Early Pregnancy Loss and Recurrent Pregnancy Loss
Definitions
Early pregnancy loss is loss before 13 weeks; recurrent pregnancy loss (RPL) is typically ≥2–3 consecutive losses. Aneuploidy accounts for the majority of sporadic losses, and risk rises with maternal age.
Management of early loss
Options are expectant, medical (misoprostol ± mifepristone), or surgical (suction curettage). Surgical management allows karyotype/cytogenetic testing. In a woman with a prior cesarean, consider cesarean scar ectopic before intervention.
RPL evaluation
After 2–3 losses, evaluate for: parental karyotype (balanced translocation), antiphospholipid antibodies, uterine anomaly (septum), and thyroid/glucose status. Antiphospholipid syndrome is the one treatable cause with proven therapy (low-dose aspirin plus heparin).
Traps
- Treating all RPL with empiric progesterone or heparin without indication.
- Missing that a septate uterus is the most common Müllerian anomaly associated with loss; resection may help.
- Failing to offer genetic testing on products of conception in a first loss when it would change counseling.
- Overlooking that a prior uterine surgery or Asherman syndrome can cause loss or infertility.
Worked example
A couple with three first-trimester losses and normal parental karyotypes: check antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, anti-β2 glycoprotein I, repeated 12 weeks apart). If positive, treat with aspirin plus prophylactic heparin in pregnancy.