Miscarriage

Investigation of recurrent pregnancy loss

The specialist will take a full history, perform general and an internal examination, and order some investigations. The initiation of recurrent pregnancy loss investigation should be tailored to meet the couple's need based on woman's age, reproductive history and health rather than arbitrary number of pregnancy losses. A history of subfertility, particularly ovulation problems is present in 25%-30% of women with recurrent miscarriage and confers a poor prognosis for future pregnancy outcome. In a significant proportion of women the cause of the recurrent pregnancy loss remains unexplained after careful investigation.

The investigations the specialist may order include some or all of the following tests.

• Blood test from both partners for karyotyping. About 3-5% of couples presenting with recurrent pregnancy losses carries chromosomal abnormalities, the wife being affected twice as frequently as the male partner.
• Karyotyping of all fetal products.
• Pelvic ultrasounds scan to diagnose polycystic ovaries and uterine abnormalities.
• A hysterosalpingogram or hysteroscopy in order to assess the uterus and cervix. An ultrasound examination can suggest but usually can not provide a definitive diagnosis.  
• Blood test to check for the presence of antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibodies). Before a diagnosis of antiphospholipid syndrome is made it is mandatory that the patient has two positive tests at least six weeks apart for either lupus anticoagulant or anticardiolipin antibodies in medium or high titre.
• Blood test to check the levels of FSH, LH and thyroid function tests.
• Blood tests from the female partner to test her for thrombophilic defects (antithrombin III, protein C, protein S, hyperhomocysteinemia, activated protein C resistance).
• High vaginal swab to check for infection.
• Some specialists recommend endometrial biopsy and blood samples to perform a Natural Killer Cell Assay, tissue type compatibility and auto-antibody screen. However, these tests are not endorsed by either the Royal College of Obstetricians and Gynecologists in the UK or the American College of Obstetricians and Gynecologists. Furthermore, these tests are costly and are only performed by special laboratories.

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