The Investigation and Treatment

of Couples with Recurrent First-

trimester and Second-trimester
Miscarriage
Green-top Guideline No. 17
April 2011
The Investigation and Treatment of Couples with Recurrent
First-trimester and Second-trimester Miscarriage

This is the third edition of this guideline, which was first published in 1998 and then in 2003 under the
title The Investigation and Treatment of Couples with Recurrent Miscarriage.

1. Purpose and scope

The purpose of this guideline is to provide guidance on the investigation and treatment of couples with
three or more first-trimester miscarriages, or one or more second-trimester miscarriages.

2. Background and introduction

Miscarriage is defined as the spontaneous loss of pregnancy before the fetus reaches viability. The term
therefore includes all pregnancy losses from the time of conception until 24 weeks of gestation. It should
be noted that advances in neonatal care have resulted in a small number of babies surviving birth before
24 weeks of gestation.

Recurrent miscarriage, defined as the loss of three or more consecutive pregnancies, affects 1% of couples
trying to conceive.1 It has been estimated that 1–2% of second-trimester pregnancies miscarry before 24
weeks of gestation.2

3. Identification and assessment of evidence

The Cochrane Library and Cochrane Register of Controlled Trials were searched for relevant randomised
controlled trials, systematic reviews and meta-analyses. A search of Medline from 1966 to 2010 was also
carried out.The date of the last search was November 2010. In addition, relevant conference proceedings
and abstracts were searched.

The databases were searched using the relevant MeSH terms including all sub-headings.This was combined
with a keyword search using ‘human’, ‘female’, ‘pregnancy’, ‘abortion’, ‘miscarriage’, ‘habitual’, ‘recurrent’,
‘randomised controlled trials’ and ‘meta-analysis’.

The definitions of the types of evidence used in this guideline originate from the Scottish Intercollegiate
Guidelines Network (SIGN) grading scheme.Where possible, recommendations are based on, and explicitly
linked to, the evidence that supports them.Areas lacking evidence are highlighted and annotated as ‘good
practice points.’

4. Risk factors for recurrent miscarriage

What are the causes of recurrent first trimester miscarriage and second trimester miscarriage?

4.1 Epidemiological factors

Maternal age and number of previous miscarriages are two independent risk factors for a further
miscarriage.3,4 Advancing maternal age is associated with a decline in both the number and quality of the
remaining oocytes.A large prospective register linkage study3 reported the age-related risk of miscarriage
in recognised pregnancies to be: 12–19 years, 13%; 20–24 years, 11%; 25–29 years, 12%; 30–34 years, 15%;
35–39 years, 25%; 40–44 years, 51%; and ≥45 years, 93%.Advanced paternal age has also been identified as
a risk factor for miscarriage. The risk of miscarriage is highest among couples where the woman is ≥35
years of age and the man ≥40 years of age.5

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Previous reproductive history is an independent predictor of future pregnancy outcome. The risk of a
further miscarriage increases after each successive pregnancy loss, reaching approximately 40% after three
consecutive pregnancy losses, and the prognosis worsens with increasing maternal age.3,4 A previous live
birth does not preclude a woman developing recurrent miscarriage.6

The evidence on the effect of environmental risk factors is based mainly on data studying women with
sporadic rather than recurrent miscarriage. The results are conflicting and biased by difficulties in
controlling for confounding factors and the inaccuracy of data on exposure and the measurement of toxin
dose. Maternal cigarette smoking and caffeine consumption have been associated with an increased risk
of spontaneous miscarriage in a dose-dependent manner. However, current evidence is insufficient to
confirm this association.7–9 Heavy alcohol consumption is toxic to the embryo and the fetus. Even moderate
consumption of five or more units per week may increase the risk of sporadic miscarriage.10 Working with
or using video display terminals does not increase the risk of miscarriage.11 The evidence on the effect of
anaesthetic gases for theatre workers is conflicting.12,13

Recent retrospective studies have reported that obesity increases the risk of both sporadic and recurrent
miscarriage.14–16

4.2 Antiphospholipid syndrome

Antiphospholipid syndrome is the most important treatable cause of recurrent miscarriage. Antiphos-
pholipid syndrome refers to the association between antiphospholipid antibodies – lupus anticoagulant,
anticardiolipin antibodies and anti-B2 glycoprotein-I antibodies – and adverse pregnancy outcome or
vascular thrombosis.17,18

Adverse pregnancy outcomes include:

● three or more consecutive miscarriages before 10 weeks of gestation

● one or more morphologically normal fetal losses after the 10th week of gestation
● one or more preterm births before the 34th week of gestation owing to placental disease.

The mechanisms by which antiphospholipid antibodies cause pregnancy morbidity include inhibition of
trophoblastic function and differentiation,19–23 activation of complement pathways at the maternal–fetal
interface resulting in a local inflammatory response24 and, in later pregnancy, thrombosis of the uteropla-
cental vasculature.25–27 In vitro studies have shown that the effect of antiphospholipid antibodies on
trophoblast function28,29 and complement activation30 is reversed by heparin.

