recurrent pregnancy loss

Question 1

what is definition of RPL

Answer 1

2 or more spontaneous recurrent pregnancy loss

Question 2

ddx of RPL

Answer 2

• chromosomal (recurrent aneuploidy, robertson translocation)
• uterine
• metabolic (thyroid, PRL, DM)
• infectious (CMV, listeria, rubella)
• luteal phase deficiency
• autoimmune (APAS)
• PCOS
• unexplained (50%)

Question 3

work-up for RPL

Answer 3

• H&P: personal hx, family pedigree, exposures; exam: signs of endocrine abnromalities/abnl pelvic anatomy
• karyotype (both partners, preg loss if possible)
• uterine eval (SIS, HSG, HSC)
• TSH, PRL, A1c
• APAS work-up

Question 4

what is there no evidence to do in work-up:

Answer 4

• luteal phase progesterone
• endometrial biopsy
• infectious work-up
• ANA
• inherited thrombophilias
• semen analysis
• vaginal/uterine/cervical discharge

Question 5

criteria for APAS diagnosis

Answer 5

Clinical (at least 1)

• Vascular: arterial or venous thrombosis
• Reproductive: fetal death at 10 or more weeks (structurally normal), severe pre-eclampsia or IUGR requiring delivery < 34 weeks, 3 or more SABs at <10 weeks with other causes excluded

Laboratory (any abnormality seen on 2 occasions 12 weeks apart)

• Lupus Anticoagulant
• Anti-cardiolipin antibody (ACA) IgG or IgM (medium or high titer)
• Anti-beta 2 glycoprotein I IgG or IgM (>99%le)

Question 6

What is significance of anti-ro (SSA)

Answer 6

increased risk of congenital lupus (cardiac or cutaneous abnormalities)

Question 7

risks with APS

Answer 7

• Thrombosis risk (10%)
• recurrent pregnancy loss
• Pre-eclampsia
• IUGR 50%
• IUFD
• PTL

Question 8

treatment for APAS

Answer 8

• if hx of thrombosis:
  ppx anticoagulation (UFH or LMWH) + ldASA
  continue 6 weeks PP
• if no hx of thrombosis - consider surveillance vs above noted plan

ASA may decrease risk of pregnancy loss by 50%

Question 9

treatment for RPL

Answer 9

• if idiopathic, there is chance of successful pregnancy 50-70% in next pregnancy
• encourage wt loss if obese, decrease in coffee intake if > 3 cups/day, smoking cessation
• ivf with embryo transfer if appropriate
• tx underlying DM, thyroid and hyperprolactinemia if appropriate
• APAS tx if needed

Question 10

role of IVF with embryotransfer?

Answer 10

• evidence to do this with parental karyotype abnormalities

- no evidence to do this with idiopathic RPL

Question 11

what not to for treatment?

Answer 11

• don’t give heparin or ASA if not APAS

- don’t support pregnancy or luteal phase with progesterone