Green-top guideline no

RCOG Green-top Guideline No. 17April 2011 The Investigation and Treatment of
Couples with Recurrent First-trimester
and Second-trimester Miscarriage
1. Women with recurrent first-trimester and second-trimester miscarriage should be looked after by a health professional with the necessary skills and expertise. Where available, this might be within a recurrent miscarriage clinic.
2. Antiphospholipid antibodies: All women with recurrent first-trimester miscarriage and all women with one or more second-trimester miscarriage should be screened before pregnancy for antiphospholipid antibodies.
3. Karyotyping : Cytogenetic analysis should be performed on products of conception of the third andsubsequent consecutive miscarriage(s).Parental peripheral blood karyotyping of both partners should be performed incouples with recurrent miscarriage where testing of products of conception reportsan unbalanced structural chromosomal abnormality.
4. Anatomical factors: All women with recurrent first-trimester miscarriage and all women with one ormore second-trimestermiscarriages should have a pelvic ultrasound to assess uterineanatomy. Suspected uterine anomalies may require further investigations to confirm the diagnosis, using hysteroscopy, laparoscopy or three-dimensional pelvic ultrasound.
5. Thrombophilias : Women with second-trimester miscarriage should be screened for inherited thrombophilias including factor V Leiden, factor II (prothrombin) genemutation and protein S.
6. No TORCH test for investigation of recurrent pregnancy loss 1. Women with recurrent miscarriage should be offered referral to a 2. Pregnant women with antiphospholipid syndrome should be considered for treatment with low-dose aspirin plus heparin to prevent further miscarriage.
3. Neither corticosteroids nor intravenous immunoglobulin therapy improve the live birth rate of women with recurrent miscarriage associated with Antiphospholipid antibodies compared with other treatment modalities; their use may provoke significant maternal and fetal morbidity.
4. The finding of an abnormal parental karyotype should prompt referral to a clinical geneticist. Preimplantation genetic screening with in vitro fertilisation treatment in women with unexplained recurrent miscarriage does not improve live birth rates.
5. There is insufficient evidence to assess the effect of uterine septum resection in women with recurrentmiscarriage and uterine septumto prevent furthermiscarriage.
6. Cervical cerclage is associated with potential hazards related to the surgery and the risk of stimulating uterine contractions and hence should be considered only in women who are likely to benefit. Women with a history of second-trimester miscarriage and suspected cervical weakness who have not undergone a history-indicated cerclage may be offered serial cervical sonographic surveillance. In women with a singleton pregnancy and a history of one second-trimester miscarriage attributable to cervical factors, an ultrasound-indicated cerclage should be offered if a cervical length of 25mmor less is detected by transvaginal scan before 24 weeks of gestation.
7. There is insufficient evidence to evaluate the effect of progesterone supplementation in pregnancy to prevent a miscarriage in women with recurrent miscarriage.
8. There is insufficient evidence to evaluate the effect of human chorionic gonadotrophin supplementation in pregnancy to prevent a miscarriage in women with recurrent miscarriage.
9. Suppression of high luteinising hormone levels among ovulatory women with recurrent miscarriage and polycystic ovaries does not improve the live birth rate.
10. There is insufficient evidence to evaluate the effect of metformin supplementation in pregnancy to prevent a miscarriage in women with recurrent miscarriage.
11. Paternal cell immunisation, third-party donor leucocytes, trophoblast membranes and intravenous immunoglobulin in women with previous unexplained recurrent miscarriage does not improve the live birth rate.
12. There is insufficient evidence to evaluate the effect of heparin in pregnancy to prevent amiscarriage in women with recurrent first-trimestermiscarriage associated with inherited thrombophilia. Heparin therapy during pregnancy may improve the live birth rate of women with second-trimester miscarriage associated with inherited thrombophilias.
13. Women with unexplained recurrent miscarriage have an excellent prognosis for future pregnancy outcome without pharmacological intervention if offered supportive care alone in the setting of a dedicated early pregnancy assessment unit.
Scientific Advisory CommitteeOpinion Paper 26June 2011 The Use of Antithromboticsin the Prevention of RecurrentPregnancy Loss 1. Four recent randomised controlled trials including women with two or more pregnancy losses have failed to demonstrate any improvement in pregnancy outcome in women with idiopathic recurrent pregnancyloss with low-dose aspirin with or without LMWH.
2. The only place for heparin and aspirin in the prevention of pregnancy loss in the absence of APS is in well conducted randomised controlled trials of high-risk women. However, in the case of APS and recurrent pregnancy loss, aspirin and heparin are still recommended.
Sukumar BarikAcademic Director and Consultant Obstetrician and GynaecologistWestbank Hospital. Howrah. West Bengal.
[email protected]

Source: http://bogs.org.in/RPL-BOGS_website.pdf