Antiphospholipid antibodies are present in 15% of women with recurrent miscarriage.31 By comparison,
the prevalence of antiphospholipid antibodies in women with a low-risk obstetric history is less than
2%.32,33 In women with recurrent miscarriage associated with antiphospholipid antibodies, the live birth
rate in pregnancies with no pharmacological intervention has been reported to be as low as 10%.34

4.3 Genetic factors

4.3.1 Parental chromosomal rearrangements

In approximately 2–5% of couples with recurrent miscarriage, one of the partners carries a balanced
structural chromosomal anomaly: most commonly a balanced reciprocal or Robertsonian translocation.35–38

Although carriers of a balanced translocation are usually phenotypically normal, their pregnancies are at
increased risk of miscarriage and may result in a live birth with multiple congenital malformation and/or
mental disability secondary to an unbalanced chromosomal arrangement. The risk of miscarriage is
influenced by the size and the genetic content of the rearranged chromosomal segments.

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4.3.2 Embryonic chromosomal abnormalities

In couples with recurrent miscarriage, chromosomal abnormalities of the embryo account for 30–57% of
further miscarriages.39,40 The risk of miscarriage resulting from chromosomal abnormalities of the embryo
increases with advancing maternal age. However, it is important to note that as the number of miscar-
riages increases, the risk of euploid pregnancy loss increases.40,41

4.4 Anatomical factors

4.4.1 Congenital uterine malformations

The exact contribution that congenital uterine anomalies make to recurrent miscarriage remains unclear
since the prevalence and reproductive implications of uterine anomalies in the general population are
unknown. The reported prevalence of uterine anomalies in recurrent miscarriage populations ranges
between 1.8% and 37.6%.42,43 This variability reflects the differences in the criteria and techniques used
for diagnosis and the fact that available studies have included women with two, three or more miscar-
riages in both the first and second trimester of pregnancy.The prevalence of uterine malformations appears
to be higher in women with second-trimester miscarriages compared with women who suffer first-
trimester miscarriages, but this may be related to the cervical weakness that is frequently associated with
uterine malformation.44 It has been reported that women with arcuate uteri tend to miscarry more in the
second trimester while women with septate uteri are more likely to miscarry in the first trimester.45

A retrospective review of reproductive performance in women with untreated uterine anomalies has
suggested that these women experience high rates of miscarriage and preterm delivery, with a term
delivery rate of only 50%.42 However, retrospective studies are biased by patient selection and, until well
controlled prospective data become available, the role of uterine anomalies in recurrent miscarriage will
remain debatable.

4.4.2 Cervical weakness

Cervical weakness is a recognised cause of second-trimester miscarriage, but the true incidence is
unknown, since the diagnosis is essentially a clinical one. There is currently no satisfactory objective test
that can identify women with cervical weakness in the non-pregnant state.The diagnosis is usually based
on a history of second-trimester miscarriage preceded by spontaneous rupture of membranes or painless
cervical dilatation.

4.5 Endocrine factors

Systemic maternal endocrine disorders such as diabetes mellitus and thyroid disease have been associated
with miscarriage. Women with diabetes who have high haemoglobin A1c levels in the first trimester are
at risk of miscarriage and fetal malformation.46 However, well-controlled diabetes mellitus is not a risk
factor for recurrent miscarriage, nor is treated thyroid dysfunction.47,48 The prevalence of diabetes mellitus
and thyroid dysfunction in women who suffer recurrent miscarriage is similar to that reported in the
general population.49,50

Anti-thyroid antibodies have been linked to recurrent miscarriage. However, one case–control
study51 from 1998 has reported that women with recurrent miscarriages are no more likely
Evidence
than women without recurrent miscarriage to have circulating thyroid antibodies. A single level 3
prospective study52 has shown that the presence of thyroid antibodies in euthyroid women
with a history of recurrent miscarriage does not affect future pregnancy outcome.

Polycystic ovary syndrome (PCOS) has been linked to an increased risk of miscarriage but the exact
mechanism remains unclear. Polycystic ovarian morphology, elevated serum luteinising hormone levels or
elevated serum testosterone levels, although markers of PCOS, do not predict an increased risk of future

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pregnancy loss among ovulatory women with a history of recurrent miscarriage who conceive sponta-
neously.53 The increased risk of miscarriage in women with PCOS has been recently attributed to insulin
resistance, hyperinsulinaemia and hyperandrogenaemia.The prevalence of insulin resistance is increased in
women with recurrent miscarriage compared with matched fertile controls.54 An elevated free androgen
index appears to be a prognostic factor for a subsequent miscarriage in women with recurrent miscarriage.55

4.6 Immune factors

There is no clear evidence to support the hypothesis of human leucocyte antigen incompatibility between
couples, the absence of maternal leucocytotoxic antibodies or the absence of maternal blocking antibodies.
Hence, they should not be offered routinely in the investigation of couples with recurrent miscarriage.

Natural killer (NK) cells are found in peripheral blood and the uterine mucosa. Peripheral blood NK cells
are phenotypically and functionally different from uterine NK (uNK) cells.56 There is no clear evidence that
altered peripheral blood NK cells are related to recurrent miscarriage.57,58 Therefore, testing for peripheral
blood NK cells as a surrogate marker of the events at the maternal–fetal interface is inappropriate and
should not be offered routinely in the investigation of couples with recurrent miscarriage.

