Table 2

Some evidence-based guidelines for diagnosis and management of recurrent miscarriage

StatementEvidence levelGrade of recommendation
APS is the leading cause of RM2aB
All women with recurrent first-trimester miscarriage and all women with one or more second-trimester miscarriage should be screened before pregnancy for aPLs2aB
There is insufficient evidence to support the relationship between thyroid autoimmunity and RM in euthyroid women4C
Cytogenetic analysis should be performed on products of conception of the third and subsequent consecutive miscarriage(s)4D
Parental peripheral blood karyotyping of both partners should be performed in couples with RM where testing of products of conception reports unbalanced structural chromosomal abnormality4D
If karyotyping results of the product of conception are abnormal, the outcome of further pregnancies will improve4C
Sperm morphology analyses, fluorescent in situ hybridisation and DNA fragmentation are not recommended, since they do not appear to be predictive of further miscarriages2aB
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 anatomy2bB
Suspected uterine anomalies may require further investigation to confirm the diagnosis, using hysteroscopy, laparoscopy or three-dimensional pelvic ultrasound2bB
Women with second-trimester miscarriage should be screened for inherited thrombophilia including factor V Leiden, factor II gene mutation and protein S2aB
Pregnant women with APS should be considered for treatment with low-dose aspirin plus heparin to prevent further miscarriage1aA
Neither corticosteroids* nor intravenous immunoglobulin therapy improve the live birth rate of women with recurrent miscarriage associated with aPLs compared with other treatment modalities1bA
Preimplantation genetic screening with in vitro fertilisation treatment in women with unexplained recurrent miscarriage does not improve live birth rates2aB
There is insufficient evidence to assess the effect of uterine septum resection in women with RM to prevent further miscarriage3C
In women with a singleton pregnancy and a history of one second-trimester miscarriage attributable to cervical factors, ultrasound-indicated cerclage could be offered if cervical length ≤25 mm is detected by transvaginal scan before 24 weeks of gestation1bA
Preliminary evidence shows that the effect of progesterone supplementation in pregnancy may prevent a further miscarriage in women with RM2bB
Immunotherapy, active or passive, in women with previous unexplained recurrent miscarriage does not improve the live birth rate1bA
There is insufficient evidence to evaluate the effect of heparin in pregnancy to prevent miscarriage in women with recurrent first-trimester miscarriage associated with inherited thrombophilia4C
Heparin therapy during pregnancy may improve the live birth rate of women with second-trimester miscarriage associated with inherited thrombophilia1bA
Treatment of women with RM suffering from overt hyperthyroidism or overt hypothyroidism does improve further pregnancy outcomes2aB
Women with unexplained RM have an excellent prognosis for future pregnancy outcome without pharmacological intervention if offered supportive care alone (tender loving care) in the setting of a dedicated early pregnancy assessment unit2aB
  • From diverse listed papers, mainly: Branch et al,10 Franssen et al,19 Haas and Ramsey68; Porter et al69; Practice Committee of American Society of Reproductive Medicine1; Royal College of Obstetricians and Gynaecologist.70

  • *A recent controlled study reported benefits in the group treated with low-dose prednisolone for 8–10 weeks (Bramham et al71).

  • aPL, antiphospholipid antibody; APS, antiphospholipid syndrome; RM, recurrent miscarriage.