Recurrent Pregnancy Loss

RECURRENT PREGNANCY LOSS ( recurrent miscarriage or habitual abortion)

Spontaneous pregnancy loss is a surprisingly common occurrence, with approximately 15% of all clinically recognized pregnancies resulting in pregnancy failure. Recurrent pregnancy loss (RPL) has been inconsistently defined. When defined as 2 or more  consecutive pregnancy losses prior to 20 weeks from the last menstrual period, it affects approximately 1% to 2% of women.

The majority of miscarriages are sporadic and most result from genetic causes that are greatly influenced by maternal age.

Recurrent pregnancy loss (RPL) is defined by two or more failed clinical pregnancies, and up to 50% of cases of RPL will not have a clearly identifiable cause.

Causes of RPL

These include parental chromosomal abnormalities, untreated hypothyroidism, Luteal phase defect (LPD), polycystic ovarian syndrome (PCOS) uncontrolled diabetes mellitus, certain uterine anatomic abnormalities,hyperprolactinemia  and antiphospholipid antibody syndrome (APS), systemic lupus erythematosis. Other probable or possible etiologies include additional endocrine disorders, heritable and/or acquired thrombophilias, immunologic abnormalities, infections (Listeria monocytogenes, Toxoplasma gondii, rubella, herpes simplex virus (HSV), measles, cytomegalovirus, and coxsackieviruses,mycoplasma, ureaplasma, Chlamydia trachomatis, L monocytogenes )  and environmental factors. approximately half of all cases will remain unexplained.

 Suggested diagnostic evaluation in RPL

• ANATOMIC CAUSES –  HSG, SSG, 2D/3D Ultrasound scan, hysteroscopy, laparoscopy
• ENDOCRINE CAUSES – Thyroid profile , testing for insulin resistance and diabetes, prolactin levels, ovarian reserve testing, antithyroid antibodies
• Infections – no evaluation recommended unless patient has evidence of chronic endometritis/cervicitis on examination, or is immunocompromised. The common tests include testing for TORCH INFECTIONS, tuberculosis and  cervical / vaginal swabs for culture.
• Autoimmune diseases – Tests for anticardiolipin antibodies, lupus anticoagulant, antiphospholipid antibodies, antinuclear antibodies.
• Genetic causes – test for karyotyping of couple
• Thrombophilias – Homocysteine, factor V leiden mutations, prothrombin promoter mutation, activated protein C and S resistance, MTHFR mutations , Beta 2 glycoprotein.

Management/ treatment of RPL

Management of RPL depends on the cause detected.