Recurrent Pregnancy Loss

Recurrent pregnancy loss is classically defined as the occurrence of three or more consecutive pregnancy loss; however, the American Society of Reproductive Medicine (ASRM) has recently redefined recurrent pregnancy loss as two or more pregnancy losses.

A pregnancy loss is defined as a clinically-recognized pregnancy involuntarily ending before 20 weeks. A clinically-recognized pregnancy means that the pregnancy has been visualized on an ultrasound or that pregnancy tissue was identified after a pregnancy loss.

First, a physician will take a detailed medical, surgical, family, and genetic history and perform a physical examination. Testing that may be done includes karyotype analysis of both partners. The karyotype is the chromosomal, or genetic, make-up of a person. The purpose is to find abnormalities in the parents that could be passed on to the offspring, resulting in miscarriage. Because karyotype abnormalities are relatively rare, a doctor may choose to not perform this test unless other, more common, abnormalities are ruled out.

The uterus (the womb) and the uterine cavity (inside of the womb) will often be evaluated. There are several ways to evaluate the uterine cavity, including a/an ultrasound, saline ultrasound, hysterosalpingogram X-ray, MRI (magnetic resonance imaging), and/or hysteroscopy (to look inside the uterus). An ultrasound is often done as a first test. The ultrasound can give information about the shape of the uterus and the presence of fibroids (benign round muscle tumors). A saline ultrasound is when fluid is injected into the inside of the uterus so that the physician can see if there are abnormalities with the inside of the uterus, including polyps (growths of the lining of the uterus), fibroids, or scarring. A hysterosalpingogram is an X-ray of the uterus and tubes, and can help a doctor to evaluate not only the inside of the uterus, but also the tubes (whether they are open or not). A hysteroscopy is a minor surgical procedure where a camera is placed through the cervix into the uterus so that the doctor can directly visualize the inside of the uterus. The doctor can also remove polyps and fibroids and can resect a septum or scar tissue, if present. A uterine septum is an abnormality of the shape of the uterus that a woman has since birth. An MRI may be done to evaluate the location of fibroids and in cases of abnormalities of the shape of a uterus.

Antiphospholipid antibodies, particularly anticardiolipin antibody and lupus anticoagulant, will likely be checked. These antibodies are related to the antiphospholipid syndrome, which may be related to pregnancy loss.

Any woman with a pregnancy loss at or beyond the 10th week of gestation (with a “normal” appearing fetus) or with 3 recurrent losses at any gestational age should be screened, according to the American College of Obstetrics and Gynecology (ACOG).

Testing for inherited thrombophilias, or abnormally increased blood clotting, is not routinely recommended in women who have experienced recurrent fetal loss because studies have not shown a benefit of giving medicine to prevent clots in these patients.

However, testing for abnormal blood clotting should be done if there is a personal history of blood clots associated with risk factors such as surgery, bone fractures, or prolonged immobilization, or if a patient has a parent or sibling with a disorder of excessive blood clotting.

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