It has been suggested that uNK cells may play a role in trophoblastic invasion and angiogenesis in addition
to being an important component of the local maternal immune response to pathogens.59 It should be
noted that the largest study60 examining the relationship between uNK cell numbers and future pregnancy
outcome reported that raised uNK cell numbers in women with recurrent miscarriage was not associated
with an increased risk of miscarriage.This remains a research field and testing for uNK cells should not be
offered routinely in the investigation of recurrent miscarriage.

Cytokines are immune molecules that control both immune and other cells. Cytokine responses are
generally characterised either as T-helper-1 (Th-1) type, with production of the pro-inflammatory cytokines
interleukin 2, interferon and tumour necrosis factor (TNF ) alpha, or as T-helper-2 (Th-2) type, with
production of the anti-inflammatory cytokines interleukins 4, 6 and 10. It has been suggested that normal
pregnancy might be the result of a predominantly Th-2 cytokine response, whereas women with recurrent
miscarriage have a bias towards mounting a Th-1 cytokine response.

A meta-analysis61 concluded that the available data are not consistent with more than modest
associations between cytokine polymorphisms and recurrent miscarriage. Further research is Evidence
level 2++
required to assess the contribution that disordered cytokines make to recurrent miscarriage
before routine cytokine tests can be introduced to clinical practice.

4.7 Infective agents

Any severe infection that leads to bacteraemia or viraemia can cause sporadic miscarriage.The
role of infection in recurrent miscarriage is unclear. For an infective agent to be implicated in
the aetiology of repeated pregnancy loss, it must be capable of persisting in the genital tract and Evidence
avoiding detection, or must cause insufficient symptoms to disturb the woman.Toxoplasmosis, level 3

rubella, cytomegalovirus, herpes and listeria infections do not fulfil these criteria and routine
TORCH screening should be abandoned.62

The presence of bacterial vaginosis in the first trimester of pregnancy has been reported as a risk factor
for second-trimester miscarriage and preterm delivery,63,64 but the evidence for an association with first-
trimester miscarriage is inconsistent.65,66 A randomised placebo-controlled trial67 reported that treatment
of bacterial vaginosis early in the second trimester with oral clindamycin significantly reduces the
incidence of second-trimester miscarriage and preterm birth in the general population. There are no
published data to assess the role of antibiotic therapy in women with a previous second-trimester
miscarriage.

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4.8 Inherited thrombophilic defects
Both inherited and acquired thrombophilias, including activated protein C resistance (most commonly
due to factor V Leiden mutation), deficiencies of protein C/S and antithrombin III, hyperhomocysteinaemia
and prothrombin gene mutation, are established causes of systemic thrombosis. In addition, inherited
thrombophilias have been implicated as a possible cause in recurrent miscarriage and late pregnancy
complications with the presumed mechanism being thrombosis of the uteroplacental circulation.

A meta-analysis68 of pooled data from 31 retrospective studies suggested that the magnitude of
the association between inherited thrombophilias and fetal loss varies according to type of fetal
loss and type of thrombophilia.The association between thrombophilia and late pregnancy loss
has been consistently stronger than for early pregnancy loss. In this meta-analysis, factor V Leiden
was associated with recurrent first-trimester fetal loss (OR 2.01, 95% CI 1.13–3.58), recurrent
fetal loss after 22 weeks (OR 7.83, 95% CI 2.83–21.67) and non-recurrent fetal loss after 19
weeks (OR 3.26, 95% CI 1.82–5.83).Activated protein C resistance was associated with recurrent
Evidence
first-trimester fetal loss (OR 3.48, 95% CI 1.58–7.69). Prothrombin gene mutation was associated level 2++
with recurrent first-trimester fetal loss (OR 2.32, 95% CI 1.12–4.79), recurrent fetal loss before
25 weeks (OR 2.56, 95% CI 1.04–6.29) and late non-recurrent fetal loss (OR 2.3, 95% CI 1.09–
4.87). Protein S deficiency was associated with recurrent fetal loss (OR 14, 95% CI 0.99–218)
and non-recurrent fetal loss after 22 weeks (OR 7.39, 95% CI 1.28–42.83). Methylenetetrahy-
drofolate mutation and protein C and antithrombin deficiencies were not associated with fetal
loss. However, since protein C and antithrombin III deficiencies are rare, the number of women
included in the study was too small to show any difference in pregnancy outcome.

Similarly, another meta-analysis69 of 16 case–control studies reported that carriers of factor V

Evidence
Leiden or prothrombin gene mutation have double the risk of experiencing recurrent level 2++
miscarriage compared with women without these thrombophilic mutations.

Prospective data on the outcome of untreated pregnancies in women with hereditary

thrombophilias are scarce. One small study70 of six hereditary thrombophilias reported no
adverse effects on the live birth rate of women with recurrent miscarriage. By contrast, two Evidence
small prospective studies71,72 reported an increased risk of miscarriage in untreated pregnancies level 2+

for women with recurrent miscarriage who carry the factor V Leiden mutation compared with
those with a normal factor V genotype.

