SIS).installation sonography (SIS). A small plastic tube is passedA small plastic tube is passed
through the cervix and a water-likethrough the cervix and a water-like
 solution injected through it. The scan can determine whether theresolution injected through it. The scan can determine whether there
is any abnormality inside theis any abnormality inside the
 uterus.uterus.

28. All women with recurrentAll women with recurrent
miscarriage should have amiscarriage should have a
pelvic ultrasound to assesspelvic ultrasound to assess
uterine anatomy anduterine anatomy and
morphologymorphology
Two dimensional pelvic ultrasoundTwo dimensional pelvic ultrasound
assessment of the uterine cavity withassessment of the uterine cavity with
(or without) Sonohysterography(or without) Sonohysterography

29. three-dimensional ultrasoundthree-dimensional ultrasound
The diagnostic value of three-dimensionalThe diagnostic value of three-dimensional
ultrasound has been explored andultrasound has been explored and
appears promising.appears promising.
 Since three-dimensional ultrasound offerSince three-dimensional ultrasound offer
both diagnosis and classification of uterineboth diagnosis and classification of uterine
malformation its use may obviate the needmalformation its use may obviate the need
for diagnostic hysteroscopy andfor diagnostic hysteroscopy and
laparoscopy.laparoscopy.

30. HysteroscopyHysteroscopy
This investigation, performed underThis investigation, performed under
general anaesthetic, examines the insidegeneral anaesthetic, examines the inside
of the uterus with a thinof the uterus with a thin
telescope (3-5 mm in diameter) . Bytelescope (3-5 mm in diameter) . By
inserting this telescope through the cervixinserting this telescope through the cervix
and into the uterus,and into the uterus,
the doctor can see the shape of the uterusthe doctor can see the shape of the uterus
and examine its lining.and examine its lining.

31. Cervical weaknessCervical weakness

32.  Cervical cerclage is associated with potentialCervical cerclage is associated with potential
hazards related to the surgery and the risk ofhazards related to the surgery and the risk of
stimulating uterine contractions and hencestimulating uterine contractions and hence
should only be considered in women who areshould only be considered in women who are
likely to benefit.likely to benefit.
 Cervical weakness is oftenCervical weakness is often over-diagnosedover-diagnosed as a causeas a cause
of mid-trimester miscarriage.of mid-trimester miscarriage.
 The diagnosis is usually based onThe diagnosis is usually based on a historya history of lateof late
miscarriage, preceded by spontaneous rupture ofmiscarriage, preceded by spontaneous rupture of
membranes or painless cervical dilatation.membranes or painless cervical dilatation.
Transvaginal ultrasound assessment of the cervixTransvaginal ultrasound assessment of the cervix
during pregnancyduring pregnancy maymay be useful in predicting pretermbe useful in predicting preterm
birth in some cases of suspected cervical weaknessbirth in some cases of suspected cervical weakness
 Transabdominal cerclage has been advocated as aTransabdominal cerclage has been advocated as a
treatment for second-trimester miscarriage and thetreatment for second-trimester miscarriage and the
prevention of early preterm labour in selected womenprevention of early preterm labour in selected women
with previous failed transvaginal cerclage and/or a verywith previous failed transvaginal cerclage and/or a very
short and scarred cervixshort and scarred cervix

33. Endocrine factorsEndocrine factors

34. Routine screening for occultRoutine screening for occult
diabetes and thyroid disease withdiabetes and thyroid disease with
oral glucose tolerance and thyroidoral glucose tolerance and thyroid
function tests in asymptomaticfunction tests in asymptomatic
women presenting with recurrentwomen presenting with recurrent
miscarriage is uninformativemiscarriage is uninformative
well-controlled diabetes mellitus is not a riskwell-controlled diabetes mellitus is not a risk
factor for recurrent miscarriage, nor is treatedfactor for recurrent miscarriage, nor is treated
thyroid dysfunctionthyroid dysfunction

35. There is insufficient evidence toThere is insufficient evidence to
evaluate the effect of progesteroneevaluate the effect of progesterone
supplementation in pregnancy tosupplementation in pregnancy to
prevent a miscarriageprevent a miscarriage
 hormonal treatments for luteal phase deficiency concluded thathormonal treatments for luteal phase deficiency concluded that
the benefits are uncertain the low progesterone levels that havethe benefits are uncertain the low progesterone levels that have
been reported in early pregnancy loss may reflect a pregnancybeen reported in early pregnancy loss may reflect a pregnancy
that has already failed. Exogenous progesteronethat has already failed. Exogenous progesterone
supplementation should only be used in the context ofsupplementation should only be used in the context of
randomised controlled trials.randomised controlled trials.
 Progesterone doesn't prevent miscarriages. Miscarriages
happen for many reasons,
but lack of progesterone as a cause for miscarriage is not
proven. The low progesterone levels found in pregnancies
which go on to become miscarriages is a sign that the
pregnancy is already failing

