Welcome to the Kick Your Expert led podcast, helping you explore and learn everything about getting pregnancy, birth, and becoming a parent.
On the podcast and our online pregnancy program grow My Baby, we share my experience of helping more than four thousand babies to be born and.
Our experience of running a women's health clinic and parenting for boys.
We're here to help everyone to feel empowered in pregnancy and birth with real life, practical information.
Welcome everyone. I'm Bridget Maloney.
And I'm obstetrician doctor Patrick Maloney.
And today we've got a really important podcast to share with everybody.
I think, yeah, recurrent miscarriage is a such a big topic within obstetrics. It's such a heartbreaking problem for a couple to have. And the interesting thing is that the Australian guidelines have just been redone on this topic to give us perhaps a more certainty on when we're supposed to intervene and what tests are of high value to do, and hopefully how we can help people move on from our current miscarriage situation to having the family size that they desire.
As we go through the guidelines, it will sound like where I read them and thought well, they're kind of hedging their bets.
A little bit.
Yeah, but can you just describe to the audience what are guidelines for and who has developed these guidelines.
Yeah. So these guidelines are developed by RAN's COG with the Australian og College and it's a worthwhile thing to do to produce guidelines. It's important that we remember that that's all they are. They're guidelines. They're not the law that you must intervene at this point or you must do these tests. One thing when they produce guidelines is that they tend to look at things that have already been done in the past, such as a certain test, and rate it on the evidence behind actually doing that.
And sometimes the evidence for something that we've always done turns out to be pretty disappointing, and there are a couple of potential explanations for that that we have to remember. So if a test has very little evidence that it actually helps, that just means that the evidence is not there. It doesn't mean that it doesn't actually help. It might actually be good, but the evidence does not exist to say this has been proven to help.
And I read a lot of them are based on the findings of an RCT or a randomized control trial, just really quickly, what is that?
Yeah, So these guidelines always rate a current practice in terms of how much evidence there is behind it. And there's a scale from excellent evidence, which would be a really well constructed, really big randomized control trial where we yet half the people with the problem to agree to have treatment x and half the people that have the problem to agree to have treatment why, and look at
which group does the better? And obviously we have some of those in obstetrics, some really really well constructed ones, and lots of what we do in medicine obstetrics is no exception. We're looking at evidence way less persuasive than a double blinded randomized control trial. So sometimes it might say that the evidence behind course of action ABC is nowhere near A level evidence. It might be Z level evidence, which is just it's the way I was taught by my professor Will as a student.
Yeah, And it's anecdotal and observation.
Yeah. Yeah, the last time I did this at work, therefore I did it the next time.
It worked again treatment. But it's not a sample size that has any you know, real high clarity or high level of evidence.
Absolute, So Whilst we should be Whilst we should always be reaching for better levels of evidence in our medical practice, we also have to remember that sometimes we have to make a decision to do something or not do something, and the evidence may be lacking, and then we're going to or high grade evidence may be lacking, and then we kind of accept whatever evidence there is, remembering, of course, there's no randomized control trial that says you could you
should go to hospital if you cut your legg off. And yet it seems like a good idea. Okay, so we don't do nothing just because we don't have an RCT.
So in some circumstances, an RCT may not be approved by ethics either, yes, it's actually going to do harm to their control group.
That's right. It might be that you just can't get such a study up and going. It might be that ethics would never approve it. It might be too much to ask of people to be randomized. Often at the start of a randomized control study, when you're approaching someone to be part of it, we've got two treatments. We're trying to work out which is the best one, and sometimes the post will just give me the one that you think really works, and well we don't know. That's why we're doing the trial.
Good, all right, well let's get into it. I think, firstly, how is rans COG now defining what a recurrent miscarriage is?
Yeah, so that's tightened up a lot, and that's that's that's of interest. So we used to really define a recurrent miscarriage and certainly intervene when somebody had had three in a row. So three early pregnancy losses less than twenty weeks in a row, and we would we would attach more significance to say, someone who lost an otherwise normal pregnancy at fifteen weeks, to somebody who had a positive pregnancy test at five weeks and then it was gone a week later. But still it was three in
a row. And now they're saying that we should be considering it a recurrent miscarriage hit situation. If a woman's lost two pregnancies under twenty weeks under any circumstances, not necessarily in a row.
Gosh, that's a big change, isn't it.
Yes, so it would it would capture more people, It would encapsulate a greater group of women, some of whom had been previously told that they didn't reach the criteria to have the tests that have.