5. What are the recommended investigations of couples with recurrent first-trimester

miscarriage and second-trimester miscarriage?

P
Women with recurrent first-trimester and second-trimester miscarriage should be
looked after by a health professional with the necessary skills and expertise. Where
available, this might be within a recurrent miscarriage clinic.

The loss of pregnancy at any stage can be a devastating experience and particular sensitivity is required
in assessing and counselling couples with recurrent miscarriage. Ideally,the couple should be seen together
at a dedicated recurrent miscarriage clinic and given accurate information to facilitate decision making
about future pregnancies. Clearly written patient leaflets are recommended to provide written information
that the couple can take home.

5.1 Antiphospholipid antibodies

All women with recurrent first-trimester miscarriage and all women with one or
D
more second-trimester miscarriage should be screened before pregnancy for
antiphospholipid antibodies.

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To diagnose antiphospholipid syndrome it is mandatory that the woman has two positive tests at least 12
weeks apart for either lupus anticoagulant or anticardiolipin antibodies of immunoglobulin G and/or
immunoglobulin M class present in a medium or high titre over 40 g/l or ml/l, or above the 99th percentile).

In the detection of lupus anticoagulant, the dilute Russell’s viper venom time test together with a platelet
neutralisation procedure is more sensitive and specific than either the activated partial thromboplastin time
test or the kaolin clotting time test.31 Anticardiolipin antibodies are detected using a standardised enzyme-
linked immunosorbent assay.

The detection of antiphospholipid antibodies is subject to considerable inter-laboratory variation.73 This

is a result of temporal fluctuation of antiphospholipid antibody titres in individual women, transient
positivity secondary to infections, suboptimal sample collection and preparation and lack of standardi-
sation of laboratory tests for their detection.

5.2 Karyotyping
Cytogenetic analysis should be performed on products of conception of the third and
subsequent consecutive miscarriage(s).
D

Parental peripheral blood karyotyping of both partners should be performed in

D
couples with recurrent miscarriage where testing of products of conception reports
an unbalanced structural chromosomal abnormality.

Knowledge of the karyotype of the products of conception allows an informed prognosis for a
future pregnancy outcome to be given. While a sporadic fetal chromosome abnormality is the
Evidence
most common cause of any single miscarriage, the risk of miscarriage as a result of fetal level 4
aneuploidy decreases with an increasing number of pregnancy losses.41 If the karyotype of the
miscarried pregnancy is abnormal, there is a better prognosis for the next pregnancy.39

A Dutch study38 reported that couples with balanced translocations have a low risk (0.8%) of
pregnancies with an unbalanced karyotype surviving into the second trimester and that their
chance of having a healthy child is 83%. A recent retrospective UK audit74 of four UK centres
over periods of 5–30 years reported that balanced translocations were found in 1.9% (406 of 20
432) of parents with recurrent miscarriage, but only four unbalanced translocations were found
Evidence
after referral for prenatal diagnosis because of balanced parental translocation ascertained for level 3
recurrent miscarriage. At an estimated cost of £3–4 million (the total cost of karyotyping 20
432 individuals calculated at £160–200 per karyotype), the data suggest that routine karyotyping
of couples with recurrent miscarriage cannot be justified. Selective parental karyotyping may
be more appropriate when an unbalanced chromosome abnormality is identified in the
products of conception.

5.3 Anatomical factors

P
All women with recurrent first-trimester miscarriage and all women with one or
more second-trimester miscarriages should have a pelvic ultrasound to assess uterine
anatomy.

P
Suspected uterine anomalies may require further investigations to confirm the
diagnosis, using hysteroscopy, laparoscopy or three-dimensional pelvic ultrasound.

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A review75 of studies comparing the diagnostic accuracy of various imaging modalities has
reported that two-dimensional ultrasound scanning and/or hysterosalpingography can be used
Evidence
as an initial screening test. Combined hysteroscopy and laparoscopy and possibly three- level 3
dimensional ultrasound scanning should be used for definitive diagnosis.The value of magnetic
resonance imaging scanning remains undetermined.

5.4 Thrombophilias
Women with second-trimester miscarriage should be screened for inherited
thrombophilias including factor V Leiden, factor II (prothrombin) gene mutation and
D
protein S.

A meta-analysis68 of retrospective studies has reported a strong association between second-

Evidence
trimester miscarriage and inherited thrombophilias: factor V Leiden, factor II (prothrombin) level 2++
gene mutation and protein S deficiency.

6. Treatment options for recurrent miscarriage

6.1 What are the treatment options for recurrent first trimester and second trimester miscarriage?

P
Women with recurrent miscarriage should be offered referral to a specialist clinic.

6.2 Antiphospholipid syndrome

Pregnant women with antiphospholipid syndrome should be considered for
treatment with low-dose aspirin plus heparin to prevent further miscarriage.
B

A meta-analysis76 of randomised controlled trials examined the outcomes of various treatments –

including aspirin, steroids, intravenous globulin and heparin – given to improve pregnancy
outcome of women with recurrent miscarriage associated with antiphospholipid antibodies.
This meta-analysis reported that the only treatment or treatment combination that leads to a Evidence
level 1+
significant increase in the live birth rate among women with antiphospholipid syndrome is
aspirin plus unfractionated heparin. This treatment combination significantly reduces the
miscarriage rate by 54% (aspirin plus unfractionated heparin compared with aspirin alone: RR
0.46, 95% CI 0.29–0.71).

