Neobook — clinical reference

This is defined as 3 consecutive miscarriages. Good history taking is essential, to direct further investigations. Even without any specific intervention, successful pregnancy rates are as high as 80%. The patient may present in pregnancy or non-pregnant.

Causes of recurrent miscarriage

Many cases have no recognizable cause – idiopathic
Cervical incompetence - second trimester
Uterine anomalies and uterine fibroids – second trimester
Antiphospholipid syndrome (APLS) – 3 consecutive miscarriages <10 weeks with normal fetus; premature birth <34 weeks due to eclampsia or preeclampsia; 1 or more intra-uterine fetal deaths < 10 weeks confirmed by sonar; at least 1 of 3 serological tests
Infections – syphilis, possibly bacterial vaginosis (rare)
Luteal phase defect – of uncertain significance, first trimester
Balanced translocations in the parents – first trimester (rare)
Chronic medication – e.g. warfarin
Diabetes mellitus & thyroid disorders – probably not causes unless poorly controlled

Important questions on history taking

Outcomes of all previous pregnancies
Paternity of all pregnancies
Gestation at each pregnancy loss
Duration & presence of uterine pain & bleeding
Where & how the miscarriages were managed
If the fetuses were seen, their size & whether they were alive
Any medical disorders: thrombosis, endocrine conditions etc.
Previous gynaecological surgery including myomectomy, curettage & cervical cone biopsy
History of sexually transmitted conditions
What the patient thinks might be the cause of the miscarriages

Examination

General examination is essential and must include blood pressure
Fibroids or an obvious uterine abnormality may be found on examination or sonar
An incompetent cervix is almost always closed in the non-pregnant patient
Usually, nothing abnormal is found on examination

Investigations

RPR & HIV serology in all patients
Anticardiolipin antibodies IgG, IgM, IgA; Lupus anticoagulant; anti beta 2 glycoprotein 1
Sonar for fibroids, uterine anomaly
Hysterosalpingogram, laparoscopy & hysteroscopy can show suspected uterine abnormalities
There are no reliable tests for cervical incompetence in non-pregnant patients. Although easy passage of a size 9 Hegar dilator is strongly suggestive, this is not a valid test. History will suggest the diagnosis. In pregnancy a scan finding at >12-15 weeks of ‘funelling’ or length <1.5cm suggests cervical incompetence. Consider cerclage. A cervical length of 1.5-2.5cm is included if the history is strong
Blood glucose, thyroid function & vaginal swabs are of limited value

Management

Manage any treatable cause e.g. penicillin for syphilis, myomectomy, correction of uterine anomaly if appropriate
Reassure & encourage women to try a pregnancy when ready
Ensure early antenatal clinic attendance and ultrasound scan when pregnant, & attendance at a high risk clinic
Cervical incompetence should be managed during the pregnancy with cervical cerclage at aprox 14 weeks. Cerclage is of MacDonald. Always consider reflecting the bladder to get an adequate cervical length as a modified Mcdonald. If the cervix is too short, then Shirodkhar. If the cervix has no length abdominal cerclage is indicated.
Progesterone – with recurrent late 2^nd trimester miscarriage/premature labour progesterone has benefit. If available (perhaps with motivation) it should be given
Patients with APLS require clexane or others & aspirin from diagnosis of pregnancy up to at least 35 weeks. One clinical criteria and at least one serological is required for APLS diagnosis. This should be managed by a high risk obstetric clinic if possible

Recurrent Miscarriage

Drugs mentioned