A new medical guideline has been released for consultation by the Royal College of Obstetricians and Gynaecologists, bringing together all the available evidence on possible risks and causes of recurrent miscarriage, potential treatment options, management of subsequent pregnancies and best practice in supportive care.
The new draft Recurrent Miscarriage guideline – last published in 2011 – supports a move towards a graded model of care, as proposed by experts in The Lancet in April, where women are provided with individualised care earlier.
In the UK, women can only access support after they have experienced three miscarriages in a row. The new approach would see women offered information and guidance to support future pregnancies after one miscarriage, an appointment at a miscarriage clinic for initial investigations after two miscarriages, and a full series of evidence-based investigations and care – as described in this guideline - after three miscarriages.
The term ‘recurrent miscarriage’ is also being redefined in this guideline to include non-consecutive miscarriages, meaning more women will be able to have investigations at an earlier stage.
The guideline highlights the health disparities facing women from Black, Asian or minority ethnic backgrounds who are at a higher risk of having a miscarriage and calls for more research to be done to understand why this is the case.
Lead guideline developer, Professor Dame Lesley Regan, said: “A significant proportion of cases of recurrent miscarriage remain unexplained, despite detailed investigation. These women and their partners can be reassured that the prognosis for a successful future pregnancy with supportive care alone is in the region of 75%.
“Miscarriage can be a devastating loss for women, their partners and families. We, therefore, hope this guideline will provide women and the clinicians caring for them with a consistent and evidence based approach to diagnostic tests, treatment options and supportive care to increase their chances of a successful birth in future.”
What else does the guideline show?
The guideline highlights that increasing paternal age is a risk factor for recurrent miscarriage, although not as markedly as with maternal age. Other risk factors include having previous miscarriages, being underweight or overweight, smoking and excess caffeine intake – although the authors note that a significant proportion of women with unexplained recurrent miscarriage are healthy women with repeated sporadic miscarriages and no known cause.
The guideline also incorporates the results from a major clinical trial published in 2019 - PRISM - which found that giving women with early pregnancy bleeding and a history of miscarriage self-administered twice daily progesterone pessaries can prevent some miscarriages.
Crucially, the guideline also highlights where the evidence is lacking for interventions such as preimplantation genetic screening (PGS) in conjunction with IVF/ICSI, which the authors note couples should be informed of the risk and significant cost of undergoing such treatment as well as the lack of evidence regarding any improvement in reproductive outcomes.
The guideline includes the results of a study in women with recurrent miscarriage that reported their preferred supportive care options for their next pregnancy, including a plan with one doctor who shows understanding, takes them seriously, has knowledge of their obstetric history, listens to them, gives information about recurrent miscarriage, shows empathy, informs on progress and enquires about emotional needs.
Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: “Miscarriage is a distressing, shocking and traumatic experience for many women and their partners. For too long, the topic has been under-researched and the care for women and their partners, under-resourced.
“We believe women should access appropriate and standardised care after their first miscarriage and that is why we are endorsing the graded model for miscarriage care in this guideline. This model addresses the balance between the need for evidence based management and supportive care, whilst targeting health care resources effectively.
“We know this is the first step in addressing the gap in care women who experience one or more miscarriages have and urge the NHS to further support this approach and explore ways of implementing this into the care pathway.”