Two small prospective studies77,78 reported no difference in efficacy and safety between unfra-
Evidence
ctionated heparin and low-molecular-weight heparin when combined with aspirin in the level 1+
treatment of women with recurrent miscarriage associated with antiphospholipid antibodies.

The value of heparin has been questioned in two studies.79,80 However, there were methodological
weaknesses in both demographic and laboratory entry criteria and time of randomisation.

There are no adverse fetal outcomes reported in the meta-analysis of randomised controlled
trials of low-dose aspirin for the prevention of pre-eclampsia in pregnancy.81 Heparin does not
cross the placenta and hence there is no potential to cause fetal haemorrhage or teratogenicity.
Heparin can, however, be associated with maternal complications including bleeding, hypersen- Evidence
sitivity reactions, heparin-induced thrombocytopenia and, when used long term, osteopenia level 2+

and vertebral fractures. Two prospective studies82,83 have shown that the loss of bone mineral
density at the lumbar spine associated with low-dose long-term heparin therapy is similar to that
which occurs physiologically during normal pregnancy.

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Low-molecular-weight heparin is as safe as unfractionated heparin and has potential advantages during
pregnancy, since it causes less heparin-induced thrombocytopenia, can be administered once daily and is
associated with a lower risk of heparin-induced osteoporosis.84

Pregnancies associated with antiphospholipid antibodies treated with aspirin and heparin
remain at high risk of complications during all three trimesters. Although aspirin plus heparin
treatment substantially improves the live birth rate of women with recurrent miscarriage Evidence
associated with antiphospholipid antibodies, these pregnancies remain at high risk of compli- level 2+

cations during all three trimesters, including repeated miscarriage, pre-eclampsia, fetal growth
restriction and preterm birth;85,86 this necessitates careful antenatal surveillance.

Neither corticosteroids nor intravenous immunoglobulin therapy improve the live

birth rate of women with recurrent miscarriage associated with antiphospholipid
A
antibodies compared with other treatment modalities; their use may provoke
significant maternal and fetal morbidity.

A meta-analysis76 of randomised controlled trials reported that treating women who suffer
recurrent miscarriage associated with antiphospholipid antibodies with corticosteroids during
pregnancy does not improve the live birth rate compared with aspirin or aspirin plus heparin Evidence
(prednisone and aspirin compared with placebo or aspirin alone:RR 0.85, 95% CI 0.53–1.36; and level 1+

compared with heparin and aspirin: RR 1.17, 95% CI 0.47–2.93). Steroid therapy is associated
with significant maternal and fetal morbidity.

A randomised controlled trial87 reported that women with recurrent miscarriage associated
with antiphospholipid antibodies treated with low-molecular-weight heparin plus aspirin had
a higher rate of live births than those treated with intravenous immunoglobulin (RR 2.28, 95%
Evidence
CI 0.81–6.4). Similarly, another randomised controlled trial88 reported that low-molecular-weight level 1+
heparin plus aspirin resulted in a higher live birth rate than intravenous immunoglobulin in the
treatment of women with recurrent miscarriage associated with antiphospholipid antibodies
(OR 1.80, 95% CI 1.14–2.84).

6.3 Genetic factors

The finding of an abnormal parental karyotype should prompt referral to a clinical
D
geneticist.

Genetic counselling offers the couple a prognosis for the risk of future pregnancies with an unbalanced
chromosome complement and the opportunity for familial chromosome studies.

Reproductive options in couples with chromosomal rearrangements include proceeding to a further

natural pregnancy with or without a prenatal diagnosis test, gamete donation and adoption.

Preimplantation genetic diagnosis has been proposed as a treatment option for translocation
carriers.89,90 Since preimplantation genetic diagnosis necessitates that the couple undergo in
vitro fertilisation to produce embryos, couples with proven fertility need to be aware of the
financial cost as well as implantation and live birth rates per cycle following in vitro fertili- Evidence
sation/preimplantation genetic diagnosis. Furthermore, they should be informed that they have level 4

a higher (50–70%) chance of a healthy live birth in future untreated pregnancies following
natural conception37,38,91 than is currently achieved after preimplantation genetic diagnosis/in
vitro fertilisation (approximately 30%).92

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Preimplantation genetic screening with in vitro fertilisation treatment in women with
unexplained recurrent miscarriage does not improve live birth rates.
C

Preimplantation genetic screening in conjunction with in vitro fertilisation has been advocated
as a treatment option for women with recurrent miscarriage, the rationale being that the identi-
fication and transfer of what are thought to be genetically normal embryos will lead to a live Evidence
birth. The live birth rate of women with unexplained recurrent miscarriage who conceive level 2+

naturally is significantly higher than currently achieved after preimplantation genetic

screening/in vitro fertilisation (20–30%).92–95

6.4 Anatomical factors

6.4.1 Congenital uterine malformations

There is insufficient evidence to assess the effect of uterine septum resection in

C
women with recurrent miscarriage and uterine septum to prevent further miscarriage.

