Recurrent Miscarriage

Key Message

Only refer if 3 consecutive miscarriages with the same biological partner.

Assessment

Recurrent miscarriage may be primary with no previous live births or secondary following birth. However referral will only be accepted if 3 consecutive miscarriages with same biological father.

Red Flags

  • Miscarriage is incomplete − admission for surgical evacuation of retained products of conception has the advantage that symptoms resolves rapidly, but has the disadvantage of risks associated with an operation
  • The patient is haemodynamically unstable; or
  • Bleeding heavily
  • There is evidence of septic miscarriage

Management

Patient support and information includes:

  • Information about the symptoms of miscarriage
  • Advise patient about treatment options
  • Advise patient that surgical management is available at any time
  • Advise patient about appropriate counselling and psychological support services:
Advice about sex and contraception:
  • Advise avoidance of sexual intercourse until miscarriage symptoms have completely settled and until after the woman's next period
  • Explain that menstruation can be expected to resume within 4-8 weeks of the miscarriage, but may take several cycles to re-establish a regular pattern
  • For women who wish to become pregnant:
    • advise that that they can do so as soon as they feel psychologically and physically ready
    • offer pre-conception advice, including advice about folic acid
  • For women who do not wish to become pregnant − advise the use of contraception immediately after the miscarriage

Referral

Referral Criteria

The following tests need to be completed before referral to the recurrent miscarriage service:

  • Lupus anticoagulant for female
    • This test should be done when the patient is not pregnant and 6 weeks after a miscarriage. Blood bottles to use are 2 x blue top, and 1 x gold top
  • Anticardiolipin antibodies for female
    • Patients with these raised antibodies have an increased chance of miscarriage

Both Lupus Anticoaglant and Anticardiolipin antibodies need to be processed within 3 hours and must therefore be rung through to the Lab in advance - contact 01752 433244 (or 433245) to book the test.

However, because of this, GP's may find it easier to easier to fill out a request form and ask the patient to go to Derriford to get one of their phlebotomists to take the blood, along with the other blood tests required:

  • AMH (anti-mullerian hormone) for female – biochemistry bottle, test is done at Derriford
  • Thyroid function tests (TFTs)
  • 1 X semen analysis for male (even if previously fathered a child) to check poor morphology

Ultrasound of pelvis is no longer required as patient will already have had a pelvic ultrasound at the assessment of their miscarriage.

GPs should explain to patients that these are specialised tests and advise that the consultant will explain the test results at their consultation,

Any referrals for recurrent miscarriage which have not had the above investigations should be returned to the referring clinician with advice of what needs to be included in the referral letter.

Referral Instructions

For referral to Gynaecology, refer via DRSS using the e-Referral Service:

e-Referral Service Selection

  • Specialty: Gynaecology
  • Clinic type: Not Otherwise Specified
  • Service: DRSS-Western-Gynaecology-CCG-99P

e-Referral Service Selection

  • Specialty: Gynaecology
  • Clinic type: Recurrent Miscarriage
  • Service: Recurrent Miscarriage-Gynaecology-Derriford-RK9

Referral Forms

DRSS Referral Proforma

Supporting Information

Patient Information

Miscarriage Association

Pathway Group

This guideline has been signed off by the Western Locality on behalf of NHS Devon CCG.

Publication date: May 2015

Updated: May 2022

Last updated: 13-05-2022

 

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