To provide guidance for the care of women experiencing recurrent pregnancy loss.
All healthcare providers in primary and secondary care within NHS Borders involved in the care of women experiencing Recurrent Miscarriage.
Recurrent Miscarriage (RM) is defined as 3 or more first trimester miscarriages and excludes molar or ectopic pregnancies. The RCOG updated guideline does not restrict the definition to consecutive miscarriage or miscarriage with the same partner.
RM is associated with significant grief and stress. Care should be delivered sensitively and aim to meet the psychosocial needs of the couple.
Women with ≥3 first trimester miscarriages should be referred to a clinician with a special interest in RM. Referral after 2 early pregnancy losses may be considered in women ≥38 years old or when there are other risk factors identified by Pregnancy Assessment Unit (PAU) or referring GP, such as history of assisted conception.
Women with RM may present to clinic having accessed information from a variety of sources and a clear explanation of the investigation and treatments available may be helpful. It is important to allow sufficient time to obtain a detailed history and to explain that in many cases there is no cause for RM identified and often no specific risk factor contributing to the losses.
Investigations should be tailored to each individual woman. The prognosis is based on the number of preceding pregnancy losses and maternal age. Written information should be given regarding the investigations being offered and support services available. Women should be asked to wait for the results before conceiving.
The Scottish Government Framework for miscarriage care (February 2025) suggests the following enhanced care should be offered to women who have experienced recurrent miscarriage –
women should be offered information on optimisation of health and lifestyle, which is currently provided by PAU staff in the form of a Miscarriage Association leaflet. They should be referred to specialist support if necessary (eg. Wellbeing Service).
- offer vaginal micronised progesterone if any bleeding in a subsequent pregnancy.
Blood should be taken to assess full blood count, thyroid function, anticardiolipin and lupus anticoagulant. These bloods should be taken at 6-8 weeks post miscarriage by PAU staff, please contact ext 26735 to arrange an appointment for this. The woman should be informed that the results will take 3-4 weeks and the consultant will contact them by letter after this point to advise them of the results. PAU staff will make a note to check the results after 3 weeks, they should print the results and place them in Dr Rodger’s tray to be actioned. These bloods should only be taken after 2 previous miscarriages and do not need to be repeated in the case of any further losses, if normal.
- early scan at around 7 weeks in any subsequent pregnancy and offer vaginal micronised progesterone if any bleeding.
- individualised care by clinical specialist in RM (Dr Rodger in NHS Borders)
- non-pregnant uterine assessment by ultrasound in main ultrasound department
- pregnancy tissue cytogenetics.
- early scan at around 7 weeks in any subsequent pregnancy and offer vaginal micronised progesterone if any bleeding.
- early scan at around 7 weeks in any subsequent pregnancy and offer vaginal micronised progesterone regardless of whether there is any PV bleeding.
- parental karyotype
- early scan at around 7 weeks in any subsequent pregnancy and offer vaginal micronised progesterone regardless of whether there is any PV bleeding.
Issues to remember when considering pregnancy tissue genetic testing
- The pregnancy losses do not need to be consecutive.
- POC must NOT be sent in formalin, tissue should be sent dry in a universal container.
- Around one third of samples sent for cytogenetics will be reported as having “no suitable material” for genetic analysis. Suitable material is recognisable fetal tissue or chorionic villi.
- Testing for parental karyotypes is indicated if there is an unbalanced structural chromosomal abnormality identified from analysis of the POC. This will prompt referral to Medical Genetics
-Testing for parental karyotype may be offered by Medical Genetics if a different genetic abnormality (for example trisomy ) is identified on analysis of POC
- If pregnancy tissue is not available at the 3rd or subsequent miscarriage (i.e. pregnancy loss managed at home) then discussion with Medical Genetics may be indicated to determine suitability for testing the parental karyotype.
Progestogen supplementation in the first trimester of pregnancy may reduce the rate of early pregnancy loss in those with unexplained recurrent miscarriage when there is early pregnancy bleeding in the current pregnancy (Progesterone in Spontaneous Miscarriage, PRISM trial, 2019).
Self-administered progesterone pessaries can be offered in this case.·
o 1st line : Cyclogest 400mg, administered vaginally twice a day.
o 2nd line Utrogestan 400mg, administered vaginally twice a day.
Progesterone is not thought to improve the pregnancy outcome in those with RM without early pregnancy bleeding (Progesterone in Recurrent Miscarriage, PROMISE, 2015)
NHS Borders clinical guidelines