Pocket ObGyn – Recurrent Pregnancy Loss (RPI)
See Abbreviations
Definition (N Engl J Med 2010;363:1740)
- 3 or more consecutive Preg losses before 20 w gest; some recommend w/u after 2 consecutive losses, esp if age >35 yo or pt requests
Epidemiology & Etiology
- 1% of all couples attempting Increases in women <18 yo & >35 yo.
- Most very early (<10 w) miscarriages due to aneuploidy
- Autoimmune dz, anatomic abnormalities, & thrombophilias may lead to vascular insufficiency for developing conceptus, leading to miscarriage
Evaluation
- Determine actual gestational age at time of miscarriage rather than time of onset of sx if poss
- Ask about Hx of thrombosis or prev fetal death; Hx of prev Preg w/ breech presentation, dysmenorrhea, or menorrhagia (may suggest uterine anomaly or fibroids); chronic medical conditions such as thyroid dz, diabetes, or autoimmune dz such as lupus; smoking, obesity, EtOH use, caffeine use
Diagnostic Workup (Int J Gynaecol Obstet 2002;78:179)
- Parental karyotype for balanced Aneuploid karyotype of prior loss fetuses makes other causes less likely.
- Antiphospholipid Ab syn w/u: Lupus anticoagulant (RVVT and hexagonal phospholipid, or aPTT with mixing studies), b2 glycoprotein Ab (IgM/IgG), anticardiolipin Ab (IgM/IgG). Need 2 positive tests 12 w apart to make
- Consider thrombophilia w/u only if pt has a Hx of Test for Factor V Leiden, prothrombin G20210A mut, prot C, prot S, antithrombin III deficiency.
- Evaluate uterine cavity using HSG, hysteroscopy, sonohysterography, or transvaginal US
- No dx is made in 50% of cases of recurrent Preg loss (Fertil Steril 2012)
Treatment (N Engl J Med 2010;363:1740)
- If positive antiphospholipid antibodies, heparin 5000 U subcut twice daily & low-dose ASA can ¯ miscarriage Low-molecular-weight-heparin dose not established.
- If genetic abnormality such as balanced translocation present, up to 70% live birth w/o intervention, but may consider preimplantation genetic screening
- If uterine septum ® hysteroscopic Repair of bicornuate or unicornuate uterus not necessary as obstetric outcome often good & repair has higher risk.
- No rx for women w/ thrombophilias thus far has been found beneficial