OGCO- Recurrent pregnancy loss

Question 1

Define recurrent pregnancy loss

Answer 1

Recurrent pregnancy loss is defined as the loss of >=2 pregnancies

Question 2

Recommended Ix for RPL

Answer 2

• All women with recurrent 1st trimester miscarriage and all women with more than one second trimester miscarriage should be screened for antiphospholipid antibodies i.e. lupus anticoagulant, anticardiolipin antibody (IgG and IgM) and B2 glycoprotein I antibodies.
• Should be checked at least 6 weeks after miscarriage
• APS is diagnosed when the women has 2 positive tests at least 12 weeks apart in non pregnant state for either lupus anticoagulant or anticardiolipin antibodies (IgG>40 GPL or IgM >40MPL) together with 3 or more pregnancies loss
• TSH and anti TPO. If abnormal check T4
• Karyotyping of both partners. Cytogenetic analysis on products of conception can be provided for explanatory purpose but it does not provide prognostic implication on future pregnancy.
• Screening for uterine malformations: saline infusion sonogram and/or 3D pelvic USG should be performed in all women with recurrent 1st trimester miscarriage or those with one or more second trimester miscarriage. If uterine anomaly found –> diagnostic hysteroscopy +/- laparoscopy +/- therapeutic surgery should be offered
• Thrombophilias: women with 2nd trimester miscarriage may be screened for inherited thrombophilia including antithrombin III, protein C and protein S deficiency

Question 3

Mx of women with antiphospholipid syndrome?

Answer 3

Low dose aspirin + heparin to prevent further miscarriage
* Low dose aspirin (75-100mg/day) before conception
* Prophylactic dose heparin starting at date of a positive pregnancy test (recommended dose of enoxaparin in women with body weight <50kg is 20mg daily and for those with body weight >/=50kg is 40mg daily)
* Women should be referred to high risk obstretics team for prepregnancy counselling (not yet pregnant) and antenatal care (when pregnancy)

Question 4

Mx of women with abnormal thyroid function?

Answer 4

• Overt hypothyroidism should be referred to the medical department for treatment. The aim is to keep TSH <=2.5mU/l
• Treatment for subclinical hypothyroidism with thyroxine is not recommended

Question 5

Mx of couples with abnormal karyotype?

Answer 5

• Refer to clinical geneticist for counselling
• Couple should be assessed and counselled for the option of preimplantation genetic testing for structural re-arrangement

Question 6

Mx of congenital uterine malformation?

Answer 6

Hysteroscopic resection should be offered to women with uterine
septum. Use of Hyalobarrier® should be discussed and a course of hormonal treatment (estradiol 6mg daily for 6 weeks and medroxyprogesterone acetate 10mg daily in the 5th-6th weeks) should be considered to reduce post-operative intrauterine adhesion

Question 7

Mx of inherteited thrombophilia?

Answer 7

• Heparin therapy, e.g. enoxaparin 20-40mg daily, may improve live birth rate of women with history of second trimester miscarriage with
  inherited thrombophilias and should be considered.
• There is insufficient evidence to evaluate the use of heparin in women with recurrent first trimester miscarriage with inherited thrombophilia. Management in this group of patients should be individualised.

Question 8

Treatments not to be routinely offered in RPL

Answer 8

• Progesterone supplementation
• Immunotherapy e.g. parental cell immunization, IVIG
• Metformin in women with RPL and insulin resistance