Further investigations, and like, if you're thinking about three consecutive miscarriages, might have taken that woman a few months to get pregnant in the first time, so that in the first place, so that could be a few years.
Yes, yes, and so on the one hand, with the old system, we must have been telling some people who had a significant issue, don't worry, just try again, and they may actually get the necessary tests earlier with the new definition. On the other hand, surely with the new definition will be investigating some people who don't have much wrong with them and would have conceived normally if they just tried again.
Yeah. And this definition is a bit different wherever you are in the world. I did see that Europe it's a loss of two or more pregnancies, but in the UK it's a loss of three or more first trimester losses. Yes, all right, before we go on, Patty, can we just very basically talk about what does the research say that causes recurrent miscarriages?
Yeah? That's the question at the heart of all of this, isn't it. Because if only we knew most of the cases we don't identify. Course and that makes guidelines difficult, But there are some known causes. It's very relevant maternal and paternal age, some lifestyle factors like alcohol and smoking,
The woman's obstetric history is quite relevant. Medical maternal medical conditions like diabetes or hypothyroidism known to be relevant in particular if those diseases that are there and are untreated. But plenty of cases we never identify exactly what the cause is too.
All right, so someone's just come in and you know it's their second miscarriage. What screening tests does rang Skog now recommend that you do according to the guidelines.
So there's a list, But we have to remember that this is not a one size fits all problem, and we have to remember that the tests that we might do for someone who'd lost two very very early pregnancies before there was even something seen in the uterus, you know, a five and a half week loss might be different to someone who's two losses were both at eighteen weeks.
And that's important that the advice is personalized. But certainly the tests that they recommend concentrate on potentially untreated maternal Nothing we can do about maternal age or paternal age in most cases. But untreated maternal disease is important, and of course lifestyle factors are very important. So a test for maternal diabet is a test for thyroid disease.
All right, So we'll get into the screening tests because that all depends on the different conditions that they want to test for, which have changed a little bit. But let's go to this recommendation, which is that in previous recommendations in recurrent miscarriages, there was a routine analysis of the pregnancy tissue. This has changed is that?
Well, I think it used to be said that whenever possible, if we were doing a curate for a pregnancy loss, then if there was a chance to get the tissue that was evacuated from the uterus and send it for genetic analysis, that that would be that that was a highly worthwhile
thing to do. The new guidelines aren't so fast about that, and suggests that knowing that genetic analysis is rarely important, there would be some scenarios where a genetic basis to the recurrent miscarriage was strongly suspected, where that might still
be a worthwhile thing to do. But these guidelines are more in favor of a maternal and paternal carrier type where the genes of the parents are analyzed rather than necessarily going to the lengths of analyzing the genetics of the material from the miscarriage.
So the next recommendation is around thrombophilia. Can we start with the definition?
What is that? Yeah, thrombophilias are a group of conditions, quite a big group of conditions where the body is more likely to form a blood clot. And when I did my training, they were identifying more and more of these thrombophilias, and they were getting more and more excited about them being an identifiable cause of recurrent miscarriage and infertility and a potentially treatable cause. And in a lot of cases for these various thrombopelias, it's actually been a
bit disappointing. It has not panned out quite as it was originally thought it would be. They thought they'd found the holy grail to early pregnancy loss, and unfortunately it's been a bit disappointing. Some of them have not had the association with early pregnancy loss that was predicted, and others have not had a worthwhile treatment. So whether you've got it or not, maybe there may be nothing you
can do about it either way. There's a group of related there's a relate condition called antiphosphilipid syndrome where the body makes an immune response that is more likely to form clots. And antiphosphilipid syndrome does have good evidence that it's involved in pregnancy loss, and so we should definitely be testing for that one.
So of those issues that caused thrombophilia, what were some of the changes in the guidelines.
Yes, that they were less keen for people to be tested for conditions like activated protein C resistance, something that's caused by by a common genetic phenomenon called factor five light, and there are other conditions and protein C protein s and these were part of a handful of tests that are commonly done and should be done as part of the investigation, say of an adult with bug clot in their leg, but have not proven as useful as we thought they were going to in the investigation of a
current miscarriage.
Right, So you mentioned the anti phospholipid What are some of the tests that people have for that.
It's a blood test. Yeah, yeah, test, and that basically says yes, I know, Okay. The reason why that one's relevant to know about is that it can there is a treatment so that particular condition. For example, if you go on to low dose aspirin and a powerful blood thinner like Colecksain, that does change pregnancy outcomes.
