Clinical practice guidelines for recurrent miscarriage in high-income countries: a systematic review

Marita Hennessy,Rebecca Dennehy,Sarah Meaney,Laura Linehan,Declan Devane,Rachel Rice,Keelin O'Donoghue

doi:10.1016/j.rbmo.2021.02.014

Marita Hennessy, Rebecca Dennehy + Show 5 more

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https://doi.org/10.1016/j.rbmo.2021.02.014

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Abstract

Recurrent miscarriage affects 1–2% of women of reproductive age, depending on the definition used. A systematic review was conducted to identify, appraise and describe clinical practice guidelines (CPG) published since 2000 for the investigation, management, and/or follow-up of recurrent miscarriage within high-income countries. Six major databases, eight guideline repositories and the websites of 11 professional organizations were searched to identify potentially eligible studies. The quality of eligible CPG was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool. A narrative synthesis was conducted to describe, compare and contrast the CPG and recommendations therein. Thirty-two CPG were included, from which 373 recommendations concerning first-trimester recurrent miscarriage were identified across four sub-categories: structure of care (42 recommendations, nine CPG), investigations (134 recommendations, 23 CPG), treatment (153 recommendations, 24 CPG), and counselling and supportive care (46 recommendations, nine CPG). Most CPG scored ‘poor’ on applicability (84%) and editorial independence (69%); and to a lesser extent stakeholder involvement (38%) and rigour of development (31%). Varying levels of consensus were found across CPG, with some conflicting recommendations. Greater efforts are required to improve the quality of evidence underpinning CPG, the rigour of their development and the inclusion of multi-disciplinary perspectives, including those with lived experience of recurrent miscarriage.

Highlights

Recurrent miscarriage is estimated to affect 1–2% of women of reproductive age, depending on the definition used, and with the caveat that the actual prevalence is difficult to obtain owing to difficulty accessing data (Hemminki and Forssas, 1999; Oliver-Williams and Steer, 2015; European Society of Human Reproduction and Embryology [ESHRE] Early Pregnancy Guideline Development Group, 2017; Rasmark Roepke et al, 2017; Woolner, et al, 2020)
The term used to describe the condition varies between countries and professional bodies (Youssef et al, 2020); for example, ESHRE uses the term ‘recurrent pregnancy loss’ (ESHRE Early Pregnancy Guideline Development Group, 2017), whereas the Royal College of Obstetricians and Gynaecologists (RCOG) in the UK uses the term ‘recurrent miscarriage’ (RCOG, 2011)
Some professional bodies or organizations, such as ESHRE (ESHRE Early Pregnancy Guideline Development Group, 2017) and the American Society for Reproductive Medicine (ASRM) in the USA (Practice Committee of the ASRM, 2012) define recurrent miscarriage as the loss of two or more consecutive pregnancies for investigations; the previous definition of three or more consecutive pregnancy losses remains in use by others, such as the RCOG (2011), the Health Service Executive (HSE) in Ireland (HSE, 2016) and the French College of Gynaecologists and Obstetricians (Huchon et al, 2016)

Summary

Introduction

Recurrent miscarriage is estimated to affect 1–2% of women of reproductive age, depending on the definition used, and with the caveat that the actual prevalence is difficult to obtain owing to difficulty accessing data (Hemminki and Forssas, 1999; Oliver-Williams and Steer, 2015; European Society of Human Reproduction and Embryology [ESHRE] Early Pregnancy Guideline Development Group, 2017; Rasmark Roepke et al, 2017; Woolner, et al, 2020). Some professional bodies or organizations, such as ESHRE (ESHRE Early Pregnancy Guideline Development Group, 2017) and the American Society for Reproductive Medicine (ASRM) in the USA (Practice Committee of the ASRM, 2012) define recurrent miscarriage as the loss of two or more consecutive pregnancies for investigations; the previous definition of three or more consecutive pregnancy losses remains in use by others, such as the RCOG (2011), the Health Service Executive (HSE) in Ireland (HSE, 2016) and the French College of Gynaecologists and Obstetricians (Huchon et al, 2016). The risk of further miscarriage increases after each successive pregnancy loss, reaching about 40% after three consecutive pregnancy losses; a previous live birth does not prevent a woman experiencing recurrent miscarriage, and the prognosis worsens with increasing maternal age (Clifford et al, 1997; Nybo Andersen et al, 2000)

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