From the Guidelines
The most appropriate next step in management of this patient's recurrent pregnancy loss is to perform a hysteroscopic resection of the submucosal fibroid. This 35-year-old woman has experienced three first-trimester spontaneous abortions within the past year, and her evaluation has revealed a 2-cm submucosal fibroid at the uterine fundus. Submucosal fibroids can distort the uterine cavity and interfere with embryo implantation or early placentation, potentially leading to recurrent pregnancy loss, as supported by a study published in 2000 1. The patient's other evaluation results, including thyroid function, antiphospholipid antibodies, lupus anticoagulant, and karyotype, are all normal, suggesting that the fibroid may be the underlying cause of her recurrent miscarriages. Hysteroscopic resection is a minimally invasive procedure that can be performed as an outpatient surgery with relatively quick recovery time. Following the procedure, the patient should wait approximately 2-3 months before attempting conception again to allow for complete healing of the endometrium. This approach addresses the anatomical factor that may be contributing to her pregnancy losses and offers the best chance for a successful future pregnancy. Some studies have suggested that other treatments, such as uterine artery embolization (UAE), may also be effective in managing uterine fibroids, but the evidence for their use in patients with recurrent pregnancy loss is less clear, as noted in a 2024 study 1. Additionally, medical management options, such as hormonal therapies, may be considered for patients with symptomatic fibroids, but they are not directly applicable to this patient's situation, as discussed in another 2024 study 1. Therefore, based on the available evidence, hysteroscopic resection of the submucosal fibroid is the most appropriate next step in management of this patient's recurrent pregnancy loss. Key points to consider in this patient's management include:
- The presence of a submucosal fibroid, which is a known risk factor for recurrent pregnancy loss
- The patient's history of three first-trimester spontaneous abortions, which suggests a possible underlying anatomical cause
- The need for a minimally invasive procedure that can be performed as an outpatient surgery with relatively quick recovery time
- The importance of allowing for complete healing of the endometrium before attempting conception again.
From the Research
Recurrent Pregnancy Loss Management
The patient's history of recurrent pregnancy loss, combined with the presence of a 2-cm submucosal fibroid at the uterine fundus, suggests that the fibroid may be a contributing factor to her pregnancy losses.
- The patient's laboratory results, including a normal TSH level and negative results for lupus anticoagulant and antiphospholipid antibody, help to rule out other potential causes of recurrent pregnancy loss 2, 3.
- The presence of a submucosal fibroid, which can interfere with implantation and increase the risk of miscarriage, is a significant finding in this case 4.
- Given the patient's history and the presence of the submucosal fibroid, the most appropriate next step in management would be to consider surgical removal of the fibroid, such as hysteroscopic myomectomy, to improve her chances of carrying a pregnancy to full term 5, 4.
- It is essential to note that recurrent pregnancy loss is a complex condition, and a thorough evaluation and management approach should be taken to address the patient's specific needs and circumstances 2, 6.
Considerations for Surgical Intervention
- The patient's overall health, including her normal vital signs and lack of chronic medical conditions, suggests that she is a good candidate for surgical intervention 2.
- The use of hysteroscopic myomectomy, which has been shown to be a safe and effective procedure for removing submucosal fibroids, may be an appropriate treatment option for this patient 4.
- The potential benefits of surgical intervention, including improved fertility outcomes and reduced risk of miscarriage, should be carefully weighed against the potential risks and complications of the procedure 5, 4.