Australasian Recurrent Pregnancy Loss Clinical Management Guideline 2024 Part I
RANZCOG-affiliated Australasian guidelin… · 2024 · Australia
Source and licence
- Authors
- Adriana Suker, Ying Li, Danielle Robson et al.
- Title
- Australasian Recurrent Pregnancy Loss Clinical Management Guideline 2024 Part I
- Journal
- The Australian & New Zealand Journal of Obstetrics & Gynaecology, 2024
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC11660023
Licence statement of the original publication
This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
MATERIALS AND METHODS
- RPL is defined by at least two clinical pregnancy losses prior to 20 weeks gestationLevel of evidence Grade of consensus: GPP Consensus grade β
- Women with RPL should be managed by a medical practitioner with the necessary skill set, expertise, and where available multi‐disciplinary supportLevel of evidence Grade of consensus: GPP Consensus grade α
Management
- Parental genetic abnormalities may be implicated in the aetiology of recurrent pregnancy lossLevel of evidence Grade of consensus: Level III evidence Consensus grade α
- A detailed family history including consanguinity noting subfertility, stillbirths, miscarriages, neonatal deaths, disability or congenital anomalies is indicated in couples with recurrent pregnancy lossLevel of evidence Grade of consensus: GPP Consensus grade α
- Karyotyping of both partners is indicated in couples with recurrent pregnancy lossLevel of evidence Grade of consensus: GPP Consensus grade α
- Chromosomal assessment (via an array‐based technology) of products of conception should be offered in a subsequent pregnancy lossLevel of evidence Grade of consensus: GPP Consensus grade α
- When a parental karyotypic abnormality is identified genetic counselling should be offeredLevel of evidence Grade of consensus: GPP Consensus grade α
- When parental karyotypic abnormality is identified preimplantation genetic testing (PGT) should be offeredLevel of evidence Grade of consensus: GPP Consensus grade α
- A discussion detailing the relative merits of PGT as a means to increase the probability of a successful pregnancy may be of valueLevel of evidence Grade of consensus: Level II evidence Consensus grade β
Intrauterine adhesions
- Müllerian anomalies are associated with an increase in recurrent first trimester pregnancy lossLevel of evidence Grade of consensus: Level III‐2 Consensus grade β
- Combined hysteroscopy and laparoscopy remains the gold standard for the investigation of Müllerian anomaliesLevel of evidence Grade of consensus: GPP Consensus grade α
- Sonohysterogram in combination with two‐dimensional ultrasound OR three‐dimensional ultrasound has a high sensitivity and specificity. As such, this would be an appropriate first‐line investigationLevel of evidence Grade of consensus: Level III‐3 Consensus grade α
- Hysterosalpingogram is no longer a first‐line investigation as it gives no information about the fundal contour of the uterus, and also gives no information about other important aspects in fertility such as antral follicle count. It additionally exposes patients to radiationLevel of evidence Grade of consensus: GPP Consensus grade α
- The evidence that resection of the uterine septum reduces recurrent pregnancy loss is uncertainLevel of evidence Grade of consensus: Level II Consensus grade α
- However, the ACCEPT group believe that it is reasonable for hysteroscopic septum resection to be offered after appropriate counselling and discussion of risks and benefitsLevel of evidence Grade of consensus: GPP Consensus grade α
- Evidence for surgical correction of other uterine anomalies is poorLevel of evidence Grade of consensus: Level III‐3 Consensus grade α
Thyroid autoimmwunity (TAI)
- In women with RPL, thyroid function tests (TSH and FT4) and thyroid antibodies (TPO and Tg) should be measured In the absence of population‐based reference ranges, a TSH ≥4.0 mIU/L should be considered abnormal If TSH is low/suppressed, then FT3 and TRAb should also be performedLevel of evidence Grade of consensus: GPP Consensus grade α
- There is strong evidence that overt hypothyroidism or overt hyperthyroidism is associated with (R)PL Women with RPL with overt hypothryoidism or overt hyperthyroidism should be investigated and treated according to accepted guidelines 47Level of evidence Grade of consensus: Level I to III‐3 Consensus grade α
