Doing enough without doing everything: evidence-based management of recurrent first-trimester miscarriage in resource-limited settings

Recurrent first-trimester miscarriage is a common but difficult problem in obstetric and gynaecological practice. The difficulty is greater in resource-limited settings, where genetic testing, specialised coagulation assays and advanced imaging may be unavailable or unaffordable. This narrative review examines a practical question: which investigations and treatments are sufficiently useful to justify their cost and burden in women with recurrent early pregnancy loss? A focused literature search of PubMed/MEDLINE, the Cochrane Library and major professional guidelines was updated to October 2026. The evidence supports a careful reproductive and medical history, assessment of maternal age and modifiable risk factors, evaluation of uterine anatomy, thyroid function testing and appropriately prioritised testing for antiphospholipid syndrome. Glycaemic assessment should be risk-directed. Genetic analysis of miscarriage tissue is informative when available, but routine inherited thrombophilia, natural-killer-cell, broad immunological and infection screening have limited first-line value. Folic acid remains appropriate preconception care but is not a specific treatment for recurrent miscarriage. Aspirin and heparin should principally be used for appropriately diagnosed antiphospholipid syndrome. Vaginal micronized progesterone has the clearest evidence in women with previous miscarriage who develop bleeding in a subsequent intrauterine pregnancy; evidence for routine progestogen use in otherwise unexplained recurrent miscarriage is weaker. Routine prednisolone is not supported. Resource limitation should therefore favour selective investigation, cause-directed treatment and structured early-pregnancy supportive care.