Early pregnancy ultrasound scans and talking to an early pregnancy specialist midwife or clinician can provide a great amount of support and reassurance for patients in subsequent pregnancies. Women should be aware of the referral process to the EPU (via trakcare or by phone) from 6 weeks if asymptomatic or earlier depending on clinical symptoms or history. Patients can self refer to EPU by phone or a referral can be made via Trakare by a clinician.
Pregnancy loss counselling and support services are available via the Miscarriage Association (tel: 01924 200 799). In addition, referral to Clinical Psychology within GGC (tel: 0141 211 4532 (24532)) can be made via Badgernet (found under ‘emotional wellbeing’) or via the GP. Currently appointments are held within the Princess Royal Maternity and Queen Elizabeth University Hospital maternity buildings but are available for all patients within GG+C. For more advanced pregnancy losses, referral to the Child Bereavement Service (tel: 0141 370 4747) within the Royal Hospital for Children in Glasgow may be offered.
Advice and support should be offered on smoking cessation, regular exercise, weight management and limiting alcohol intake.
Genetic counselling should be offered where there is an abnormal fetal +/- parental karyotype.
Anti-thrombotic prophylaxis for the treatment of hereditary thrombophilias is not recommended to reduce the risk of RPL or in those with unexplained RPL (although it may however be required to reduce the risk of VTE if risk factors exist).
Antiphospholipid (APL) Syndrome:
- This is defined as pregnancy loss or vascular thrombosis in addition to positive LA or ACA (on two occasions, at least 12 weeks apart)
- There is limited evidence to support the use of pre-conceptual Aspirin 75-100mg/day plus heparin from the start of pregnancy in those with APL syndrome and a background of RPL.
- Low molecular weight heparin (LMWH) is preferred over unfractioned heparin due to its’ lower side effect profile however there is very limited evidence to support the use of LMWH in reducing RPL
- The risks and benefits of treatment should therefore be discussed with the patient when attending the EPU
- A VTE risk assessment should routinely be performed in early pregnancy and women with APL syndrome may therefore require LMWH anyway if they meet criteria for treatment
- For those with a positive initial test for APS syndrome that conceive before a second confirmatory test is performed, the risks and benefits of aspirin+/-LMWH in pregnancy should be discussed. The second test should be performed >6weeks after pregnancy for confirmation of the result.
- Levothyroxine should only be offered to women with proven hypothyroidism
- Subclinical hypothyroisim and thyroid autoimmunity
- Treatment with levothyroxine should only be offered if there is true hypothyroidism (i.e. the T4 level are low). TFTs should only be checked if there is a clinical indication for this
- Progestogen supplementation in the first trimester of pregnancy may reduce the rate of early pregnancy loss in those with unexplained recurrent miscarriage
- A recent systematic review and meta-analysis showed that the rate of pregnancy loss was lower when synthetic progestogen supplementation was used in the first trimester. The preferred dose or route of progestogen therapy was inconclusive and further trials are needed to establish this
Hysteroscopic resection of a uterine septum or removal of submucosal fibroid or polyps:
- This may be discussed and offered in certain circumstances although there is limited evidence that it reduces the rate of RPL
Recurrent second trimester losses:
- Recurrent pregnancy loss in the second trimester is associated with cervical weakness and therefore serial cervical length scans +/-cervical cerclage is recommended
Treatment with the following is not routinely recommended:
- IV immunoglobulin or glucocorticoid for immunological or unexplained RPL
- Heparin or aspirin for unexplained RPL