What is the management approach for recurrent pregnancy loss?

From the Guidelines

The management of recurrent pregnancy loss (RPL) should involve a comprehensive approach tailored to identified underlying causes, with a focus on antiphospholipid antibody testing, as recommended by the American College of Chest Physicians evidence-based clinical practice guidelines 1. The initial evaluation should include parental karyotyping, uterine cavity assessment, antiphospholipid antibody testing, and hormonal evaluation.

• For chromosomal abnormalities, genetic counseling and preimplantation genetic testing may be offered.
• Uterine anomalies often require surgical correction, with hysteroscopic resection for septate uteri or myomas.
• Antiphospholipid syndrome is treated with low-dose aspirin (81 mg daily) plus prophylactic heparin (either unfractionated heparin 5,000-10,000 units subcutaneously twice daily or enoxaparin 40 mg daily) starting when pregnancy is confirmed and continuing throughout pregnancy, as supported by recent studies 1.
• Hormonal imbalances like hypothyroidism require levothyroxine to maintain TSH below 2.5 mIU/L, while luteal phase defects may benefit from progesterone supplementation (vaginal progesterone 200 mg daily or intramuscular progesterone 50 mg daily) starting after ovulation until 10-12 weeks gestation. For unexplained RPL (approximately 50% of cases), supportive care with early and frequent prenatal visits, psychological support, and lifestyle modifications (smoking cessation, limiting caffeine and alcohol, maintaining healthy weight) is recommended, with empiric treatments like low-dose aspirin, progesterone supplementation, or tender loving care alone may be considered, as subsequent pregnancy success rates reach 70% even without specific interventions 1.

From the Research

Management Approach for Recurrent Pregnancy Loss

The management approach for recurrent pregnancy loss (RPL) involves a thorough evaluation and evidence-based treatment strategies. Key aspects of management include:

• Evaluation of the patient's medical history and screening for antiphospholipid syndrome and anatomical abnormalities of the uterus 2
• Investigation of the causes of RPL, which may include genetic, hormonal, and immunological factors 3, 4
• Treatment of underlying conditions, such as antiphospholipid syndrome, with low-dose aspirin and heparin 2, 5
• Genetic counseling for patients with abnormal parental karyotype 2
• Management of cervical insufficiency based on the patient's reproductive history 2

Treatment Options

Treatment options for RPL may include:

• Low-dose aspirin and heparin for patients with antiphospholipid syndrome 2, 5
• Levothyroxine for patients with overt hypothyroidism 2
• Progesterone supplementation for patients with unexplained RPL 2
• Surgical repair of congenital and acquired uterine anomalies 2

Challenges and Future Directions

Despite advances in the management of RPL, there are still challenges and uncertainties in the field, including:

• The lack of a universally accepted definition of RPL 3
• The heterogeneity of definitions and criteria used in international guidelines 3
• The need for further research on the etiology and risk factors of RPL, particularly idiopathic cases 3, 4
• The importance of developing consistent international practice protocols for the investigation and management of RPL 2