So, Patty, you already mentioned about genetic testing, what do the guidelines say about that now?
Well, they say that there's value in doing a maternal and paternal carrier type so that both both people and the couple go and have their genetics analyzed. And occasionally some people have a thing called a balanced translocation where they may have a little bit of genetic material that has broken off one chromosome and attached to another chromosome.
And while that's fine for them because all the genetic material is there, when their cells goes to divide, they can wind up with the wrong amount in the sperm or the egg that they're creating. Well, and so knowing about balanced translocations is relevant, all right.
So there's a place in the guideline for talking about anatomical factors. What's different there?
Yeah, it's interesting. These are the ones that they thought had Some of them had low evidence, a low degree of evidence, but some of them would seem to be no brainers. For example, if you did an ultrasound and you found that Norman's uterus had a number of polyps or a big septum down the middle of it, then they're saying there's low evidence that intervening to fix those things would help. I suspect that there's an absence of evidence,
not evidence that doing it doesn't help. Does that make sense? Yeah? Yeah, yeah, So in general terms, we would do simple things that would help correct the intrauterine environment.
Just quickly go through what some of the common anatomical features that they're talking about in the guidelines. Ah.
Yes, So they're talking about polyps within the uterus, septums within the uterus, like where there's a wall down the middle, and then other things that really change the size and the shape of the uterus like black fibroids.
Yeah. And adhesions are read too.
Yeah, intrauterine adhesions where the front and the back of the uterine cavity is stuck together, so called Asherman syndrome, which can be seen in people who've had recurrent previous curetes with someone with recurrent miscarriage might have had. Then that would be relevant, and you break those adhesions down and try and let a nice clean lining start again. And the other interesting one is caesarean scar niche or
caesarean scar defect, and it's something really interesting. The last gynecological conference I went to there were no few of them, about five presentations on exactly this. There's definitely a phenomenon where a woman has had apparently normal fertility and she's had two or three seasons and then trying to have another baby and experiencing a secondary infertility or a secondary
current pregnancy lost situation where she's previously been fined. And it's thought that the cesarean section scar might have developed a little niche or or sort of a pocket or alcove within it, and that might hang on to fluid that inhibits the healthy environment within the uterus. And there's a procedure where you can cut the scar out, make a new one start again. And like a lot of these things, the science of making the operation to fix it has surged ahead, well ahead of the evidence that
suggests that that would actually help. But anecdotally it seems to be promising.
So tricky, isn't it, Because like you've got clinical experience of this not just the cesareanscarnage, but like all of those anatomical issues, and you've had experience where people have had that particular surgery to move a fibrod or a poll up or something like that, and then subsequently, yeah, they're pregnant. It's really it must be really difficult as a governing body to go, Okay, well, what we're working with is people that perhaps are all different skill levels
or all access to different services. We've got to make something that is the guideline. I'm going to say it for the bare minimum.
Well, yes, and that's that's what guidelines really are. And it's important that we remember that if a guideline says that there is a poor a low level of evidence for a particular intervention, it doesn't mean that they're saying it necessarily should be done. They're saying that there's a low level of evidence to support it's better.
Do you think they make these guidelines with any financial constraints in mind or thought in mind?
I don't think so. I think the clinical practice guidelines that probably exist somewhat independently of how much these things cost. And if you look at the definition, they've tightened it up so there's every chance that this will that this will result in more money being spent on this problem, not less or right.
There is something in the guidelines which is like a strong recommendation, something we can do something about, and that is hypothirotism.
Yeah, that's got good evidence. So we check the thyroid and if someone has been walking around with a low thyroid and you correct that, you'll improve their chance of holding onto the pregnancy. So that's great. We knew that already, but it's good that that's known to have good evidence. There's an interesting comment in the guidelines about whether we should treat asymptomatic where the blood tests are mildly abnormal
but the woman looks and feels fine. A lot of people in a recurrent miscarriage situation would latch onto any mild abnormal the one percenter. Let's just try and get everything as normal as we can.
So what about the person who has a subclinical finding about their thyroid.
Yeah, so they look and feel fine, but there's a very mild abnormality to the test, and these guidelines are suggesting that there's poor evidence to treat that, but that that person should have close attention paid to their thyroid as soon.
As they're pregnant, and again during their pregnancy.
Yeah, well we check anyone with thorroid disease, which gets recurrent checks.
Yep. And there's this thing called antibody positive youth thyroid. What is that.