There are no published randomised trials assessing the benefits of surgical correction of uterine
abnormalities on pregnancy outcome. Open uterine surgery has never been assessed in prospective trials
but is associated with postoperative infertility and carries a significant risk of uterine scar rupture during
pregnancy.96 These complications are less likely to occur after transcervical hysteroscopic resection of
uterine septae; experience from case series appears promising.97 However, before a clear judgement can
be made, this procedure must be evaluated in a prospective controlled trial.

6.4.2 Cervical weakness and cervical cerclage

Cervical cerclage is associated with potential hazards related to the surgery and the
risk of stimulating uterine contractions and hence should be considered only in
A
women who are likely to benefit.

Women with a history of second-trimester miscarriage and suspected cervical

weakness who have not undergone a history-indicated cerclage may be offered serial
B
cervical sonographic surveillance.

In women with a singleton pregnancy and a history of one second-trimester

miscarriage attributable to cervical factors, an ultrasound-indicated cerclage should
B
be offered if a cervical length of 25 mm or less is detected by transvaginal scan before
24 weeks of gestation.

The role of cervical cerclage in the prevention of preterm birth has been examined in a recently published
RCOG Green-top Guideline.98 A Cochrane review99 of four randomised controlled trials found no
conclusive evidence that prophylactic cerclage reduces the risk of pregnancy loss and preterm delivery
in women at risk of preterm birth or mid-trimester loss owing to cervical factors. Furthermore, the
procedure was associated with a high risk of minor morbidity but no serious morbidity.A small reduction
in deliveries before 33 weeks of gestation was noted in the largest trial.100 The benefit was most marked
in women with three or more second-trimester miscarriages or preterm births. However, there was no
significant improvement in perinatal survival.

A short cervical length on transvaginal ultrasound during pregnancy may be useful in predicting
preterm birth in some cases of suspected cervical weakness. A meta-analysis101 of individual
patient-level data from four randomised controlled trials reported that in a subgroup analysis of Evidence
women with singleton pregnancies, a short cervix (less than 25 mm) and previous second- level 1+

trimester miscarriage, cerclage may reduce the incidence of preterm birth before 35 weeks of
gestation (RR 0.57, 95% CI 0.33–99).

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Transabdominal cerclage has been advocated as a treatment for second-trimester miscarriage and the
prevention of early preterm labour in selected women with a previous failed transvaginal cerclage and/or
a very short and scarred cervix.102–104 In the absence of any control groups, the reported improvement in
pregnancy outcome is difficult to assess.A systematic review105 compared abdominal with vaginal cerclage
in women with failed vaginal cerclage in a previous pregnancy. This review concluded that abdominal
cerclage may be associated with a lower risk of perinatal death or delivery before 24 weeks of gestation
and a higher risk of serious operative complications.Whether to perform transabdominal cerclage before
pregnancy or during pregnancy remains uncertain.106

6.5 Endocrine factors

There is insufficient evidence to evaluate the effect of progesterone supplementation
in pregnancy to prevent a miscarriage in women with recurrent miscarriage.
B

Progesterone is necessary for successful implantation and the maintenance of pregnancy. This
benefit of progesterone could be explained by its immmunomodulatory actions in inducing a
pregnancy-protective shift from pro-inflammatory Th-1 cytokine responses to a more favourable
anti-inflammatory Th-2 cytokine response.107 A meta-analysis108 to assess progesterone support
for pregnancy showed that it did not reduce the sporadic miscarriage rate. However, in a
subgroup analysis of trials involving women with recurrent miscarriage, progesterone treatment Evidence
level 1+
offered a statistically significant decrease in miscarriage rate compared with placebo or no
treatment (OR 0.38, 95% CI 0.2–0.7). However, this meta-analysis was based on three small
controlled studies, none of which detected a significant improvement in pregnancy outcome.
A large multicentre study (PROMISE, http://www.medscinet.net/promise) is currently under
way to assess the benefit of progesterone supplementation in women with unexplained
recurrent miscarriage.

There is insufficient evidence to evaluate the effect of human chorionic gonado-

trophin supplementation in pregnancy to prevent a miscarriage in women with
B
recurrent miscarriage.

A multicentre placebo-controlled study of human chorionic gonadotrophin supplementation in

early pregnancy failed to show any benefit in pregnancy outcome.109 However, another small
placebo-controlled study stated that the benefit of human chorionic gonadotrophin is confined Evidence
to a small subgroup (n = 23) of women with recurrent miscarriage and oligomenorrhoea.110 level 1+

Human chorionic gonadotrophin supplementation in early pregnancy should be used only in

the context of randomised controlled trials.

Suppression of high luteinising hormone levels among ovulatory women with

A
recurrent miscarriage and polycystic ovaries does not improve the live birth rate.

