A review of reproductive outcomes of women with two consecutive miscarriages and no living child

Abstract

The definition of recurrent miscarriage ranges from two miscarriages according to the American Society for Reproductive Medicine and the European Society of Human Reproduction and Embryology, to three consecutive pregnancy losses as defined by the Royal College of Obstetricians and Gynaecologists. Recent guidelines emphasise the need for further research on the effect of various recurrent miscarriage definitions on diagnosis, treatment and prognosis. Our study examines the management and pregnancy outcomes of nulliparous women attending Cork University Maternity Hospital's Pregnancy Loss Clinic, between 2009 and 2014, with their second consecutive first-trimester miscarriage. Information was sourced from the Pregnancy Loss Clinic's database, hospital patient management and laboratory systems, and clinical letters. 294 women were identified. A subsequent pregnancy was conceived by 82.3% (242/294) of women, with 72.7% (176/242) achieving a live birth. In conclusion, supportive care and selective medical management in dedicated pregnancy loss and early pregnancy clinics achieve excellent reproductive outcomes. Impact Statement What is already known on this subject? The definition of recurrent miscarriage is varied. It ranges from two miscarriages according to the American Society for Reproductive Medicine and the European Society of Human Reproduction and Embryology, to three consecutive pregnancy losses as defined by the Royal College of Obstetricians and Gynaecologists. Recurrent miscarriage affects between 1 and 5% of women. Past studies suggest several causative factors, including epidemiologic, genetic, anatomical and endocrine. These factors may be identified in up to 50% of women with recurrent losses. Subsequent pregnancy outcomes are reported as excellent. However, recent guidelines focus on the need for further research on the effect of the various recurrent miscarriage definitions on diagnosis, investigation, treatment and prognosis. What the results of this study add? This study examined the management and pregnancy outcomes of women with two consecutive losses. A causative factor was identified in 29.3% of women in our cohort. A subsequent pregnancy was conceived by 82.3%, with 72.7% achieving a live birth. We suggest that supportive care is the single most effective therapy for women with two consecutive losses. What the implications are of these findings for clinical practice and/or further research? Over-investigation and empirical treatment should be avoided, with a greater emphasis placed on psychological support and risk factor modification in this group. Investigation protocols must be refined to only search for causes of recurrent miscarriage with evidence based treatment. Evaluation of supportive care in randomised control trials is needed.

Keywords: Miscarriage; first trimester; investigation; reproductive outcomes.