treatment

Last edited 08/2020

Management involves exclusion of known aetiological factors and tender loving care (1).

Bed rest and lifestyle changes like smoking cessation, reduction in alcohol intake and loosing weight may be helpful (2).

HCG and progesterone have been used to improve function of the corpus luteum:

• evidence supporting hCG supplementation to prevent recurrent miscarriage remains equivocal (3)
• in women with unexplained recurrent miscarriages, supplementation with progestogen therapy may reduce the rate of miscarriage in subsequent pregnancies (4)

The following treatment methods have been used but with unknown effectiveness (2):

• if raised luteinizing hormone is the problem, GnRH agonists, ovarian diathermy and somatostatin therapy may all be of benefit
• intravenous immunoglobulin therapy
• folic acid – for women with hyperhomocysteinaemia (2)

Treatment which are unlikely to be helpful:

• Immunising women (with paternal leukocytes or trophoblast membranes) against recurrent miscarriage has been attempted, but, only one randomised trial has shown any benefit
• vitamin supplementation (2)

In patients with antiphospholipid syndrome, low dose aspirin and heparin reduce placental infarction and thrombosis (1).

• the use of combined unfractionated heparin and aspirin may reduce pregnancy loss by 54% in patients with antiphospholipid antibody or lupus anticoagulant (5)

There is some limited evidence that low dose aspirin and heparin is an effective treatment for preventing recurrent miscarriages in women with Factor V Leiden mutation (6).

Notes:

• a study revealed that low molecular weight heparin + aspirin did not confer incremental benefit compared to aspirin alone for the study population (7)
  • study population comprised women with a history of recurrent pregnancy loss and at least 1 of the following: antiphospholipid antibody (aPL), an inherited thrombophilia, or antinuclear antibody

Reference:

• (1) Rai R, Cohen H, Dave M, Regan L. Randomised controlled trial of aspirin and aspirin plus heparin in pregnant women with recurrent miscarriage associated with phospholipid antibodies (or antiphospholipid antibodies). BMJ 1997 ; 314: 253-7.
• (2) Jauniaux E et al. Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage. Human Reproduction 2006;21(9):2216–2222
• (3) Morley LC et al. Human chorionic gonadotrophin (hCG) for preventing miscarriage. Cochrane Database Syst Rev 2013 Jan 31;(1):CD008611.
• (4) Haas DM et al. Progestogen for preventing miscarriage in women with recurrent miscarriage of unclear etiology Cochrane Systematic Review 2019 Nov 20;2019(11):CD003511.
• (5) Empson M et al. Prevention of recurrent miscarriage for women with antiphospholipid antibody or lupus anticoagulant. Cochrane Database Syst Rev 2005;2:CD002859
• (6) Younnis JS, Ohel G, Brenner B et al. The effects of thromboprophylaxis on pregnancy outcome in patients with recurrent pregnancy loss associated with factor V Leiden mutation. Br J Obstet Gynaecol 2000; 107: 415-9.
• (7) Laskin CA et al. Low molecular weight heparin and aspirin for recurrent pregnancy loss: results from the randomized, controlled HepASA Trial. J Rheumatol. 2009 Feb;36(2):279-87