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Recurrent pregnancy loss

Key sources
The following summarized guidelines for the evaluation and management of recurrent pregnancy loss are prepared by our editorial team based on guidelines from the European Society of Human Reproduction and Embryology (ESHRE 2023; 2018), the Canadian Association of Radiologists (CAR 2023), the Royal College of Obstetricians and Gynaecologists (RCOG 2023; 2011), the International Federation of Gynecology and Obstetrics (FIGO 2023), the European Association of Urology (EAU 2023), the British Society for Haematology (BSH 2022; 2012), the American Urological Association (AUA/ASRM 2021), the European League Against Rheumatism (EULAR 2019), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2019; 2017; 2014), the Pan-American League of Associations of Rheumatology (PANLAR 2018), the American Thyroid Association (ATA 2017), the American Society for Reproductive Medicine (ASRM 2017; 2016; 2012), the American College of Obstetricians and Gynecologists (ACOG 2014; 2012), the American College of Medical Genetics (ACMG 2013), the American College of Endocrinology (ACE/OS/AACE 2013), the American College of Chest Physicians (ACCP 2012), and the American Thyroid Association (ATA/AACE 2012).
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Guidelines

1.Screening and diagnosis

Definition
Define RPL as ≥ 2 failed clinical pregnancies. Obtain evaluation after 2 consecutive clinical pregnancy losses.
E
Recognize that up to 50% of cases of RPL will not have a clearly defined etiology.
E
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2.Classification and risk stratification

Prognosis
Base prognosis on the patient's age number and her complete pregnancy history, including the number of previous pregnancy losses, live births, and their sequence.
B
Consider using prognostic tools (Kolte and Westergaard) to provide an estimate of the subsequent chance of live birth in couples with RPL.
C

3.Diagnostic investigations

Diagnostic imaging, pelvic ultrasound, CAR
Obtain combined transabdominal and transvaginal ultrasound as the initial imaging in patients with recurrent first-trimester pregnancy loss.
A
Consider obtaining Doppler as an adjunct.
B
Consider obtaining a 3D ultrasound in patients with suspected Müllerian duct or intracavitary abnormalities based on initial assessment.
C

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  • Medical history

  • Diagnostic imaging (further investigations)

  • Thrombophilia evaluation (antiphospholipid syndrome)

  • Thrombophilia evaluation (inherited causes)

  • Endocrinological evaluation (thyroid)

  • Endocrinological evaluation (prolactin)

  • Endocrinological evaluation (other)

  • Immunological evaluation

  • Infection screening

  • Parental karyotyping

  • Preimplantation genetic screening

  • Products of conception genetic testing

  • Male partner evaluation

4.Medical management

Management of antiphospholipid syndrome: as per RCOG 2023 guidelines, initiate aspirin (75 mg/day) and heparin (UFH or LMWH, such as enoxaparin 40 mg SC) from a positive pregnancy test until at least 34 weeks of gestation in patients with antiphospholipid syndrome.
B

More topics in this section

  • Management of inherited thrombophilia

  • Management of thyroid dysfunction (overt hypothyroidism)

  • Management of thyroid dysfunction (subclinical hypothyroidism)

  • Management of thyroid dysfunction (thyroid autoimmunity)

  • Management of luteal phase insufficiency

  • Management of vaginal bleeding

  • Management of hyperprolactinemia

  • Management of glucose metabolism impairment

  • Management of cervical insufficiency

  • Management of uterine abnormalities (congenital anomalies)

  • Management of uterine abnormalities (acquired anomalies)

  • Management of uterine abnormalities (uterine septum)

  • Management of uterine abnormalities (uterine adhesions)

  • Management of uterine abnormalities (uterine fibroids)

  • Management of chromosomal rearrangements

  • Management of unexplained RPL

  • Management of male partner

5.Nonpharmacologic interventions

Weight loss: as per RCOG 2023 guidelines, advise maintaining a BMI at 19-25 kg/m² in patients with RPL.
B

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  • Physical activity

  • Smoking cessation

  • Alcohol restriction

  • Caffeine restriction

  • Vitamin supplements

6.Patient education

Counseling on risks: as per ESHRE 2018 guidelines, inform females sensitively that the risk of pregnancy loss is lowest in ages 20-35 years, and it rapidly increases after the age of 40 years.
B
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  • Psychological counseling

7.Preventative measures

Thromboprophylaxis: as per SOGC 2014 guidelines, do not administer antithrombotic prophylaxis (low-dose acetylsalicylic acid and LMWH) in patients with a history of RPL without confirmed antiphospholipid syndrome.
D