Luteinising hormone hypersecretion, a frequent feature of PCOS, has been reported as a risk
factor for early pregnancy loss. A randomised controlled trial111 has shown that prepregnancy
pituitary suppression of luteinising hormone among ovulatory women with recurrent Evidence
miscarriage and polycystic ovaries who hypersecrete luteinising hormone does not improve level 1+

the live birth rate. Furthermore, the outcome of pregnancy without pituitary suppression is
similar to that of women without raised luteinising hormone.

There is insufficient evidence to evaluate the effect of metformin supplementation in

pregnancy to prevent a miscarriage in women with recurrent miscarriage.
C

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The increased risk of miscarriage in women with PCOS has been attributed to insulin resistance
and hyperinsulinaemia. However, a meta-analysis112 of 17 randomised controlled trials of Evidence
metformin, an insulin-sensitising agent, in women with PCOS and infertility showed that level 1++

metformin has no effect on the sporadic miscarriage risk when administered prepregnancy.

Uncontrolled small studies113 have shown that use of metformin during pregnancy is associated with a
reduction in the miscarriage rate in women with recurrent miscarriage and PCOS. However, there are no
randomised controlled trials to assess the role of metformin in women with recurrent miscarriage.

6.6 Immunotherapy
Paternal cell immunisation, third-party donor leucocytes, trophoblast membranes
and intravenous immunoglobulin in women with previous unexplained recurrent
A
miscarriage does not improve the live birth rate.

A Cochrane systematic review114 has shown that the use of various forms of immunotherapy,
including paternal cell immunisation, third-party donor leucocytes, trophoblast membranes and
intravenous immunoglobulin, in women with unexplained recurrent miscarriage provides no
significant beneficial effect over placebo in preventing further miscarriage. A 2010 meta- Evidence
analysis115 confirmed this conclusion with respect to intravenous immunoglobulin. Moreover, level 1++

immunotherapy is expensive and has potentially serious adverse effects including transfusion
reaction, anaphylactic shock and hepatitis. The use of immunotherapy should no longer be
offered to women with unexplained recurrent miscarriage.

There are no published data on the use of anti-TNF agents to improve pregnancy outcome in women with
recurrent miscarriage. Furthermore, anti-TNF agents could potentially cause serious morbidity including
lymphoma, granulomatous disease such as tuberculosis, demyelinating disease, congestive heart failure
and syndromes similar to systemic lupus erythematosus.

Immune treatments should not be offered routinely to women with recurrent miscarriage outside formal
research studies.

6.7 Inherited thrombophilias

There is insufficient evidence to evaluate the effect of heparin in pregnancy to
prevent a miscarriage in women with recurrent first-trimester miscarriage associated
C
with inherited thrombophilia.

Heparin therapy during pregnancy may improve the live birth rate of women with
second-trimester miscarriage associated with inherited thrombophilias.
A

Women with known heritable thrombophilia are at an increased risk of venous thromboembolism. See
RCOG Green-top Guideline No. 37a: Reducing the risk of thrombosis and embolism during pregnancy
and the puerperium.116

The efficacy of thromboprophylaxis during pregnancy in women with recurrent first-trimester

miscarriage who have inherited thrombophilias, but who are otherwise asymptomatic, has not Evidence
been assessed in prospective randomised controlled trials. Cohort studies117–119 have suggested level 3

that heparin therapy may improve the live birth rate for these women.

RCOG Green-top Guideline No. 17 12 of 18 © Royal College of Obstetricians and Gynaecologists

One prospective randomised trial120 demonstrated the efficacy of the low-molecular-weight
heparin enoxaparin for the treatment of women with a history of a single late miscarriage after
Evidence
10 weeks of gestation who carry the factor V Leiden or prothrombin gene mutation or have level 1+
protein S deficiency.The live birth rate of women treated with enoxaparin was 86% compared
with 29% in women taking low-dose aspirin alone (OR 15.5, 95% CI 7–34).

6.8 Unexplained recurrent miscarriage

Women with unexplained recurrent miscarriage have an excellent prognosis for
future pregnancy outcome without pharmacological intervention if offered support-
B
ive care alone in the setting of a dedicated early pregnancy assessment unit.

A significant proportion of cases of recurrent miscarriage remain unexplained despite detailed

investigation. These women can be reassured that the prognosis for a successful future
pregnancy with supportive care alone is in the region of 75%.6,121 However, the prognosis
worsens with increasing maternal age and the number of previous miscarriages. The value of Evidence
psychological support in improving pregnancy outcome has not been tested in the form of a level 2+

randomised controlled trial. However, data from several non-randomised studies6,121,122 have
suggested that attendance at a dedicated early pregnancy clinic has a beneficial effect, although
the mechanism is unclear.

Aspirin alone or in combination with heparin is being prescribed for women with unexplained
recurrent miscarriage, with the aim of improving pregnancy outcome.Two recent randomised
controlled trials reported that neither of these interventions improves the live birth rate among Evidence
level 1+
women with unexplained recurrent miscarriage.123,124 However, it should be noted that both
studies included a significant number of women with only two previous miscarriages (40% and
57% of the study population, respectively).

These data suggest that the use of empirical treatment in women with unexplained recurrent miscarriage
is unnecessary and should be resisted. Furthermore, clinical evaluation of future treatments for recurrent
miscarriage should be performed only in the context of randomised trials of sufficient power to determine
efficacy.

