Recurrent pregnancy loss — structured oral station (12 minutes)

Opening prompt — "Take a focused history from her."

Model response — build a pregnancy timeline before you order anything: ^[1][5]

• For each pregnancy: the gestation, whether it was confirmed intrauterine, whether a fetal heart was ever seen, how it ended, and whether tissue was examined. Sequence matters for the prognosis.^[1]
• Ask about the pattern: a fetal death at or after 10 weeks, or severe early preeclampsia before 34 weeks, points toward antiphospholipid syndrome; a painless mid-trimester loss with a live fetus points toward cervical insufficiency rather than recurrent early loss.^[3]
• The partner: paternal age, smoking, alcohol, weight — ESHRE 2023 upgraded the male assessment to a recommendation.^[1]
• Acknowledge her folder and her reading. Say you will go through her list with her. Refusing her tests without explaining loses the consultation.^[5]

Probe 1 — "Which tests will you order, and which will you refuse?"

• "Four tests are routinely recommended: lupus anticoagulant, anticardiolipin antibodies, thyroid function with thyroid peroxidase antibodies, and a 3D pelvic ultrasound."^[21]
• "I will not order inherited thrombophilia testing — ALIFE2 showed heparin does not help and advises against screening. I will not measure natural killer cells, cytokines or HLA typing — no evidence of benefit, and false positives cause anxiety. And I will not routinely test vitamin D or ovarian reserve."^[1][4]
• "For the natural killer cell test she brought: I would explain what it measures and why it is not routinely recommended — there is no validated biomarker for immune-mediated loss — and what we will do instead."^[1][21]

Probe 2 — "Her lupus anticoagulant is positive. What now?"

• "I will not diagnose antiphospholipid syndrome on one result. The laboratory criterion requires the antibody to be present on two or more occasions at least 12 weeks apart — so I repeat it at least 12 weeks later, confirming the timing with the laboratory."^[3][21][22]
• "If it is confirmed, with a clinical criterion met, the treatment is aspirin 75 to 150 mg daily started before or at the positive pregnancy test, plus low-molecular-weight heparin from the positive test continued to at least 34 weeks — a strong recommendation on moderate evidence."^[21]

Probe 3 — "She asks about progesterone for the next pregnancy."

• "Progesterone is not for a history of losses alone. PROMISE gave first-trimester micronised vaginal progesterone to women with unexplained recurrent miscarriage and found no benefit — live birth 65.8 per cent versus 63.3 per cent."^[16]
• "But if she bleeds in the next pregnancy, the subgroup of women with previous loss and current bleeding showed a benefit. RANZCOG then recommends micronised vaginal progesterone 400 mg twice daily to 16 weeks. The indication is bleeding plus previous losses, not history alone."^[1][21]

Probe 4 — "Tell her about the prognosis."

• "Most couples in her situation go on to have a baby — in PROMISE, nearly two-thirds of women with unexplained loss had a live birth on placebo. After a full workup, many have no identified cause — and that is the expected result, not a failure. The prognosis is based on her age and her complete pregnancy history, not the loss count alone."^[1][5][16]
• "The next pregnancy is the treatment: an early reassurance scan, progesterone if she bleeds, antiphospholipid treatment if confirmed, a named clinician, and a defined route back into the service. Continuity of care in a dedicated clinic is the plan."^[1][5]

Probe 5 — "She asks when to stop trying."

• "I would discuss donor gametes, surrogacy and adoption honestly and early, not after a fifth loss — but the conversation is hers to lead, and unexplained loss still ends in live birth more often than not in trials."^[1][16]