- There is weak evidence that subclinical hypothyroidism (TSH ≥4.0 mIU/L; normal FT4/3; regardless of antibody status) is associated with RPL While the evidence for treatment with levothyroxine is weak, treatment in women with a TSH ≥4.0 mIU/L with an aim of reducing TSH to euthyroid levels is low risk and may reduce the risk of further lossLevel of evidence Grade of consensus: Level III‐3 Consensus grade α
- There is weak evidence that a euthyroid but antibody‐positive state is associated with RPL. Two management strategies are suggested: a. Monitor TFTs every four weeks during pregnancy until mid‐gestation, and treat with levothyroxine if TSH ≥4.0 mIU/L b. Commence low‐dose levothyroxine (25–50 μg PO in the morning) with an aim of maintaining TSH <4.0 mIU/LLevel of evidence Grade of consensus: Level III‐3 Consensus grade β
Management
- It is unclear if hyperprolactinaemia is implicated in RPLLevel of evidence Grade of consensus: Level IV Consensus grade α
- Women with RPL should have prolactin levels obtained when there is clinical suspicion of hyperprolactinaemiaLevel of evidence Grade of consensus: Good practice principle (GPP) Consensus grade α
- For women with hyperprolactinaemia, consultation with an endocrinologist should be consideredLevel of evidence Grade of consensus: GPP Consensus grade α
- There is WEAK evidence to suggest treating hyperprolactinaemia may improve live birth rateLevel of evidence Grade of consensus: Level II Consensus grade α
Polycystic ovarian syndrome (PCOS)
- PCOS may be associated with pregnancy lossLevel of evidence Grade of consensus: Level IV Consensus grade α
- The management of PCOS needs to be individualised but may include non‐pharmacological measures (such as diet and lifestyle interventions) and pharmacological measures (such as metformin)Level of evidence Grade of consensus: GPP Consensus grade α
Management
- Obesity is associated with RPLLevel of evidence Grade of consensus: Level III‐2 Consensus grade α
- Individuals should be encouraged to achieve and maintain a normal body mass index, through weight loss interventions such as diet and exerciseLevel of evidence Grade of consensus: Good practice principle Consensus grade α
- There is some (weak) evidence to suggest weight loss can improve live birth ratesLevel of evidence Grade of consensus: Level I Consensus grade α
- There is conflicting evidence regarding whether glucose intolerance is associated with RPLLevel of evidence Grade of consensus: Level III‐2 Consensus grade α
- Glucose intolerance should be screened with a fBGL and glycated haemoglobin (HbA1c). Consider a formal 75 g oGTT if either parameter is abnormal. If the 75 g oGTT is abnormal, referral to an endocrinologist is indicatedLevel of evidence Grade of consensus: GPP Consensus grade α
- Glucose impairment should be managed for general health benefits, and may also improve live birth rates in the context of RPLLevel of evidence Grade of consensus: GPP Consensus grade α
- The association between progesterone and RPL is uncertainLevel of evidence Grade of consensus: Level I Consensus grade α
- Progesterone supplementation should be individualised If supplementing progesterone, progesterone and not progestins should be used The exact dose is uncertain; however, based on the PROMISE and PRISM trials, 400 mg twice daily per vagina is recommended Supplementation is recommended in women with ≥2 pregnancy losses especially in the setting of a threatened miscarriageLevel of evidence Grade of consensus: Level II Consensus grade α
Abstract
Guidelines for the investigation and management of recurrent pregnancy loss (RPL) have been developed in Europe, USA and UK, but there is currently no Australasian guideline. The Australasian Certificate of Reproductive Endocrinology and Infertility Consensus Expert Panel on Trial Evidence group has prepared a two‐part guideline to provide guidance on the management of RPL. In Part I chromosomal, anatomical, and endocrine factors are outlined along with relevant recommendations for clinical management, levels of evidence and grades of consensus. In Part II thrombophilia, autoimmune factors, infective, inflammatory, and endometrial causes, environmental and lifestyle factors, male factor and unexplained causes will be outlined.
Contents of the original publication
The section headings of the original.
- INTRODUCTION
- MATERIALS AND METHODS
- RESULTS
- Chromosomal factors
- Anatomical factors
- Endocrine Factors
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