Recurrent miscarriage is defined as three recurrent first trimester pregnancy losses and affects 1–2% of the population (European Society of Human Reproduction and Embryology, 2017). The benefits of psychological support and weekly ultrasound scanning in pregnancy following recurrent miscarriage are widely reported to improve pregnancy outcomes (Homer, 2019). A specialist clinic for women with recurrent miscarriages is advised by both the Royal College of Obstetricians and Gynaecologists (RCOG, 2011) and European Society of Human Reproduction and Embryology (2017) guidelines.
The Tender Loving Care Clinic is a specialist clinic for women during the first trimester of a pregnancy following recurrent pregnancy losses. The clinic is run by a senior midwife and overseen by a consultant obstetrician, who also is the lead consultant for the recurrent miscarriage clinic. It offers women weekly visits from 8–12 weeks' gestation. Each visit includes an ultrasound scan and the opportunity for psychological support from an experienced midwife. Women who attend the recurrent miscarriage clinic in the hospital are offered antenatal care in any subsequent pregnancies at the Tender Loving Care Clinic.
The clinic focuses on psychological support for women, and additional support from the bereavement team and the perinatal mental health team is offered. Self-care and strategies to reduce anxiety are discussed at each visit. Women are provided with a pack of resources to promote mindfulness and provide information regarding support services in the hospital.
A number of routine investigations are recommended following recurrent pregnancy loss and, ideally, are carried out prior to attending the Tender Loving Care Clinic. Women with recurrent miscarriages require a pelvic ultrasound scan to assess for uterine anomaly, thyroid function tests and screening for antiphospholipid syndrome (RCOG, 2011; Linehan et al, 2023). This testing is offered to all women who attend the recurrent miscarriage clinic, before attendance at the Tender Loving Care Clinic. Outcomes in pregnancies after unexplained recurrent pregnancy loss are reassuring, with approximately 75% of women having a successful pregnancy with supportive care (RCOG, 2011). Women who have unexplained recurrent miscarriages have a very good prognosis in future pregnancies when offered supportive care alone (Linehan et al, 2023).
This study aimed to review cases of those who attended the clinic for antenatal care in the first trimester following recurrent pregnancy loss.
Methods
A descriptive, exploratory design was used, involving a retrospective chart review. Anonymous data on demographic information, obstetric history, prescribed medications, results of investigations and pregnancy outcomes were collected from all electronic records of women who attended the Tender Loving Care Clinic between July 2020 and July 2022. Data were analysed using descriptive statistics. Ethical approval was granted for this study by the National Maternity Hospital's ethics committee (reference number: RA.06 2022).
Results
During the study period, 103 women attended the clinic between one and six times. The average number of attendances was 2.5. The mean age of women attending the clinic was 35.6 years. The majority of women (69.9%) were aged 35 years or older. All women who attended had a history of three or more pregnancy losses and 61.2% had a previous live birth. Table 1 shows details of the reviewed cases.
Table 1. Case details
| Characteristic | Value |
|---|---|
| Total number of women | 103 |
| Maternal age range (years) | 22–44 |
| Mean maternal age (years) (standard deviation) | 35.6 (4.8) |
| Maternal age ≥35 years (%) | 72 (69.9) |
| History of one or more live birth (%) | 63 (61.2) |
Prior to attending the clinic, the women were all referred to the recurrent miscarriage clinic following three recurrent pregnancy losses. Seven women become pregnant and attended the Tender Loving Care Clinic prior to any investigations being completed. The investigations subsequently conducted included cytogenetics on products of conception, thyroid function tests, screening for antiphospholipid syndrome, pelvic ultrasound scan and parental karyotypes for both the woman and her partner. There were no cases where a partner was not tested.
In total, 23.3% of women who attended the clinic had abnormal cytogenetics for their most recent pregnancy loss, demonstrating their miscarriage was caused by a chromosomal abnormality in the fetus. In five cases, hypothyroidism was diagnosed and the women were treated with levothyroxine prior to conceiving and throughout pregnancy. These women were also referred to the endocrine clinic during the first trimester for management of hypothyroidism.
