OG9.2 | Recurrent Pregnancy Loss — Summary & Reflection

KEY TAKEAWAYS

Recurrent pregnancy loss (RPL) is defined as three or more consecutive pregnancy losses before 20 weeks (RCOG/ESHRE) or two or more clinical losses (ASRM). Aetiology is identified in ~50% of couples; categories include chromosomal/genetic (parental balanced translocation, sperm DNA fragmentation), uterine anatomical (septum — commonest treatable structural cause — submucous fibroid, Asherman, cervical incompetence), endocrine (hypothyroidism, hyperprolactinaemia, PCOS, diabetes), and antiphospholipid syndrome (APS — the most important treatable cause; requires two positive antibody tests ≥12 weeks apart). Investigation includes parental karyotype, TVS/hysteroscopy, thyroid panel, APS antibodies, and selective thrombophilia screen. Management is aetiology-directed: APS → LMWH + aspirin (improves live birth rate from ~10% to ~75%); septum → hysteroscopic resection; hypothyroidism → levothyroxine to TSH <2.5 mIU/L; unexplained → progesterone 400 mg bd + supportive care (PRISM trial, ~75% live birth rate). Avoid unproven treatments (IVIG, NK assays, HLA typing).

REFLECT

A couple presents with a fourth pregnancy loss. All investigations are normal — unexplained RPL. They ask: 'Is there ANYTHING that can be done?' Reflect on: How would you explain the prognosis with supportive care to this couple without giving false hope or false despair? What does the 70–75% live birth rate with supportive care mean for this individual couple (not the population statistic)? What elements of the consultation — beyond prescribing progesterone — constitute 'therapeutic care' for RPL? How does your understanding of the aetiological categories help you have an honest conversation about what is and is not known in medicine?