Treatment Options for Recurrent Pregnancy Loss
Patients with recurrent pregnancy loss should undergo comprehensive evaluation for underlying causes, followed by targeted treatment based on identified factors, including thrombophilias, anatomical abnormalities, endocrine disorders, and genetic factors.
Diagnostic Evaluation
- Initial screening should include transvaginal ultrasound (TVUS) to identify uterine cavity abnormalities, with sonohysterography (SIS) for better assessment of the uterine cavity 1
- Screening for antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibodies) is recommended for women with three or more early pregnancy losses 2, 3
- Thyroid function testing is essential as thyroid dysfunction can contribute to pregnancy loss 1, 3
- Karyotype analysis of both partners should be considered to identify chromosomal abnormalities 4, 5
- Evaluation for thrombophilias may be indicated, particularly in women with second-trimester losses 2
- Male partners should be evaluated in couples with two or more pregnancy losses, including consideration of karyotype and sperm DNA fragmentation testing 1, 4
Treatment Based on Specific Causes
Thrombophilias and Antiphospholipid Syndrome
- For women with antiphospholipid syndrome, combination therapy with low-dose aspirin and heparin is recommended 2, 6, 3
- For women with homozygous factor V Leiden or prothrombin 20210A mutation with positive family history for VTE, antepartum prophylaxis with prophylactic or intermediate-dose LMWH is recommended 2, 1, 7
- For women with other thrombophilias and no prior VTE who have a positive family history for VTE, postpartum prophylaxis with prophylactic or intermediate-dose LMWH is suggested 2
Endocrine Disorders
- Optimization of thyroid function is recommended for women with thyroid dysfunction 1, 3
- Regular monitoring for gestational diabetes in current pregnancies is recommended 1
- Management of polycystic ovary syndrome (PCOS) may be beneficial as it is associated with higher rates of pregnancy loss 4
Anatomical Abnormalities
- Surgical correction of significant uterine anomalies, intrauterine synechiae, or cervical incompetence should be considered 4, 8
Unexplained Recurrent Pregnancy Loss
- For women with unexplained recurrent pregnancy loss, first trimester progesterone administration should be considered 3
- Early and regular ultrasound monitoring in subsequent pregnancies is recommended 1, 4
- Supportive care ("tender loving care") with regular monitoring, including serial ultrasonography in the first trimester of pregnancy 8, 9
Management During Subsequent Pregnancies
- Confirm viable intrauterine pregnancy with early ultrasound 4
- Regular prenatal visits with serial ultrasound monitoring 1, 4
- Monitor for and promptly treat any endocrine conditions, such as thyroid dysfunction and gestational diabetes 1
- For women with antiphospholipid syndrome, continue aspirin and heparin throughout pregnancy 6, 3
Lifestyle Modifications
- Regular physical activity within guidelines is recommended as it may benefit factors that increase miscarriage risk, such as insulin resistance and obesity 1, 4
- Avoiding smoking, alcohol, and recreational drugs 1
- Maintaining good nutrition 1
Important Considerations and Caveats
- Approximately 55% of recurrent miscarriages may be caused by procoagulant defects that induce thrombosis and infarction of placental vessels 6
- Despite thorough investigation, the etiology remains unknown in over half of all cases 5, 8
- Mental health support should be incorporated into the care pathway for couples with a history of recurrent miscarriage 3
- Future obstetric risks, including preterm birth, fetal growth restriction, and stillbirth, should be monitored in subsequent pregnancies 3
- The recurrence risk of placenta accreta spectrum is high (28.6%) in women with a history of this condition 2