Recurrent Pregnancy Loss

Miscarriage is defined as the

spontaneous loss of pregnancy
before the fetus reaches viability
Recurrent Miscarriage is defined as
three or more consecutive,
spontaneous pregnancy loss

Epidemiology
13-15% of recognized pregnancies
are lost, 90% of these before 12-14
weeks
10-20% of pregnant women have
sporadic spontaneous abortion
2% have 2 consecutive spontaneous
abortions
0.4-1% have 3 consecutive abortions

Risk factors

Advanced maternal age

Risk of RPL
Percentage

50

25
13

11

12

15

Previous miscarriage

Risk factors (cont)

Environmental factors
Confirmed association
Ionizing radiation
Organic solvent
Alcohol
Mercury
Lead

suspected association
Cigarette smoking
Obesity

ETIOLOGY

Genetic causes
Immunologic causes
Anatomical factors
Infectious causes
Environmental causes
Endocrine causes
Hematologic causes

Genetic causes
Embryonic chromosomal abnormalities
accounts for 30-57% of miscarriages
-gametogenic error
-recurrent aneuploidy
-euploid abortion
Parental chromosomal abnormality
-balanced reciprocal or Robertsonian
translocation
-inversion
-X chromosome mosaicism

Immune factor
Autoimmune :
Systemic lupus erythematosus
Antiphospholipid syndrome

 SLE
Risk for loss is 20%. Mostly in 2nd and 3rd
trimester of pregnancy and associated with
antiphospholipid antibodies.

Antiphospholipid syndrome
5-15% of with RPL may have APA

Antiphospholipid syndrome
Clinical features;
- vascular thrombosis, or
- loss of fetus at or after 10 weeks or
- preterm delivery at or before 34 weeks
Laboratory features
- anti cardiolipin antibodies: IgG or IgM at moderate or
high
levels on 2 or more occasions at least 12 weeks apart
- lupus anticoagulant antibodies; detected on 2 or more
occasions atleast 12 weeks apart.

Anatomical factors
Uterine anomalies: prevalence of uterine anomalies in
recurrent miscarriage population ranges between 1.8% and
37.6%
Uterine septum (most common)
Unicornuate uterus
Bicornuate uterus
Didelphic uteri
Diethylistilbestrol-linked condition
Acquired defect (Ashermans syndrome)
Cervical insufficiency
Leiomyoma
Uterine polyp
Defective endometrial receptivity

UTERINE SEPTUM
BICORNUATE UTERUS

UNICORNUATE UTERUS
UTERUS

DIDELPHIC

Other uterine causes

Endometrial polyp
Intrauterine adhesions
-curettage for pregnancy complication
-traumatized basalis layer
-insufficient endometrium to support
fetoplacental growth
-menstrual irregularities

Endocrine causes
Poorly controlled diabetes
- miscarriage risk rises with the level of
HbA1c
- well controlled = No increased risk
Thyroid disease
Hyperprolactinemia
PCOS

INFECTIVE AGENTS
No infectious agent has been proven to
cause recurrent pregnancy loss
Certain infections have been associated
with spontaneous loss
- toxoplasma gondi, rubella, HSV, CMV, measles,
coxsackie

Presence of bacterial vaginosis in the 1st

trimester has been reported as a 2nd
trimester miscarriage and pre term
delivery.

Hematologic disorders
Woman with heritable or acquired
thrombophilic disorder have significantly
increased risk of pregnancy loss.
Inherited thrombophilic defects:

Activated protein C resistance

Deficiency of protein C/S and antithrombin III
Hypochromocysteinaemia
Prothrombin gene mutation

Miscellaneous
Environmental chemicals
-anesthetic agents:
Sporadic spontaneous cases (no evidence of
association to RPL)

Personal habits
- obesity
- smoking
- alcohol
- caffeine

Exercise

Male factors
Advanced paternal age may be a risk
factor for miscarriage (at a more advanced
age than females)
Apart from cytogenetic abnormalities,
male factor contribution to RPL is unknown