2+
ACOG and ASRM
Recurrent pregnancy loss is two or more pregnancy losses. ASRM includes pregnancies confirmed by urine or blood testing, not only ultrasound.
Patient guide · Pregnancy after loss
Your history is the map for this pregnancy
The number of losses matters. The story of each loss tells us more.
ListenRebuild each pregnancy timeline
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Find the patternSeparate early, cervical, placental, genetic, and unexplained pathways
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Build your planChoose care that matches your history
OpenMFM patient education · Evidence reviewed September 1, 2026
Start with the definition
Definitions differ. Care should not wait.
3+
Some international guidance
RCOG uses three or more early miscarriages, while allowing evaluation sooner when the pattern raises concern.
After two losses, ask for a structured review of your history and prior testing.
Release the blame
Most miscarriages are not caused by something you did
Not
your fault.
your fault.
ordinary exerciseworksexstressan argument
Many early losses happen because of a chance chromosome difference in the pregnancy.
Timing changes the questions
One pregnancy timeline can reveal different pathways
Positive test onlyVery early or biochemical loss
Early ultrasound lossLocation, heartbeat, and chromosomes may matter
Painless opening / PPROMReview the cervix and preterm-birth pathway
Placental diseasePreeclampsia, growth restriction, or abruption
Later fetal deathPlacenta, genetics, infection, and maternal disease review
These experiences may share the word “loss,” but they do not automatically share the same cause or care plan.
Build the phenotype
For each loss, gather the same eight facts
01DateYear or approximate date
02Gestational ageHow many weeks?
03LocationWas it seen inside the uterus?
04HeartbeatWas cardiac activity documented?
05PatternBleeding, missed loss, painless dilation, PPROM, or placental disease
06ManagementPassed naturally, medication, procedure, or delivery
07TestingPathology, chromosome, or placental results
08ContextConception method, partner, and fetal findings
Records beat recollection
Bring the records that can change the plan
One organized
pregnancy history
pregnancy history
Ultrasound and emergency reports
Procedure and operative notes
Pregnancy-tissue chromosome results
Placental pathology
APS laboratory results with dates
Uterine imaging and prior consultation notes
Getting the original results can prevent duplicate testing and incorrect assumptions.
Test with a purpose
The evaluation is targeted, not an “everything panel”
Can change care
Pregnancy-tissue chromosome testingClarifies whether aneuploidy explains a loss
Uterine-cavity evaluationSaline ultrasound, HSG, hysteroscopy, or selected imaging
APS antibodiesWhen the clinical history meets testing criteria
TSH and A1cWhen history, symptoms, risk factors, or tissue results support testing
Parental chromosomesSelected situations, especially structural rearrangement or absent tissue testing
Not routine RPL testing
Inherited thrombophilia panelsNot recommended without a separate clot-risk indication
Broad immune testingANA, NK-cell, HLA, and similar panels do not define standard RPL care
Microbiome add-onsNot established as routine evaluation
Endometrial receptivity testingDoes not explain most recurrent losses
Ovarian reserve testingNot routinely recommended for RPL alone
Antiphospholipid syndrome
APS matters because a confirmed diagnosis changes treatment
Key 1
Clinical history
Specific pregnancy complications or a personal thrombosis history
＋
Key 2
Persistent antibodies
The correct antibody panel, confirmed over time when positive
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Specialist treatment pathway
Confirmed obstetric APS may be treated with low-dose aspirin plus heparin during pregnancy.
Empiric anticoagulation does not improve unexplained RPL.
Treat what is real and actionable
Thyroid disease and diabetes matter when they are present
Thyroid
Overt hypothyroidism should be treated. Testing is guided by the loss history, symptoms, prior tissue results, and clinical risk.
Glucose
Uncontrolled diabetes increases pregnancy risk. A1c or early glucose review is targeted to people with diabetes or relevant risk factors.
The goal is control of a documented condition, not treatment of a laboratory label in isolation.
