Definition of recurrent miscarriage updated

A change in the definition of recurrent miscarriage will allow women who have experienced two miscarriages, regardless of whether they are consecutive or not, greater access to care.
 
Previously in Australia, recurrent miscarriage was defined as a woman having three miscarriages, consecutively.
 
The update is featured in the first comprehensive bi-national guidelines for the treatment of miscarriage, recurrent miscarriage and ectopic pregnancy, released last month.
 
Developed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the recommendations acknowledge that there is limited evidence that pregnancy outcomes will differ for women who have two miscarriages compared to three – including whether the losses are consecutive or not.
 
‘RANZCOG defines recurrent miscarriage as the loss of two or more intrauterine pregnancies of up to 20 weeks’ gestation (whether or not a gestational sac is present and whether or not the miscarriages are consecutive),’ the guidance states.
 
GP and fertility specialist, Dr Lisa Bedson, was part of the RANZCOG Guideline Development Group.
 
She told newsGP it will be ‘very useful’ for GPs to now have evidence-based guidelines and says the updated definition of recurrent miscarriage specifically will help to provide timelier investigations and, where applicable, reassurance for patients.
 
‘It is a very meaningful change for patients who have had recurrent miscarriages to be able to be investigated for potential causes of their miscarriages after two miscarriages rather than three,’ Dr Bedson said.
 
‘They feel heard, and their concerns addressed, and if something can be done to prevent further miscarriages it is very reassuring.
 
‘Also, for GPs it seems so unfortunate in the past for them to potentially have to tell people they were unable to investigate the miscarriages until they have had another one. So, it is reassuring for GPs as well to be able to have evidence-based guidelines on how best to investigate this distressing issue.’
 
The updated definition is in line with the 2024 Australasian Recurrent Pregnancy Loss Clinical Management Guidelines, developed by the Australasian Certificate of Reproductive Endocrinology and Infertility Consensus Expert Panel on Trial Evidence (ACCEPT) group, which also aligns with international standards from both the United States and Europe.
 
The new guidelines include a host of other evidence-based recommendations for early pregnancy loss, including for progesterone supplementation, management of subclinical hypothyroidism, as well as the administration of Rh D immunoglobulin (anti-D).
 
Early pregnancy loss is a common presentation in general practice, with one in four pregnancies in Australia ending in miscarriage. While recurrent miscarriage impacts between 1–4% of women.
 
The guidelines aim to set a benchmark for best practice in early pregnancy loss, marking a significant step forward in standardising care and support for affected patients.
 
Dr Ka-Kiu Cheung, Chair of RACGP Specific Interests Antenatal and Postnatal Care, told newsGP the recommendations will be useful for GPs who ‘often walk alongside women’ who are experiencing recurrent miscarriage.
 
‘GPs will find the recommended list of investigations in recurrent miscarriage useful, including tests that are not recommended,’ she said.
 
‘Although these guidelines are wide-ranging, there are a number of recommendations and practice points relevant to GPs particularly, as we are often the first point of contact for a woman who is newly pregnant, and we are likely to have provided care for past pregnancies or miscarriages.
 
‘GPs also have a key role in pre-conception care, particularly for women with a history of miscarriage.’
 
Dr Benson shares the sentiment.
 
She says while the recommendations are evidence-based, at their core, they are person-centred and not aimed at being prescriptive for patients.
 
‘Each recommendation has at its heart, the importance of discussing the pros and cons of interventions, investigations and management options, and to come to a mutual decision for care that is most suitable for the person involved,’ Dr Benson said.
                                                                                                                                                                              
In line with this, the guidelines also highlight the need for empathy as being central to the care provided.
 
‘Qualitative evidence indicates that good clinical care for people trying to conceive includes: empathy for both partners regarding pressure to conceive; the provision of clear information including statistics, support with decision making for testing and treatment; and emotional support and coping strategies,’ the guidelines state.
 
A global review, published in The Lancet in April 2021, found that while miscarriage is common, the impact and consequences ‘are underestimated’, resulting in a system of care which is currently ‘fragmented and can be of poor quality’.
 
The authors called for a ‘complete rethink of the narrative around miscarriage and a comprehensive overhaul of medical care and advice’ offered to women who have miscarriages.
 
While the new guidelines appear to be a step in the right direction, Dr Cheung believes they could go one step further with a greater emphasis on mental health support.
 
‘GPs support women, not only with the medical aspects of investigation and care, but more importantly the significant impact on their emotional wellbeing and mental health, including their partner and family,’ she said.
 
‘Although touched upon briefly, there are no recommendations on social and emotional supports for women who experience recurrent miscarriage. I believe this is an important aspect of miscarriage care, especially for GPs who support these women and their families.’
 
To ensure women and families are supported through miscarriage, the Federal Government announced $9.5 million in funding in May 2024 for bereavement support and to help raise awareness, as well as a scoping study for national miscarriage data collection.
 
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clinical guidelines early pregnancy loss ectopic pregnancy miscarriage pregnancy RANZCOG recurrent miscarriage