The ASK TEAMS approach: a systematic way to investigate couples with recurrent miscarriages

Abstract

Introduction: Miscarriages are one of the commonest reasons that women in their reproductive years present to an Emergency Department, and they account for a large proportion of admissions, procedures, and morbidity of such patients. While a single miscarriage occurring in 15-20% of all clinically recognized pregnancies may be an isolated event for most women, recurrent pregnancy losses (RPL) account for 1-4% of all losses and are a separate clinical entity. Most recurrent miscarriage clinics now divide miscarriages according to gestational age, with those less than or equal to ten weeks termed embryonic losses, and those from ten to twenty weeks as fetal losses, instead of the original first or second trimester losses. It is a frustrating situation both for the Couples suffering the losses, and for their Physicians, given the lack of good quality evidence regarding the management of these couples. Recurrent pregnancy loss is seldom due to a single pathogenic factor, and most have a multifactorial background, involving multiple genetic and environmental risk factors. In a dedicated recurrent miscarriage clinic, the aim was to develop an evidencebased diagnostic pathway for this group of women presenting with recurrent miscarriages. Methods: A detailed history was obtained, and the diagnostic testing eventually led to the “ASK TEAMS” approach to identify potential issues that could lead to patient specific, safe and effective interventions. The “ASK TEAMS” approach is as follows: A Age: Patients were offered an Anti Müllerian Hormone test as part of the work up; S Structure: Patients were offered a luteal phase 3D ultrasound for assessment of the pelvis and uterus; K Karyotype: Miscarriage products were sent for karyotyping. Parental Karyotyping was restricted to those in whom a translocation had been detected in the products of conception; T Thrombophilia: Screening for hereditary thrombophilias was restricted to those with a strong personal or family history of venous thromboembolism; E Endocrine: All patients were offered thyroid function tests, a 75g oral glucose tolerance test (OGTT) including insulin levels; A Autoimmune: Antibody tests included thyroid peroxidase antibodies (TPO), anti-thyroid receptor antibodies (ATA), antinuclear antibody (ANA) titres. The antiphospholipid syndrome antibodies were also included; M Metabolic: OGTT and Insulin studies, and patients also had fasting circulating homocysteine concentration quantified; S Specific: Vitamin D, B12 and folate studies were performed. Male partners were also tested for factors thought to contribute to sperm DNA damage, which may contribute to early miscarriages. Results While many of the findings were consistent with those of recurrent miscarriage clinics world-wide, some novel observations were made: a) AMH levels were found to be significantly lower than in a normal population; b) Women with raised fasting or two-hour insulin levels had an increased risk of gestational diabetes in a subsequent pregnancy; c) Low vitamin D levels were significantly associated with hyperinsulinism in miscarriage patients. Conclusions: The ASK TEAMS approach to investigations in an RPL Clinic facilitates a consistent work-up. Tests are adjusted as evidence accumulates regarding miscarriage causes/associations. Live birth rates are excellent following this approach