A different pathway
Painless second-trimester loss needs a cervical-history review
History signal
Painless opening, PPROM, or prior cervical procedure
Tell your team exactly what happened and whether contractions or infection were present.
12–14 weeks
History-based discussion
A classic history may lead to a planned cerclage discussion.
16–24 weeks
Cervical-length pathway
Other histories may lead to serial transvaginal cervical-length measurement.
If shortened
Individualized action
Progesterone, cerclage, or continued observation depends on history, length, dilation, and pregnancy type.
Important:
A second-trimester loss is not automatically cervical insufficiency. The clinical pattern matters.
The first weeks
Early care should confirm location, dating, and viability
01
Inside the uterus?
Early ultrasound helps confirm location and assess ectopic-pregnancy risk.
02
How far along?
Reliable dating makes every later comparison more meaningful.
03
What can we see today?
Follow-up timing should allow enough interval for a clear answer and avoid premature conclusions.
A planned reassurance schedule should reduce uncertainty, not create a cycle of scans that are too early to interpret.
Pregnancy after loss is emotionally different
Support is a component of care, not an extra
You and this pregnancy
Clear scan plan
MFM access
Mental-health support
Partner / support person
Call and warning-sign plan
Anxiety, grief, sleep disruption, and prior-loss trauma deserve direct screening and a named support plan.
Right patient · Right moment
Progesterone helps a specific group, not everyone
Prior miscarriage
One or more previous losses
＋
Bleeding now
Bleeding in the current early pregnancy, with clinician and ultrasound review
At this intersection: vaginal micronized progesterone may be offered or considered under the selected guideline.
Routine progesterone has not shown benefit for every patient with asymptomatic unexplained RPL.
Medication needs an indication
Aspirin and heparin are not universal miscarriage treatments
Aspirin + heparin
This combination is used for confirmed APS under specialist care.
Indication: a defined APS pathway
Low-dose aspirin alone
May be recommended for preeclampsia prevention when standard high-risk or combined moderate-risk factors are present.
Indication: preeclampsia-risk criteria
Recurrent loss alone is not a reason to self-start aspirin, heparin, or LMWH.
Build care in modules
Later monitoring follows the risks you actually have
Base for every pregnancy: routine prenatal visits + anatomy ultrasound + symptom education
Add modules when the history or current pregnancy provides a reason ↓
Cervical lengthCervical or spontaneous-preterm-birth pathway
Growth scansAPS, hypertension, diabetes, prior FGR, or current concern
DopplerWhen fetal growth restriction or placental disease is present
NST / BPPWhen maternal or fetal risk meets testing criteria
Delivery timingDriven by current maternal and fetal indications
Unexplained RPL alone does not automatically require every test or early delivery.
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Questions to ask your MFM specialist
1What pattern do you see across my prior losses?
2Which original records should we obtain?
3Which parts of an RPL evaluation are complete, and what would still change care?
4What is our early ultrasound and reassurance plan?
5Does my history support APS, cervical, genetic, uterine, thyroid, or diabetes evaluation?
6Why is each medication recommended for me?
7What symptoms should prompt an urgent call or emergency evaluation?
8What later monitoring will be added, and what specific risk triggers it?
9How can I reach the team when anxiety or symptoms escalate?
10What mental-health or pregnancy-loss support is available?
What to remember
Your plan should be specific, evidence-based, and kind
Your story
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Your pattern
→
Your care plan
More than half of recurrent loss remains unexplained. Even then, future live birth is common, and care can still be purposeful.
Known
- History phenotype guides evaluation.
- Confirmed APS, overt thyroid disease, and uncontrolled diabetes change treatment.
- Support belongs in care.
Uncertain
- The cause of many losses
- The best scan frequency for every patient
- Benefit of several add-on tests and treatments
Individualized
- Early reassurance schedule
- Cervical and placental surveillance
- Medication and delivery planning
Educational disclaimer. This presentation supports informed discussion. It does not diagnose a cause, prescribe treatment, or replace care from your obstetric and MFM team.
Privacy. No patient information is collected by this deck. Examples are general and contain no protected health information.