GPAtlas🧭 When to suspect (and when to refer)
Miscarriage is the loss of an intrauterine pregnancy before 24 weeks. Recurrent miscarriage is defined by the Royal College of Obstetricians and Gynaecologists (RCOG) as three or more first-trimester miscarriages, or one or more second-trimester miscarriages. Losses do not need to be consecutive, and do not need to have been with the same partner.
The two strongest risk factors are advancing maternal age and the number of previous losses. Investigation may reasonably be considered after two first-trimester losses where pathology is suspected – for example a previous loss with a normal fetal karyotype, in women over 35, or after a long time to conceive. The single most important treatable cause to identify is antiphospholipid syndrome (APS).
Two facts should frame every consultation. First, around half of all recurrent miscarriages remain unexplained even after a full work-up. Second, the prognosis is genuinely reassuring – even when no cause is found, roughly 65–75% of couples go on to a successful pregnancy. UK care is shifting away from the old “three-miscarriage wait” towards a graded model that offers escalating support after every loss.
| Presentation | Action in primary care (graded model) |
|---|---|
| 1 first-trimester miscarriage | Information, risk-factor advice and emotional support; signpost support services; advise on progesterone in a future pregnancy if bleeding occurs. |
| 2 first-trimester miscarriages | As above, plus consider initial bloods (full blood count [FBC], thyroid function) and refer if risk features (age > 35, subfertility, second-trimester loss, abnormal scan); offer an early reassurance scan next pregnancy. |
| ≥ 3 first-trimester miscarriages | Refer to a dedicated recurrent miscarriage clinic for full, consultant-led investigation. |
| Any second-trimester miscarriage (from 13 weeks) | Refer after a single event – investigate for cervical insufficiency and thrombophilia. |
Source: RCOG Green-top Guideline No. 17 · NICE NG126
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