36. There is insufficient evidence toThere is insufficient evidence to
evaluate the effect of humanevaluate the effect of human
chorionic gonadotrophin (hCG) inchorionic gonadotrophin (hCG) in
pregnancy to prevent miscarriagepregnancy to prevent miscarriage..
early pregnancy hCG supplementation failed toearly pregnancy hCG supplementation failed to
show any benefit in pregnancy outcomeshow any benefit in pregnancy outcome

37. Prepregnancy suppression of highPrepregnancy suppression of high
luteinising hormone (LH)luteinising hormone (LH)
concentration among ovulatoryconcentration among ovulatory
women with recurrent miscarriagewomen with recurrent miscarriage
and polycystic ovaries whoand polycystic ovaries who
hypersecrete LH does not improvehypersecrete LH does not improve
the live birth ratethe live birth rate
the outcome of pregnancy without pituitarythe outcome of pregnancy without pituitary
suppression is similar to that of patientssuppression is similar to that of patients
without raised LH.without raised LH.

38. Polycystic ovary morphology itself doesPolycystic ovary morphology itself does
not predict an increased risk of futurenot predict an increased risk of future
pregnancy loss among ovulatorypregnancy loss among ovulatory
women with a history of recurrentwomen with a history of recurrent
miscarriage who conceivemiscarriage who conceive
spontaneouslyspontaneously ..
 pelvic ultrasound criteria, is significantly higher amongpelvic ultrasound criteria, is significantly higher among
women with recurrent miscarriage (41%) whenwomen with recurrent miscarriage (41%) when
compared with the general population (22%).compared with the general population (22%).
 However, despite this high prevalence, polycysticHowever, despite this high prevalence, polycystic
ovary morphology itself does not predict an increasedovary morphology itself does not predict an increased
risk of future pregnancy loss among ovulatory womenrisk of future pregnancy loss among ovulatory women
with a history of recurrent miscarriage who conceivewith a history of recurrent miscarriage who conceive
spontaneously.spontaneously.

39. There is insufficient evidence toThere is insufficient evidence to
assess the effect ofassess the effect of
hyperprolactinaemia as a riskhyperprolactinaemia as a risk
factor for recurrent miscarriagefactor for recurrent miscarriage ..

40. Immune factorsImmune factors
One in ten women with recurrent miscarriages show evidenceOne in ten women with recurrent miscarriages show evidence
of auto immune factors on investigationof auto immune factors on investigation
As much asAs much as 40 percent40 percent of unexplained infertility may be theof unexplained infertility may be the
result of immune problems, as are as many asresult of immune problems, as are as many as 80 percent80 percent ofof
"unexplained" pregnancy losses. Unfortunately for couples"unexplained" pregnancy losses. Unfortunately for couples
with immunological problems, their chances of recurrent losswith immunological problems, their chances of recurrent loss
increase with each successive pregnancyincrease with each successive pregnancy..

41. Antithyroid antibodiesAntithyroid antibodies
Routine screening for thyroidRoutine screening for thyroid
antibodies in women with recurrentantibodies in women with recurrent
miscarriage is not recommended.miscarriage is not recommended.

42. Antiphospholipid syndromeAntiphospholipid syndrome
To diagnose APS it is mandatory that theTo diagnose APS it is mandatory that the
patient should have two positive tests atpatient should have two positive tests at
least six weeks apart for either lupusleast six weeks apart for either lupus
anticoagulant or anticardiolipin (aCL)anticoagulant or anticardiolipin (aCL)
antibodies of IgG and/or IgM class presentantibodies of IgG and/or IgM class present
in medium or high titre.in medium or high titre.
 Adverse pregnancy outcomes includeAdverse pregnancy outcomes include
(a) three or more consecutive miscarriages before ten(a) three or more consecutive miscarriages before ten
weeks of gestation,weeks of gestation,
(b) one or more morphologically normal fetal deaths(b) one or more morphologically normal fetal deaths
after the tenth week of gestation andafter the tenth week of gestation and
(c) one or more preterm births before the 34th week(c) one or more preterm births before the 34th week
of gestation due to severe pre-eclampsia,of gestation due to severe pre-eclampsia,
eclampsia or placental insufficiency.eclampsia or placental insufficiency.