In 13 cases, antiphospholipid syndrome was diagnosed based on two raised results of anti-cardiolipin antibodies, lupus anticoagulant or beta 2 glycoproteins, as per clinical guidelines (RCOG, 2011; Linehan et al, 2023). Women diagnosed with antiphospholipid syndrome were treated with aspirin and low molecular weight heparin from the time of a positive pregnancy test, as per RCOG (2011) and Linehan et al (2023) guidelines.
In 20.4% of cases, an abnormality was found on pelvic ultrasound scan. Abnormalities noted in pelvic scans included uterine polyps and fibroids. There were no cases with an abnormal parental karyotype in this review. Table 2 shows further details of the investigations performed prior to women attending the clinic.
Table 2. Investigations for recurrent pregnancy loss completed prior to attending the tender loving care clinic
| Investigations | Frequency, n=103 (%) |
|---|---|
| All maternal investigations normal | 63 (61.2) |
| Abnormal cytogenetics | 24 (23.3) |
| Abnormal thyroid function | 5 (4.8) |
| Abnormal pelvic ultrasound scan | 21 (20.4) |
| Abnormal parental karyotype | 0 (0.0) |
| Antiphospholipid syndrome | 13 (12.6) |
| None | 7 (6.8) |
Most women (90.3%) were prescribed medication either prior to pregnancy or when a pregnancy test was positive (Table 3). The most common medication used was progesterone and 75.7% of women were prescribed this from the time of a positive pregnancy test until 12 weeks' gestation. Almost a third (30.7%) of women took aspirin and 19.4% took low molecular weight heparin, with 18.4% of cases being prescribed both. Over one in five (21.3%) women were taking levothyroxine for hypothyroidism. Five of these cases were diagnosed while attending the recurrent miscarriage clinic and the remaining 17 cases had previously diagnosed hypothyroidism.
Table 3. Medications prescribed
| Medication | Frequency, n=103 (%) |
|---|---|
| Progesterone | 78 (75.7) |
| Aspirin | 32 (30.7) |
| Low molecular weight heparin | 20 (19.4) |
| Levothyroxine | 22 (21.3) |
| None | 10 (9.7) |
At the time of review, 13.4% of the women were pregnant and at 12 or more weeks' gestation. Of these, 12.6% (n=13) experienced a first trimester miscarriage, 0.9% (n=1) experienced a second trimester miscarriage and 69.2% (n=72) had a live birth. Table 4 shows complete details of pregnancy outcomes.
Table 4. Pregnancy outcomes
| Outcome | Frequency, n=103 (%) |
|---|---|
| First trimester pregnancy loss | 13 (12.6) |
| Second trimester miscarriage | 1 (0.9) |
| Live birth | 72 (69.2) |
| Ongoing pregnancy >12 weeks | 14 (13.4) |
| Pregnant <12 weeks | 0 (0.0) |
| Unknown | 3 (2.9) |
| Stillbirth or neonatal death | 0 (0.0) |
| Live birth and ongoing pregnancy combined | 86 (83.5) |
Birth outcomes were reviewed in cases where birth occurred after 24 weeks' gestation. Table 5 shows complete details of birth outcomes. The majority of women gave birth at full term (>37 weeks' gestation) with 5.6% giving birth prior to 37 weeks. The mean birth weight was 3514.6g (standard deviation=545.2g). Almost two thirds (63.9%) of women had a vaginal birth, with the remaining 36.1% giving birth via caesarean section.