That's people who've got a normal level of thyroid function, but they have a thing called thyroid auto antibodies where your body has made antibodies against thyroid tissue.
Well, that's the Hashimotos and Graves disease. And yeah, and that's treated the same, isn't it. It's just tested to see if there's any dis function in the pregnancy once you're pregnant. Once you're pregnant. I googled all of that because it is all new to me, and Google definitely says that that is all the cause of miscarriage. So this is where the punters get the information from, isn't it in the first place?
Well? Yes, and I think we have to remember that there are multiple sources of information. But the point of the guideline is to gather the quality evidence from wherever it exists in the world and put it together and have a go at recommending what best clinical practice is.
Yeah. Also, if you avidly googling, you might come across intravenous immunoglobular therapy. What is that? That is in the guidelines, But can you just quickly define that for us?
Yeah, you know, globulin therapy is an idea that for a current miscarriage that doesn't have much scientific merit behind it as far as I can see. Where you know, im immune substances are purified from blood donation, could be could be injected and used in an attempt to treat my current miscarriage. And I don't believe that has any serious science behind it at this stage.
I know that currently it's not a approved use of donated blood in Yeah, well, and it must cost a lot of money. So that's in the guidelines, but there's no recommendations.
They recommend against.
It, all right. So this leads us to the last recommendation. This is the use of progesterone when someone has had recurrent miscarriages.
This is an interesting one because because you've got to remember that recurrent miscarriage is one of those heartbreaking conditions. It's very frustrating to treat. There's a certain sort of randomness about it. It just people seem to just have the pregnancy snatch from them, and there's very little we've been able to do about that other than in a good other than in a kind way suggesting that we go home, nurture our bruised body and heart, and then
try again. So we've latched upon, we've latched on to treatments when they've come along in the hope that they are the holy graylmen we can really help people. And progesterone certainly has a role in a sort of a different problem in pregnancy, which is one of cervical insufficiency, where the cervix comes open too early and end in a sort of a painless second trimester pregnancy loss. Cervix opens, baby comes out, and that I think led to its to an increasing focus on its use to try and
help prevent first trimester pregnancy losses. The evidence for that's not quite as good, and in this guideline they recommend only doing that if there's bleeding, which is not really where frequent everyday clinical practice was sitting prior to this guideline, So it'll be interesting to see whether that changes practice. Okay, because using a little bit of vaginal progesterone pessories in a woman with the recurrent pregnancy lost situation has really been seen as a as a safe thing to do,
as something that might help that won't harm. And it's for some people the feeling of doing something is a lot more satisfactory than the feeling of doing nothing, even if the something doesn't have a lot of evidence behind it. Yeah.
Yeah, and we can see you know, that is where people have agency in their life when it comes to recurrent miscarriage. You know, they start to look at their lifestyle factors and that can also be somewhere where they concentrate on. Yes, but for you, does anything in this guideline change how you practice as a clinician?
It's a good question. I think it's very very real. Sure, it's very pleasing to see the evidence summarized in one place. I don't think it makes looking after women with this problem any easier, to be honest. I think more people will probably come forward for an assessment, and I think we will have a better opportunity to do the things that we know work for a greater number of people because more people are going to be caught up in the titan definition. Does that make sense?
Yeah?
And then so the things that we know help cut down alcohol, don't smoke, treat thyroid, those things. We may wind up treating more people for those conditions.
All right, everyone, I guess you've chosen this because you're you might have only just had one miscarriage and you're thinking, gosh, what if I have another, or you've had two miscarriages, all three or more, and you're looking for answers in this podcast. We hope you've found some and you can just you know, go to the RAMS card guidelines. They're readily available for everybody. I can't say that they're like
a really easy read. They're pretty dense and clinician focus and technical and they're a technical piece, but you know, you might like to just look at the recommendations and just see whether you're on the right.
Track and make sure to the best of your ability that your concerns about this are not dismissed, and in particular that your care providers understand that, un by the new guidelines, investigations should be started for a couple who've had two.
Yep, great, all right, that's it for us this week. Thank you so much for joining.
Us, Thanks for listening, everybody.
Bye for now. Hey, even though doctor pat is well a doctor, and we get lots of other doctors and other experts on our podcast. I just need to remind you that this podcast is for informational purposes only. We share lots of medical insights and experience, but everything we talk about is general in nature and may not apply to your specific situation. Please always consult with your own healthcare provider for your individual medical advice. When you grow your baby,