7. Suggested audit topics

● Correct assessment and investigations of couples with recurrent miscarriage.
● Pregnancy outcome of women with recurrent miscarriage.

8. Future research
● The role of uterine NK cells and cytokines in recurrent miscarriage.
● The role of uterine septum resection in women with recurrent miscarriage and septate uterus.
● Thromboprophylaxis in women with thrombophilia and recurrent first-trimester miscarriage.
● Progesterone treatment in women with unexplained recurrent miscarriage.
● Metformin treatment in women with recurrent miscarriage and insulin resistance.

RCOG Green-top Guideline No. 17 13 of 18 © Royal College of Obstetricians and Gynaecologists

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Appendix

Classification of evidence levels Grades of recommendations

1++ High-quality meta-analyses, systematic At least one meta-analysis, systematic review or
reviews of randomised controlled trials A randomised controlled trial rated as 1++ and
or randomised controlled trials with a directly applicable to the target population; or
very low risk of bias
A systematic review of randomised controlled
1+ Well-conducted meta-analyses, systematic trials or a body of evidence consisting
reviews of randomised controlled trials principally of studies rated as 1+ directly
or randomised controlled trials with a applicable to the target population and
low risk of bias demonstrating overall consistency of results
1– Meta-analyses, systematic reviews of A body of evidence including studies rated as
randomised controlled trials or B 2++ directly applicable to the target
randomised controlled trials with a high population, and demonstrating overall
risk of bias consistency of results; or
2++ High-quality systematic reviews of case– Extrapolated evidence from studies rated as
control or cohort studies or high-quality 1++ or 1+
case–control or cohort studies with a
very low risk of confounding, bias or A body of evidence including studies rated as
C 2+ directly applicable to the target population
chance and a high probability that the
relationship is causal and demonstrating overall consistency of
results; or
2+ Well-conducted case–control or cohort
studies with a low risk of confounding, Extrapolated evidence from studies rated as
bias or chance and a moderate 2++
probability that the relationship is causal Evidence level 3 or 4; or
D
2- Case–control or cohort studies with a Extrapolated evidence from studies rated as 2+
high risk of confounding, bias or chance
and a significant risk that the
relationship is not causal Good practice point

P
3 Non-analytical studies, e.g. case reports,
Recommended best practice based on the
case series
clinical experience of the guideline
4 Expert opinion development group

RCOG Green-top Guideline No. 17 17 of 18 © Royal College of Obstetricians and Gynaecologists

 This guideline was produced on behalf of the Royal College of Obstetricians and Gynaecologists by:

Professor L Regan FRCOG, Miss M Backos MRCOG, and Dr R Rai MRCOG, London

and peer-reviewed by: RCOG Consumers’ Forum;The Miscarriage Association; Royal College of Midwives; Dr A Eapen,
Research Registrar in Gynaecology, Keele University, Stoke on Trent; Mr RG Farquharson FRCOG, Liverpool; Mr DI Fraser
MRCOG, Norwich; Professor M Greaves MBChB, MD, FRCPath, FRCP, University of Aberdeen, Aberdeen, Scotland; Mr D
Jurkovic FRCOG, London; Professsor T Li FRCOG, Sheffield; Professor SM Quenby FRCOG, Warwick; Ms MS To MRCOG,
London.

Guideline Committee lead reviewers were Dr J Shillito MRCOG, Leeds and Dr SK Surendran FRCOG, London.

Conflicts of interest: none declared.

The final version is the responsibility of the Guidelines Committee of the RCOG.

The guideline review process will commence in 2014 unless evidence requires earlier review.

DISCLAIMER

The British Society of Gynaecological Endoscopists produces guidelines as an educational aid to good clinical practice.
They present recognised methods and techniques of clinical practice, based on published evidence, for consideration by
gynaecologists and other relevant health professionals.The ultimate judgement regarding a particular clinical procedure
or treatment plan must be made by the doctor or other attendant in the light of clinical data presented by the patient
and the diagnostic and treatment options available. This means that BSGE guidelines are unlike protocols or guidelines
issued by employers, not being intended to be prescriptive directions defining a single course of management. Departure
from the local prescriptive protocols or guidelines should be fully documented in the patient’s case notes at the time
the relevant decision is taken.

The Royal College of Obstetricians and Gynaecologists produces guidelines as an educational aid to good clinical practice.
They present recognised methods and techniques of clinical practice, based on published evidence, for consideration by
obstetricians and gynaecologists and other relevant health professionals.The ultimate judgement regarding a particular
clinical procedure or treatment plan must be made by the doctor or other attendant in the light of clinical data presented
by the patient and the diagnostic and treatment options available.This means that RCOG guidelines are unlike protocols
or guidelines issued by employers, as they are not intended to be prescriptive directions defining a single course of
management. Departure from the local prescriptive protocols or guidelines should be fully documented in the patient’s
case notes at the time the relevant decision is taken.

RCOG Green-top Guideline No. 17 18 of 18 © Royal College of Obstetricians and Gynaecologists