RECURRENT MISCARRIAGE

TUTORIAL FOR CI STUDENTS

By Dr Gobena Teno
( Assistant professor of Obstetrics and Gynecology)
recurrent pregnancy loss (RPL) is classically defined as three or more consecutive
pregnancy losses at <20 weeks’ gestation or with a fetal weight <500 g.
Affecting approximately 1 percent of fertile couples.
The American Society for Reproductive Medicine (2020) now defines RPL as two
or more failed pregnancies confirmed by sonographic or histopathological
examination.
Classification
• Primary RPL refers to multiple losses in a woman who has never delivered a
liveborn.
• Secondary RPL refers to multiple pregnancy losses in a patient with a prior live
birth.
 Etiology
Widely accepted causes of RPL include:
• Parental chromosomal abnormalities
• Antiphospholipid antibody syndrome
• Specific endocrinopathies
• Certain structural uterine abnormalities.
Thus, current RPL evaluation includes
• Karyotyping of both parents;
• Measuring antiphospholipid antibody levels;
• Assessing HbA1c ,
• Thyroid-stimulating hormone (TSH),
• Prolactin levels
• Performing saline-infusion sonography (SIS) or hysterosalpingography
Parental Chromosomal Abnormalities
In first-trimester RPL, the incidence of genetic abnormalities is
significantly lower than in sporadic miscarriage.
A notable exception is a parent that carries a reciprocal translocation or
Robertsonian translocation
These account for only 2 to 4 percent of RPL cases, but karyotyping of
both parents is a recognized part of RPL evaluation.
Anatomical Factors
• 15 percent of women with ≥3 consecutive miscarriages will have a congenital or
acquired uterine anomaly.
Uterine leiomyomas
• Some may cause miscarriage, especially if located near the placental implantation
site.
• The American Society for Reproductive Medicine (2017) notes that hysteroscopic
excision of large submucosal leiomyomas in women with RPL can be considered.
Uterine synechiae (Asherman syndrome)
• Result from broad destruction of endometrium and subsequent scarring, which can
follow uterine curettage or hysteroscopic surgeries.
diagnosis : With SIS, multiple hypoechoic bridging bands are seen to span the
endometrial cavity, which is filled with anechoic saline.
Treatment: hysteroscopic adhesiolysis, but success rates are lower with more severe
initial disease.
Uterine polyps
have been found more frequently in women with RPL, but causality is
unclear.
Diagnosis
• Hysteroscopy or SIS as a mass lesion extending from the uterine wall
into the endometrial cavity.
• Application of color Doppler during SIS classically reveals a single
feeder vessel reaching the mass.
Treatment: Hysteroscopic polypectomy can be considered.
• Congenital uterine anomalies often originate from abnormal müllerian
duct formation.
• Septate uterus is most closely linked with miscarriage.
Hysteroscopic resection has been associated with improved live birth
rates.
Immunological Factors
family of autoantibodies that bind to phospholipid-binding plasma
proteins are associated with RPL .
the antiphospholipid antibody syndrome (APS) is defined by these
antibodies in combination with various forms of reproductive loss or
vascular thrombosis
Clinical and Laboratory Criteria for Diagnosis of Antiphospholipid
Antibody Syndrome
Endocrine Factors
• Of recurrent miscarriages, 8 to 12 percent are caused by endocrine
factors.
• Uncontrolled diabetes mellitus
• Overt hypothyroidism and severe iodine deficiency
• progesterone deficiency caused by a luteal-phase defect.
• Hyperprolactinemia

Obesity, polycystic ovarian syndrome, and insulin resistance are also

linked to RPL.
Second trimester abortion
• The spontaneous loss rate in the second trimester is much lower than
in the first.
• Unlike earlier miscarriages that frequently stem from chromosomal
aneuploidies, causes of these later fetal losses are more diverse.
Cervical Insufficiency
Is common cause of second trimester RPL
Is characterized classically by:
• Painless cervical dilation in the second trimester.
• Followed by prolapse and ballooning of the amnionic membranes into
the vagina, and ultimately, expulsion of an immature fetus.
• This sequence often repeats in future pregnancies.
Causes:
Conization
Abnormal cervical development
Connective tissue diseases ( i.e Marfan and Ehlers-Danlos syndromes)
diagnosis
Diagnosis
History
Physical examination
Ultrasound
Treatment
Cerclage
THANKS