Synopsis
Build a targeted recurrent-loss evaluation that finds actionable antiphospholipid, genetic, uterine and endocrine factors while avoiding unvalidated panels and blame.
- RCOG defines recurrent miscarriage as three or more first-trimester miscarriages; they need not be consecutive or with the same partner.
- Use clinical discretion to investigate after two first-trimester losses when their pattern suggests pathology rather than independent sporadic events.
- Start with a verified pregnancy timeline, maternal and paternal age, gestations, ultrasound or histology findings, complications, conditions, medicines, family history and lifestyle.
Key red flags
Current severe pain, syncope, shoulder-tip pain, peritonism or haemodynamic compromise requiring emergency ectopic assessment.
Investigation priorities
Detect an acquired, treatable thrombophilia associated with recurrent and later pregnancy loss.
Management branches
There are three first-trimester miscarriages, an eligible later loss, or two early losses with features suggesting pathology.
- Reconstruct every pregnancy with records where available and take medical, obstetric, thrombotic, genetic, medication, family, social and reproductive histories.
- Offer APS testing, thyroid function with TPO antibodies and uterine ultrasound, then arrange pregnancy-tissue or parental genetic testing according to the loss number and available specimen.
Key medicines
Low-dose aspirin plus heparin for confirmed obstetric APSUse a specialist pregnancy plan: low-dose aspirin 75 to 150 mg orally once daily plus prophylactic unfractionated heparin or weight-adjusted low-molecular-weight heparin by subcutaneous injection; exact start, product, dose and stop timing depend on APS, thrombosis history, weight and delivery plan.
Vaginal micronised progesteroneOffer 400 mg vaginally twice daily when ultrasound confirms an intrauterine pregnancy and early-pregnancy bleeding occurs after at least one previous miscarriage; if a fetal heartbeat is confirmed, continue until 16 completed weeks.