43.  Currently there is no reliable evidence toCurrently there is no reliable evidence to
show that steroids improve the live birthshow that steroids improve the live birth
rate of women with recurrent miscarriagerate of women with recurrent miscarriage
associated with aPL when compared withassociated with aPL when compared with
other treatment modalities; their use mayother treatment modalities; their use may
provoke significant maternal and fetalprovoke significant maternal and fetal
morbidity.morbidity.
 In women with a history of recurrentIn women with a history of recurrent
miscarriage and aPL, future live birth ratemiscarriage and aPL, future live birth rate
is significantly improved when ais significantly improved when a
combination therapy of aspirin plus heparincombination therapy of aspirin plus heparin
is prescribed.is prescribed.
 Pregnancies associated with aPL treatedPregnancies associated with aPL treated
with aspirin and heparin remain at high riskwith aspirin and heparin remain at high risk
of complications during all three trimestersof complications during all three trimesters ..

44. Alloimmune factorsAlloimmune factors
Immunotherapy, including paternalImmunotherapy, including paternal
cell immunisation, third-party donorcell immunisation, third-party donor
leucocytes, trophoblast membranesleucocytes, trophoblast membranes
and intravenous immunoglobulinand intravenous immunoglobulin
(IVIG), in women with previous(IVIG), in women with previous
unexplained recurrent miscarriageunexplained recurrent miscarriage
does not improve the live birth ratedoes not improve the live birth rate

45. Infective agentsInfective agents

46.  TORCH (toxoplasmosis rubella,TORCH (toxoplasmosis rubella,
cytomegalovirus and herpes simplexcytomegalovirus and herpes simplex
virus), other [congenital syphilis andvirus), other [congenital syphilis and
viruses], screening is unhelpful in theviruses], screening is unhelpful in the
investigation of recurrent miscarriage.investigation of recurrent miscarriage.
 For an infective agent to be implicated in theFor an infective agent to be implicated in the
aetiology of repeated pregnancy loss, it mustaetiology of repeated pregnancy loss, it must
be capable of persisting in the genital tract andbe capable of persisting in the genital tract and
avoiding detection or must cause insufficientavoiding detection or must cause insufficient
symptoms to disturb the women.symptoms to disturb the women.
Toxoplasmosis, rubella, cytomegalovirus,Toxoplasmosis, rubella, cytomegalovirus,
herpes and listeria infections do not fulfil theseherpes and listeria infections do not fulfil these
criteria and routine TORCH screening shouldcriteria and routine TORCH screening should
be abandonebe abandone

47. Screening for and treatment ofScreening for and treatment of
bacterial vaginosis in earlybacterial vaginosis in early
pregnancy among high riskpregnancy among high risk
women with a previous history ofwomen with a previous history of
second-trimester miscarriage orsecond-trimester miscarriage or
spontaneous preterm labour mayspontaneous preterm labour may
reduce the risk of recurrent latereduce the risk of recurrent late
loss and preterm birth.loss and preterm birth.

48. Group B StreptococcusGroup B Streptococcus
 Pre and Post-conceptional, broad-Pre and Post-conceptional, broad-
spectrum intravenous antibiotic therapyspectrum intravenous antibiotic therapy
was used in patients with multiplewas used in patients with multiple
miscarriagesmiscarriages
 Although this is a relatively small series andAlthough this is a relatively small series and
does not establish a cause and effectdoes not establish a cause and effect
relationship between Group B Streptococcusrelationship between Group B Streptococcus
and habitual abortions, the beneficial effects ofand habitual abortions, the beneficial effects of
antibiotic therapy isantibiotic therapy is unquestionableunquestionable

49. Inherited thrombophilic defectsInherited thrombophilic defects

50.  Inherited thrombophilic defects,Inherited thrombophilic defects,
 including activated protein C resistanceincluding activated protein C resistance
(most commonly due to factor V Leiden gene(most commonly due to factor V Leiden gene
mutation), deficiencies of protein C/S andmutation), deficiencies of protein C/S and
antithrombin III, hyperhomocysteinaemia andantithrombin III, hyperhomocysteinaemia and
prothrombin gene mutation,prothrombin gene mutation,
 are established causes of systemicare established causes of systemic
thrombosisthrombosis

