Pregnancy After Recurrent Miscarriage

Pregnancy after recurrent miscarriage is a new pregnancy in a woman who has had 3 or more consecutive losses. The chance of a live birth is good even when no cause is found, but the risk of loss, thrombosis, growth restriction and preterm birth is raised. It matters because early support, treatment of a found cause and surveillance improve outcome.

• Risk factors: maternal age above 35 years, antiphospholipid syndrome, thyroid disease, diabetes, uterine anomaly.
• Early scans reduce anxiety.
• Early reassurance scans lower anxiety.

Women are usually well with early pregnancy symptoms, with anxiety about loss. Any bleeding or pain needs review.

• Bleeding in early pregnancy is common.
• Painless mid-trimester dilatation suggests cervical insufficiency.
• Differential diagnosis: threatened miscarriage, ectopic pregnancy, antiphospholipid related loss, cervical insufficiency, uterine septum.
• Complications: miscarriage, preeclampsia, fetal growth restriction, placental abruption, preterm birth, venous thrombosis.

The approach is early confirmation of a viable intrauterine pregnancy and review of the results of earlier investigations.

• Urine pregnancy test, then transvaginal ultrasound at 6 weeks and 8 to 9 weeks for heartbeat.
• Antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, anti beta 2 glycoprotein I), TSH and HbA1c if not done before pregnancy.
• Cervical length scan at 14 to 24 weeks if mid-trimester loss is in the history.
• Growth scans at 28, 32 and 36 weeks in antiphospholipid syndrome; uterine artery Doppler at 20 to 24 weeks.

The principle is early support, treatment of an identified cause and planned surveillance.

• Supportive: stop smoking and alcohol; limit caffeine to 200 mg daily; early pregnancy clinic with scans at 6 and 8 weeks; emotional support; no bed rest.
• Pharmacological: folic acid 400 micrograms oral daily to 12 weeks, 5 mg if diabetic or on antiepileptics; micronised progesterone 400 mg vaginally twice daily from the positive test to 16 weeks if bleeding occurs; for antiphospholipid syndrome give aspirin 75 mg oral daily from conception plus enoxaparin 40 mg subcutaneous daily from the positive test to 6 weeks postpartum; for previous thrombosis give enoxaparin 1 mg/kg subcutaneous 12-hourly; for hypothyroidism give levothyroxine to keep TSH between 0.4 and 2.5 mIU/L.
• Procedures: cervical cerclage at 12 to 14 weeks for painless mid-trimester loss or cervical length below 25 mm before 24 weeks.
• Special groups: women with diabetes keep HbA1c below 6.5 percent before and in early pregnancy; women with a uterine septum need hysteroscopic resection before the next conception.
• Red flags: bleeding with pain, leg swelling, chest pain, breathlessness, fluid loss, severe headache.
• Follow-up: review every 2 to 4 weeks to 12 weeks; scans at 20, 28, 32 and 36 weeks as indicated; delivery planning at 36 weeks; postnatal review at 6 weeks.