Miscarriage & Recurrent Pregnancy Loss — SAQ

Stem

A 31-year-old woman, gravida 4 para 0, presents at 9 weeks of gestation with vaginal bleeding for 2 days. She has had three consecutive first-trimester losses in the past four years. She is otherwise well, takes no regular medication, and is Rh-negative. On speculum examination the cervical os is closed; transvaginal ultrasound shows a live intrauterine fetus with a crown-rump length of 22 mm and a positive fetal heartbeat.

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Questions

a) Define recurrent pregnancy loss and state the single most common identifiable cause. (2 marks)

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Recurrent pregnancy loss (RPL) is defined as 3 or more consecutive first-trimester pregnancy losses (ASRM accepts 2 or more consecutive failed pregnancies, including one second-trimester loss). The single most important and treatable identifiable cause is antiphospholipid syndrome (APS), found in approximately 15 to 20 percent of women with RPL and diagnosed by persistent lupus anticoagulant, anticardiolipin, or anti-beta-2-glycoprotein-I antibodies.[1][2]

b) List the structured investigations you would perform for this woman's recurrent losses. (3 marks)

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• Parental peripheral blood karyotype — balanced reciprocal translocation (3 to 5 percent of couples with RPL).
• Antiphospholipid antibodies — lupus anticoagulant, anticardiolipin (IgG/IgM), anti-beta-2-glycoprotein-I (repeat at 12 weeks to confirm persistence).
• Pelvic imaging — 3D ultrasound or saline infusion sonohysterography / hysteroscopy to detect uterine anomalies (septum); hysterosalpingography if needed.
• Endocrine — TSH, HbA1c (thyroid disease, diabetes).
• Inherited thrombophilia screen — factor V Leiden, prothrombin gene mutation, protein C/S, antithrombin (if a late loss or strong family history).
• Karyotype of products from any future loss (if available).[1]

c) Her APS screen returns persistently positive. What specific treatment improves her chance of a live birth, and when is it started? (3 marks)

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• Low-dose aspirin 75 mg daily, plus prophylactic low-molecular-weight heparin (e.g. enoxaparin 40 mg subcutaneous once daily).
• Started once a viable intrauterine pregnancy is confirmed on scan, continued throughout pregnancy and for 6 weeks postpartum.
• This combination approximately doubles the live-birth rate in APS-related RPL versus untreated controls. Warfarin is contraindicated (teratogenic).[2]

d) Despite treatment she later has a heavy bleed at 10 weeks with an open cervical os and tissue at the os. She is Rh-negative. Outline your immediate management. (2 marks)

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• Assess ABCs and haemodynamic status; secure IV access, send FBC and group and save.
• Diagnose incomplete miscarriage (open os, partial passage of products, ongoing heavy bleeding).
• Proceed to surgical evacuation (suction curettage / ERPC) for heavy bleeding, and give anti-D immunoglobulin 250 IU IM within 72 hours (she is Rh-negative).
• Offer empathic support and follow-up counselling. Antibiotics if any features of sepsis.[1]

References

1. [1]Deng T, Liao X, Zhu S. Recent Advances in Treatment of Recurrent Spontaneous Abortion. Obstetrical and Gynecological Survey, 2022.PMID 35672876
2. [2]Jeve YB, Davies W. Evidence-based management of recurrent miscarriages. Journal of Human Reproductive Sciences, 2014.PMID 25395740
3. [3]Chu JJ, Devall AJ, Beeson LE, et al. Mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage (MifeMiso): a randomised, double-blind, placebo-controlled trial. The Lancet, 2020.PMID 32853559
4. [4]Coomarasamy A, Devall AJ, Cheed V, et al. A Randomized Trial of Progesterone in Women with Bleeding in Early Pregnancy. New England Journal of Medicine, 2019.PMID 31067371
5. [5]Quenby S, Booth K, Hiller L, et al. Heparin for women with recurrent miscarriage and inherited thrombophilia (ALIFE2): an international open-label, randomised controlled trial. The Lancet, 2023.PMID 37271152