51. Environmental factorsEnvironmental factors

52. Exposture to noxious or toxic substances areExposture to noxious or toxic substances are
known to be associated withknown to be associated with recurrentrecurrent
miscarriage ( social drugs, cigarretes,alcoholmiscarriage ( social drugs, cigarretes,alcohol
and caffeine ,anaestetic gases,petroliumand caffeine ,anaestetic gases,petrolium
products )products )

53. Unexplained recurrentUnexplained recurrent
miscarriagemiscarriage
In about half the women in the researchIn about half the women in the research
studies,studies, no causeno cause could be found, so no
specific treatment could be given.
However, this group responded very well toHowever, this group responded very well to
a programme which removed as manya programme which removed as many stressstress
factorsfactors as possible from their lives, resultingas possible from their lives, resulting
in an 80% success rate with the subsequentin an 80% success rate with the subsequent
pregnancypregnancy

54. Women with unexplained recurrentWomen with unexplained recurrent
miscarriage have an excellentmiscarriage have an excellent
prognosis for future pregnancyprognosis for future pregnancy
outcome without pharmacologicaloutcome without pharmacological
intervention if offered supportive careintervention if offered supportive care
alone in the setting of a dedicatedalone in the setting of a dedicated
early pregnancy assessment unitearly pregnancy assessment unit ..
After all these investigations 50% of recurrentAfter all these investigations 50% of recurrent
aborters will be found to have no abnormalitiesaborters will be found to have no abnormalities
and these should be attributed toand these should be attributed to
chromosomal defect in the conceptuschromosomal defect in the conceptus..

55. According to the American College ofAccording to the American College of
Obstetricians and GynecologistsObstetricians and Gynecologists
 cultures for bacteria and virusescultures for bacteria and viruses
 glucose tolerance testingglucose tolerance testing
 thyroid teststhyroid tests
 antibodies to infectious agentsantibodies to infectious agents
 antithyroid antibodiesantithyroid antibodies
 paternal human leukocyte antigen status, or maternalpaternal human leukocyte antigen status, or maternal
antiparental antibodiesantiparental antibodies

are not beneficialare not beneficial and, therefore,and, therefore,
 areare not recommendednot recommended in the evaluation ofin the evaluation of
otherwise normal women with recurrent pregnancy lossotherwise normal women with recurrent pregnancy loss..

56. Things unlikely to cause recurrentThings unlikely to cause recurrent
miscarriagemiscarriage
 RetroversionRetroversion - or backward tilting of the uterus.- or backward tilting of the uterus.
 InfectionInfection - such as toxoplasmosis, listeria, brucella,- such as toxoplasmosis, listeria, brucella,
chlamydia, herpes simplex and cytomegalovirus.chlamydia, herpes simplex and cytomegalovirus.
 Endocrine or metabolic diseaseEndocrine or metabolic disease - hypothyroidism- hypothyroidism
(underactive thyroid), diabetes mellitus, Crohn's disease, sickle(underactive thyroid), diabetes mellitus, Crohn's disease, sickle
cell or endometriosis.cell or endometriosis.
 Occupational exposuresOccupational exposures - very little reliable evidence exists- very little reliable evidence exists
for things such as herbicide spraying, electromagnetic fields,for things such as herbicide spraying, electromagnetic fields,
chemical inhalation, anaesthetic gases or VDU usage.chemical inhalation, anaesthetic gases or VDU usage.
 Not resting enoughNot resting enough - bedrest doesn't alter whether you- bedrest doesn't alter whether you
miscarry or not. Nor does working when you're pregnant,miscarry or not. Nor does working when you're pregnant,
exercise, making love or flying.exercise, making love or flying.

58. ManagementManagement
 Miscarriages, like infertility, is a problem of aMiscarriages, like infertility, is a problem of a
couple and they should be seen together.couple and they should be seen together.
The majority can be reassuared.The majority can be reassuared.
most cases, neither a woman nor hermost cases, neither a woman nor her
doctor can do anything to prevent adoctor can do anything to prevent a
miscarriagemiscarriage

59. Controversies surroundingControversies surrounding
treatment for pregnancy losstreatment for pregnancy loss
Evidence-based medicine (EBM) has notEvidence-based medicine (EBM) has not
succeeded in giving patients andsucceeded in giving patients and
physicians the data they need to choosephysicians the data they need to choose
(or not choose) a therapy in the field of(or not choose) a therapy in the field of
pregnancy losspregnancy loss

60. If any of the above tests should comeIf any of the above tests should come
back indicating an underlying reasonback indicating an underlying reason
for the problemfor the problem
treatment is direced at the causetreatment is direced at the cause
eg : genetic counselling,eg : genetic counselling,
removal of fibroids,removal of fibroids,
cervical stitchcervical stitch

