Quantitative assessment of pregnancy outcome following recurrent miscarriage clinic care: a prospective cohort study

Abstract

AbstractObjectivesTo measure pregnancy outcome following attendance at a recurrent miscarriage service and identify factors that influence outcome.DesignProspective, observational electronic cohort study.SettingParticipants attending specialist recurrent miscarriage clinic, within a tertiary centre, with a history of two or more pregnancy losses. The clinic serves a diverse population (33% of residents belong in a minority ethnic group and over 33% in low-income households). Participant data were recorded on a bespoke study database, ‘Tommy’s Net’.Participants777 women consented to participate. 639 (82%) women continued within the cohort, and 138 were lost to follow up. Mean age of active participants was 34 years for women and 37 years for partners, with a mean of 3.5 (1-19) previous pregnancy losses. Rates of obesity, BMI>30 (maternal: 23.8%, paternal: 22.4%), smoking (maternal:7.4%, paternal: 19.4%) and alcohol consumption (maternal: 50%, paternal: 79.2%) were high and 55% of participants were not taking folic acid.Outcome measuresBiannual collection of pregnancy outcomes (ongoing pregnancy, live birth, still birth, pregnancy loss prior to 24 weeks), either through prompted self-reporting, or existing hospital systems.Results639 (82%) women were followed up. 404 reported conception and 106 reported no pregnancy, at least 6 months following registration. Of those that conceived, 72.8% (294/404) had a viable pregnancy. Analysis identified a conception of rate of over 80% and viable pregnancy rate of 60% two years after attending the recurrent miscarriage clinic. 30% of couples had potentially modifiable risk factors for miscarriage.ConclusionsTommy’s Net provides a secure electronic repository on data for couples with recurrent pregnancy loss and associated outcomes. The study identified that subfertility, as well as repeated miscarriage, contributed to failure to achieve live birth. Study findings can enable comparison of clinic management strategies and inform the development of a personalized holistic care package.FunderTommy’s CharitySponsorUniversity Hospitals Coventry and Warwickshire (UHCW) NHS TrustTrial RegistrationInternational Standard Randomized Controlled Trial Number (ISRCTN) Registry ISRCTN17732518; https://doi.org/10.1186/ISRCTN17732518EthicsApproval from West Midlands-South Birmingham Regional Ethics Committee IRAS No: 213740, 2225751 REC Ref: 17/WM/0050: 17/WM/208Strengths and Limitations of this study (related to the method)The ‘Tommy’s Net’ e-repository and associated database contains baseline and prospective pregnancy outcome data from the largest known population of couples with recurrent miscarriage in the UK.Time to conception and viable pregnancy can be calculated from this data using time to event analysis.Obtaining follow up data is challenging but can be improved by using a variety of data collection methods.Follow up data is only requested biannually, therefore this is an inevitable lag in data collection.Limited use of the English language can be a barrier for participants completing the initial lengthy questionnaire.Key points20% of this recurrent miscarriage population do not conceive and two years after first consultation 40% have not had a viable pregnancy. Early identification of this group could help facilitate early referral to fertility services or targeted research.Miscarriage is physically and psychologically challenging. Some couples may decide not to try to conceive again because of this. Ensuring appropriate psychological support is essential.Preconception care is inadequate. Over one third of couples attend their initial consultation with modifiable risk factors known to impact on miscarriage. Tackling these should be a priority.Having a BMI over 30 and being a smoker is more common within this cohort in women that do not conceive. Targeting of these risk factors may improve conception rate.