Table 5. Birth details
| Birth | Frequency, n=103 (%) |
|---|---|
| Gave birth >24 weeks' gestation | 72 (69.2) |
| Preterm birth (<37 weeks' gestation) | 5 (5.6) |
| Mean birth weight (g) (standard deviation) | 3514.6 (545.2) |
| Vaginal birth | 46 (63.9) |
| Caesarean section | 26 (36.1) |
Discussion
The first trimester of a pregnancy following recurrent miscarriages is likely to cause stress and anxiety, meaning women may require emotional support (Bailey et al, 2019; Gavrizi et al, 2022). While supportive care has not been studied in any randomised control trials, numerous studies have found regular ultrasound scanning combined with physiological care improves outcomes for women who are pregnant following recurrent miscarriages (RCOG, 2011; Homer, 2019). Psychological support and screening for mental health issues following recurrent pregnancy loss is a vital component of antenatal care for this group of women (Coomarasamy et al, 2021).
Vital treatments for recurrent miscarriage include progesterone supplementation, levothyroxine for hypothyroidism and the combination of low molecular weight heparin and aspirin for antiphospholipid syndrome (Coomarasamy et al, 2021; Linehan et al, 2023). The literature regarding use of progesterone following recurrent miscarriages is conflicted. In the present study, 75.7% of women were prescribed progesterone from the time of a positive pregnancy test. However, the European Society of Human Reproduction and Embryology (2017) have reported that the use of progesterone does not improve live birth rates in women with idiopathic recurrent miscarriages. Despite this, a number of authors advocate for the use of progesterone in this cohort of women (Roepke et al, 2018; Coomarasamy et al, 2021; Linehan et al, 2022) and progesterone is widely used in recurrent miscarriage clinics, both in Ireland and internationally. Recently published Irish guidelines for recurrent miscarriage recommend the use of progesterone supplementation for women following three or more miscarriages (Linehan et al, 2023).
All women with hypothyroidism (4.8%) were treated with levothyroxine and referred to the endocrine clinic for monitoring throughout their pregnancy, as is recommended by clinical guidelines (RCOG, 2011; Linehan et al, 2023). All women with antiphospholipid syndrome (12.5%) were treated with low molecular weight heparin and aspirin, as per RCOG (2011) guidelines.
The present study reported a high proportion of subsequent live births among those who became pregnant again following recurrent pregnancy loss (69.2%). This is consistent with current literature and is important information to provide couples following recurrent miscarriages (Brigham et al, 1999; Ali et al, 2020; Linehan et al, 2022). In a large Irish study of pregnancies following recurrent miscarriages, a live birth rate of 63% was found (Linehan et al, 2022).
The authors recommend a dedicated antenatal clinic for women following recurrent miscarriages, ongoing emotional support and reassurance for women during pregnancy following recurrent pregnancy loss, and further research to examine the needs of women who are pregnant following recurrent miscarriages.
Strengths and limitations
This study was conducted using accurate data collection and the electronic patient record allowed for complete follow up of patients. This review adds important data to the literature in relation to pregnancies following recurrent miscarriage and the importance of regular reassurance in the first trimester.
This study was limited by its small sample size and further research is required in this area to investigate the most appropriate treatments and women's experiences of recurrent miscarriage. In particular, qualitative studies examining women's experiences of antenatal care following recurrent miscarriage are needed.
Conclusion
This review of women who attended a dedicated antenatal clinic following recurrent miscarriage highlights the importance of supportive care for this group of women. Investigations following recurrent pregnancy loss are important; in particular, screening and treatment for hypothyroidism and antiphospholipid syndrome are vital in this cohort. Larger studies are required to further examine the needs of women who are pregnant following recurrent pregnancy loss.
Key points
- A dedicated antenatal clinic for women following recurrent miscarriages is advised.
- Ongoing emotional support and reassurance are beneficial for women during pregnancy after recurrent pregnancy loss.
- Further research is needed to examine the needs of women who are pregnant following recurrent miscarriages.
CPD reflective questions
- What investigations are important for couples with recurrent pregnancy loss?
- What kind of support is needed for couples experiencing recurrent miscarriages?
- How can you provide better support to women who are pregnant following recurrent miscarriages?