Recurrent miscarriage is defined as the loss of three or more pregnancies. Recurrent miscarriage is a heterogeneous condition that has many possible causes; more than one contributory factor may underlie the recurrent pregnancy losses.
Recurrent miscarriage is a distressing problem that affects 1% of all women.1 This incidence is greater than that expected by chance alone, since 10–15% of all clinically recognised pregnancies end in a miscarriage2 and the theoretical risk of three consecutive pregnancy losses is 0.34%.3 Hence, only a proportion of women presenting with recurrent miscarriage will have a persistent underlying cause for their pregnancy losses.
Maternal age and previous number of miscarriages are two independent risk factors for a further miscarriage.2,4 Advanced maternal age adversely affects ovarian function, giving rise to a decline in the number of good quality oocytes, resulting in chromosomally abnormal conceptions that rarely develop further.
Investigations and treatments
1. Genetic factors
All couples with a history of recurrent miscarriage should have peripheral blood C karyotyping performed. The finding of an abnormal parental karyotype should prompt referral to a clinical geneticist.
2. Anatomical factor
3. cervical weakness
Cervical cerclage is associated with potential hazards related to the surgery and the risk of B stimulating uterine contractions and hence should only be considered in women who are likely to benefit.
4. Endocrine factors
Routine screening for occult diabetes and thyroid disease with oral glucose tolerance and thyroid function tests in asymptomatic women presenting with recurrent miscarriage is uninformative.
5. Immune factors
5.1. Antithyroid antibodies
Routine screening for thyroid antibodies in women with recurrent miscarriage is not
To diagnose APS it is mandatory that the patient should have two positive tests at least six C weeks apart for either lupus anticoagulant or anticardiolipin (aCL) antibodies of IgG and/or IgM class present in medium or high titre.
5.3. Alloimmune factors
Immunotherapy, including paternal cell immunisation, third-party donor leucocytes, trophoblast membranes and intravenous immunoglobulin (IVIG), in women with previous unexplained recurrent miscarriage does not improve the live birth rate.
6 Infective agents
7 Inherited thrombophilic defects
Inherited thrombophilic defects, including activated protein C resistance (most commonly due to factor V Leiden gene mutation), deficiencies of protein C/S and antithrombin III, hyperhomocysteinaemia and prothrombin gene mutation, are established causes of systemic thrombosis.
8. Unexplained recurrent miscarriage
Women with unexplained recurrent miscarriage have an excellent prognosis for future C pregnancy outcome without pharmacological intervention if offered supportive care alone in the setting of a dedicated early pregnancy assessment unit.
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