To conclude : take home message: Royal College of Obstetricians and Gynecologists (RCOG). The investigation and treatment of couples with recurrent first-trimester and second-trimester miscarriage.
Royal College of Obstetricians and Gynaecologists (RCOG). The investigation and treatment of couples with recurrent first-trimester and second-trimester miscarriage. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2011 Apr. 18 p. (Green-top guideline; no. 17). [124 references]
Guideline Status
this is the current release of the guideline.
This guideline updates a previous version: Royal College of Obstetricians and Gynaecologists (RCOG). The investigation and treatment of couples with recurrent miscarriage. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2003 May. 13 p. (Guideline; no. 17).
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Recurrent miscarriage, specifically:
• Three or more first-trimester miscarriages
• One or more second-trimester miscarriages
Guideline Category
on the investigation and treatment of couples with three or more first-trimester miscarriages or one or more second-trimester miscarriages
Target Population
Evaluation
1. Screening for antiphospholipid antibodies
2. Peripheral blood karyotyping
3. Screening for inherited Thrombophilia
4. Referral to a clinical geneticist
5. Cytogenetic analysis of the products of conception
Management/Treatment
1. Aspirin plus heparin therapy for antiphospholipid antibodies
2. Cervical cerclage (not recommended routinely)
3. Supportive care for women with unexplained recurrent miscarriage
Note: The following interventions were considered but not recommended: progesterone supplementation, human chorionic gonadotrophin supplementation, prepregnancy suppression of high luteinizing hormone (LH), metformin supplementation, steroid treatment, immunotherapy, serial sonographic surveillance, preimplantation genetic screening, uterine septum resection, routine TORCH (toxoplasmosis, other [congenital syphilis and viruses], rubella, cytomegalovirus, and herpes simplex virus) screening.
Major Outcomes Considered
• Miscarriage rate
• Incidence of abnormal parental karyotype
• Healthy live birth rate following miscarriagePrevalence of fetal chromosomal abnormality
• Perinatal survival after ultrasound-indicated cervical cerclage
• Maternal and fetal morbidity and mortality from treatments
Ba
1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias
1– Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2– Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal
3 Non-analytical studies, e.g., case reports, case series
4 Expert opinion
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Rating Scheme for the Strength of the Recommendations
Grades of Recommendations
A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++, and directly applicable to the target population; or
A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results.
B - A body of evidence including studies rated as 2++ directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
following discussion in the Guidelines Committee (GC), each Green-top guideline is formally peering reviewed. At the same time, the draft guideline is published on the Royal College of Obstetricians and Gynaecologists (RCOG) Web site for further peer discussion before final publication.
All comments will be collated by the RCOG and tabulated for consideration by the guideline leads. Each comment will require discussion. Where comments are rejected then justification will need to be made. Following this review, the document will be updated and the GC will then review the revised draft and the table of comments.