61. If all of the above have beenIf all of the above have been
excludedexcluded
 (as they will do in most cases), the diagnosis is recurrent miscarriage of(as they will do in most cases), the diagnosis is recurrent miscarriage of
unknown causeunknown cause
 the use of empirical treatment in women with unexplained recurrentthe use of empirical treatment in women with unexplained recurrent
miscarriage is unnecessary andmiscarriage is unnecessary and should be resistedshould be resisted
 for both partners to be as healthy as possible beforefor both partners to be as healthy as possible before
she conceive (avoid drugs, alcohol, chemicals, etc)she conceive (avoid drugs, alcohol, chemicals, etc)
and to get any other medical conditions under control.and to get any other medical conditions under control.
 The only intervention to have demonstrated benefit is serial ultrasoundThe only intervention to have demonstrated benefit is serial ultrasound
scans in the early months of pregnancy.scans in the early months of pregnancy.
 It is certainly not unreasonable to expect this psychological support toIt is certainly not unreasonable to expect this psychological support to
improve outcome given the close interaction between the higher areas of theimprove outcome given the close interaction between the higher areas of the
mind and the delicately balanced hormonal system.mind and the delicately balanced hormonal system.
 Education and reassuarance with these good statistical oddsEducation and reassuarance with these good statistical odds
 Education about smoking, alcohol and drug abuse is also importantEducation about smoking, alcohol and drug abuse is also important

62. Psychological supportPsychological support
 The value of psychological support in improvingThe value of psychological support in improving
pregnancy outcome has not been tested in the form of apregnancy outcome has not been tested in the form of a
randomised controlled trial. However, data from severalrandomised controlled trial. However, data from several
non-randomised studiesnon-randomised studies86–88 have suggested that86–88 have suggested that
attendance at a dedicated early pregnancy clinic has aattendance at a dedicated early pregnancy clinic has a
beneficial effect, although the mechanism is unclearbeneficial effect, although the mechanism is unclear
 All professionals should be aware of theAll professionals should be aware of the
psychological sequelae associated withpsychological sequelae associated with
miscarriage and should provide support andmiscarriage and should provide support and
follow-up, as well as access to formalfollow-up, as well as access to formal
counselling when necessary.counselling when necessary.

63. Emprical treatmentEmprical treatment
 the use of empirical treatment in women with unexplained recurrentthe use of empirical treatment in women with unexplained recurrent
miscarriage is unnecessary andmiscarriage is unnecessary and should be resistedshould be resisted
BUTBUT
Some doctors give treatment likeSome doctors give treatment like
 Low dose asprinLow dose asprin
 Subcutaneous hepaeinSubcutaneous hepaein
 Folic acidFolic acid
 ProgesteroneProgesterone
 Solcoseryl(increase oxygen supply)Solcoseryl(increase oxygen supply)
 Nitroglycerin (increase implantation by increase uterine blood flow)Nitroglycerin (increase implantation by increase uterine blood flow)
 tocolytictocolytic

64. TreatmentTreatment of miscarriageof miscarriage
 Surgical uterine evacuation for miscarriage should beSurgical uterine evacuation for miscarriage should be
performed using suction curettage.performed using suction curettage.
 All at risk women undergoing surgical uterineAll at risk women undergoing surgical uterine
evacuation for miscarriage should be screened forevacuation for miscarriage should be screened for
Chlamydia trachomatis.Chlamydia trachomatis.
 Medical and expectant methods are also effective inMedical and expectant methods are also effective in
the management of confirmed miscarriage.the management of confirmed miscarriage.
 Medical and expectant management should beMedical and expectant management should be
offered only in units where patients have access tooffered only in units where patients have access to
24-hour telephone advice and immediate admission24-hour telephone advice and immediate admission
can be arranged.can be arranged.
 Tissue obtained at the time of miscarriage should beTissue obtained at the time of miscarriage should be
examined histologically to confirm pregnancy and toexamined histologically to confirm pregnancy and to
exclude ectopic pregnancy or gestationalexclude ectopic pregnancy or gestational
trophoblastic disease.trophoblastic disease.

65. FateFate
A woman who has suffered a singleA woman who has suffered a single
sporadic miscarriage has an 80% chancesporadic miscarriage has an 80% chance
and a woman with three consecutiveand a woman with three consecutive
miscarriages a 60% chance of her nextmiscarriages a 60% chance of her next
pregnancy being successfulpregnancy being successful