Description
Recurrent pregnancy loss (RPL), defined as two or more consecutive pregnancy losses, affects up to 5% of couples trying to conceive. A thorough diagnostic approach includes evaluation for genetic abnormalities, uterine anomalies, antiphospholipid syndrome, hormonal imbalances, and infections. Parental karyotyping, pelvic imaging, and hormonal assays are commonly used investigations. Management is tailored to the underlying cause—ranging from surgical correction of uterine defects to anticoagulation for thrombophilia's and hormonal support for luteal phase defects. In many cases, no specific cause is found, and empirical treatments or supportive care may be recommended. Multidisciplinary care and emotional support are crucial components of management.
Summary Listen
- Recurrent pregnancy loss (RPL) is defined as two or more consecutive pregnancy losses before 20 weeks gestation, affecting 1-5% of fertile couples. RPL can be primary, in women who have never had a live birth, or secondary, in women with prior live births. The etiology of RPL is idiopathic in 40-50% of cases, while the remaining 50% can be attributed to genetic, anatomic, endocrine, thrombophilic, immunologic, infectious, lifestyle, and environmental factors.
- Genetic factors in RPL include parental chromosome abnormalities, such as translocations and inversions, leading to unbalanced gametes and embryonic aneuploidy. Anatomic factors encompass congenital uterine anomalies like septate, bicornuate, and didelphys uteri, as well as acquired anomalies such as intrauterine adhesions (Asherman's syndrome), submucosal fibroids, and endometrial polyps.
- Endocrine factors contributing to RPL involve insufficient progesterone production, polycystic ovary syndrome (PCOS), thyroid disorders (overt or subclinical hypothyroidism, autoimmune thyroiditis), diabetes mellitus, and hyperprolactinemia. Thrombophilic factors include antiphospholipid syndrome (APS) and inherited thrombophilias like Factor V Leiden mutation and prothrombin gene mutation.
- Immunological factors, such as elevated natural killer (NK) cells, are controversially linked to RPL. Infectious factors, particularly chronic endometritis, are emerging as significant causes. Lifestyle and environmental factors, including advanced maternal age, obesity, smoking, alcohol intake, caffeine, and exposure to environmental toxins, also play a role.
- The diagnostic approach to RPL includes a detailed history, physical examination, and laboratory investigations. History taking should cover obstetric, medical, surgical, family, and lifestyle aspects. Physical examination involves a general and pelvic assessment. Laboratory investigations include genetic workup (parental karyotyping), thrombophilia screening (antiphospholipid antibodies), endocrine screening (thyroid, prolactin, HbA1c), and infectious screening (endometrial biopsy for chronic endometritis).
- Imaging studies, such as transvaginal ultrasound, saline infusion sonohysterography, hysterosalpingography, and hysteroscopy, are crucial for assessing uterine structure. Hysteroscopy is considered the gold standard for diagnosing and treating intrauterine pathologies. Management strategies are etiology-specific. Genetic factors may necessitate IVF with preimplantation genetic testing or donor gametes. Anatomic factors often require surgical correction.
- Endocrine factors are managed with levothyroxine for thyroid disorders, glycemic control for diabetes, metformin for PCOS, and dopamine agonists for hyperprolactinemia. Antiphospholipid syndrome requires aspirin and low molecular weight heparin (LMWH). In unexplained RPL, empirical treatments include low-dose aspirin and progesterone supplementation. Lifestyle modifications and psychological support are essential for all patients with RPL.
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About the Speakers
Dr Saima Asghar
Senior Registrar obs & gynae Gurayyat General Hospital Gurayyat KSA, Saudi Arabia
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