Recurrent pregnancy loss (RPL) is defined as the loss of 2-3 or more consecutive pregnancies in the first or early second trimester of pregnancy. Other terms for RPL include recurrent spontaneous abortion, miscarriage, or habitual abortion. It is estimated that about half of all embryos that implant will not lead to a successful pregnancy. The majority of pregnancy loss occurs before 10 week of pregnancy. The rate of miscarriage increases with maternal age, especially after age 35.
Recurrent pregnancy loss is a distressing problem as frequently the cause(s) are unknown. Even when a detailed evaluation is completed, a definite cause is established in no more than 50% of couples. There are also many unproven hypotheses and poorly designed clinical studies, resulting in various treatments for RPL, many of which are without proven benefit.
Two recent articles in the Medical literature (NEJM.2010; 363:1740-7 and Hum Reprod. 2010; 25:2203-2209) have provided Physicians with a contemporary approach to the diagnosis and treatment of RPL.
The evaluation of RPL should include:
· Review of all prior pregnancies and their outcome
· Chromosome Analysis of couple to screen for a balanced translocation
· Sonohysterogram or Hysterosalpingiogram (HSG) to screen for uterine abnormalities
· Thyroid Function tests
· Screening for Diabetes (if indicated)
· Testing for Lupus Anticoagulant and Anticardiolipin Antibodies to screen for the Antiphospholipid syndrome
The treatment of RPL should be based on the above evaluation. If all testing is normal, the chances of a favorable outcome are good. In studies of women with unexplained pregnancy loss where no active medical intervention is used, successful pregnancies occur in 65% of cases.
Immunologic causes of RPL remain controversial and largely unproven. It has been proposed that there may be a group of women in whom their immune system recognizes pregnancy and rejects it. Immunotherapy has been proposed to reduce the risk of rejection of pregnancy and improve the opportunity for a successful pregnancy. The results of published medical studies are conflicting. The best available studies do not indicate that Immunotherapy is any more successful than no treatment. At this time, Immunologic testing and treatment should be considered experimental and should be undertaken under a strict research protocol.
~ Dr. Carmelo Sgarlat
