Management of a 20-Year-Old Woman with 2 Spontaneous Abortions Trying to Conceive
This patient requires a comprehensive evaluation for recurrent pregnancy loss, including assessment for diabetes, chromosomal abnormalities, anatomic uterine defects, thrombophilic disorders, and endocrine abnormalities, followed by targeted treatment of any identified causes. 1
Initial Diagnostic Workup
The evaluation should begin after 2 or more unexplained spontaneous abortions, as this threshold justifies investigation for underlying causes. 1
Essential Laboratory Testing
Diabetes screening with HbA1c: Elevated glucose levels during embryogenesis are directly associated with increased spontaneous abortion rates, and achieving HbA1c <7% preconceptionally reduces this risk substantially. 2
Cytogenetic studies (karyotyping of both partners): Chromosomal abnormalities account for approximately 50% of spontaneous abortions. 1, 3
Thrombophilia panel: Test for blood coagulation protein and platelet defects, including antiphospholipid antibodies (anticardiolipin antibodies and lupus anticoagulant), as thrombotic defects are a common treatable cause of recurrent pregnancy loss. 1
Thyroid function testing (TSH): Given the 5-10% coincidence of thyroid dysfunction, particularly in women with autoimmune conditions. 2
Antinuclear antibody (ANA) testing: Positive ANA is associated with lower live birth rates in recurrent pregnancy loss. 4
Anatomic Evaluation
Hysterosalpingography or pelvic ultrasound: Uterine anomalies can cause recurrent abortion and require identification. 1, 5
Consider MRI if initial imaging is inconclusive or suggests complex anatomic abnormalities. 1
Preconception Optimization
If Diabetes is Identified
Achieve optimal glycemic control with HbA1c <6.5% (ideally <6%) before attempting conception, as this dramatically reduces congenital malformations and spontaneous abortion rates to levels comparable with non-diabetic pregnancies. 2
Implement intensive glucose monitoring with pre- and postprandial blood glucose checks. 2
Discontinue ACE inhibitors and statins immediately, as these are teratogenic. 2
Establish care with a multidisciplinary team including endocrinology and maternal-fetal medicine. 2
Use effective contraception until glycemic targets are achieved. 2
If Thrombophilic Disorder is Identified
Initiate low-dose aspirin (81 mg daily) preconceptionally, followed by low-dose heparin (5000 units subcutaneously every 12 hours) after conception, as this regimen has demonstrated 100% success rates in achieving normal-term delivery in women with thrombotic defects and recurrent pregnancy loss. 1
General Preconception Measures for All Patients
Folic acid supplementation: 400 mcg daily minimum, started before conception. 2, 6
Achieve healthy body weight: Both underweight and overweight/obesity increase pregnancy complications. 6
Complete abstinence from alcohol and tobacco: These substances increase miscarriage, preterm birth, and low birth weight risks. 6
Review all medications for potential teratogenic effects, including over-the-counter drugs and supplements. 6
Screen for and treat depression/anxiety: Women are at increased risk for significant depression and anxiety for up to one year after spontaneous abortion. 3
Treatment Based on Specific Findings
Anatomic Abnormalities
Surgical correction of uterine anomalies may be indicated depending on the specific defect identified. 1
Endocrine Abnormalities
Optimize thyroid function and treat any identified hormonal imbalances before conception. 2
Unexplained Recurrent Loss
If no cause is identified after comprehensive evaluation, expectant management with close monitoring is appropriate, as many women will achieve successful pregnancy without specific intervention. 1, 3
Critical Pitfalls to Avoid
Do not delay evaluation: Waiting for additional pregnancy losses before investigating causes unnecessarily exposes the patient to repeated trauma and delays potentially curative treatment. 1
Do not overlook diabetes screening: Even in young patients, undiagnosed diabetes is a highly treatable cause of recurrent pregnancy loss that requires preconception optimization. 2, 7
Do not start pregnancy attempts before optimization: If diabetes or other treatable conditions are identified, conception should be delayed until optimal control is achieved to minimize risks. 2
Do not neglect psychosocial support: Address feelings of guilt, grief, and provide counseling on coping strategies, as psychological impact is substantial. 3