Recurrent Pregnancy Loss (RPL): An Overview

by Premier Hospitals | June 21, 2018 |

Isn’t it so exciting to know that you are going to become parents. No words are sufficient to explain the happiness. But as things goes on well there are chances where the pregnancy becomes a miscarriage. It is a terrible experience to go through a miscarriage, however you still have that ray of hope that you can make it it in the second go but just in case, this pregnancy also results in a miscarriage due to various reasons, it is time for you to know about Recurrent Pregnancy Loss. Before it had been 3 or more miscarriages before 20 weeks of pregnancy, but now, it is 2 or more miscarriages after which it is known as Recurrent Pregnancy Loss (RPL). Get To Know How Recurrent Pregnancy Loss Happens In 50% of cases the causes are unknown i.e. unexplained etiology In 20% of cases it is due to Endocrine or Hormonal causes like DM or Hypothyroidism or Luteal phase defect or PCOS. In 15 % of cases it is an Autoimmune disorder

1. Hereditary thrombophilias by eliciting prothrombotic state
2.  Acquired thrombophilias mostly Antiphospholipid Antibody Syndrome. In this       case the antibodies induce themselves in the decidual vessels and dysregulate maternal immune system

In 10% of cases it is an Anatomic abnormalities ie uterus anomalies

1. Congenital anomalies- Septate uterus, Bicornuate or Unicornuate uterus, Cervical incompetence.
2. Acquired anomalies- Polyps in the uterine cavity, Uterine Fibroids and intrauterine adhesions.

In 2-5% it is because of Parental chromosome aberrations- Common aberrations are Translocations. What are the investigations to be done to know the cause of RPL? To exclude Endocrine or hormonal etiology-

1. For Diabetes Mellitus- Blood sugar testing by glucose tolerance test and HbA1C levels
2. For thyroid dysfunction- Serum T3, T4, TSH levels and if necessary estimation of Antithyroid Antibodies.
3. For Hyperprolactinemia- Estimation of Serum Prolactin levels

To exclude Autoimmune disorders- To diagnose Hereditary thrombophilias

1.  Estimation of Factor V Leiden
2.  Protein C & S levels
3.  Antithrombin III levels

To diagnose Antiphospholipid APS syndrome- Estimation of

1. Anticardiolipin APS
2. Lupus anticoagulant
3. Anti B2-glycoprotein I

To exclude Anatomical abnormalities- USG especially 3D USG to diagnose uterine anomalies and uterine fibroids. MRI can complement USG sometimes in the diagnosis Hysterosalpingography to diagnose uterine anomalies and intracavitary polyps and fibroids Transvaginal Sonohysterography- Increasingly used for evaluation of uterus cavity Diagnostic Hysteroscopy- it is the gold standard for evaluation of uterine cavity Diagnostic Laparoscopy- To assess the endometriosis and pelvic adhesions To exclude parenteral chromosomal aberrations-

1. Karyotyping of both parents

To diagnose unexplained recurrent pregnancy loss-

1. In spite of all the above thorough investigations if the cause of recurrent pregnancy loss is still  unknown we can then label it as unexplained RPL which accounts of or 50% of cases of RPL.

How To Manage A Case Of Recurrent Pregnancy Loss? After investigating a case of RPL if the doctor diagnose the cause of RPL, then further treatment is directed to correct the problem. Treatment for Endocrinological cause:

1. If Diabete Mellitus and thyroid dysfunction are controlled the results for future pregnancy are extremely good
2. If luteal phase defect is diagnosed then it should be supported with progestogen hormone
3. If it is hyperprolactinemia, treatment with Bromocriptine and Cabergoline is advisory
4. If it is PCOD, then it requires lifestyle modification, weight reduction exercises and insulin sensitizers

Autoimmune disorder causes

1. Hereditary thrombophilias and APLA which can be treated using Heparin and low dose of Aspirin

Treatment of anatomical causes-

1. Acreditary anomalies like Septat & Bicornuate & Unicornuate uterus usually as a initial line of treatment in these cases bed rests and progestogen support are tried if it fails, then surgical correction is needed
2. For septate uterus- Hysteroscopic resection of septum
3. For bicornuate uterus- Metroplasty ie unification of two cavities are done
4. For cervical incompetence- Cerclage stitch

Acquired anatomical causes-

1. Myomas- location of fibroids especially submucous(inside uterine cavity) need removal to improve future pregnancy outcome.
2. Polyps - can be removed hysteroscopically
3. Intrauterine adhesions- hysteroscopic adhesiolysis can be done

Treatment of parenteral chromosomal aberrations is quite difficult

1. Couples with abnormal Karyotype are advised to continue attempting pregnancy and it improves the chances of having a child
2. Preimplantation genetic Diagnosis is a diagnostic tool for parents with known genetic anomalies

Management of unexplained RPL- As the cause in these cases isn’t known, there is no specific therapy. Psychological support aone can offer promising results. Low dose Aspirin can be tried. What are other chances of successful pregnancy in RPL? The prognosis for successful pregnancy depends on the underlying cause for RPL.

1. Endocrinological causes like DM, thyroid dysfunction if controlled properly have more than 90% success rate.
2. Anatomical abnormalities if surgically corrected provide 60-90% success rate
3. Autoimmune disorders if managed properly has 70-90% success rate
4. Parental chromosomal aberrations has a varied success rate between 20-80%
5. In unexplained RPL even after 4 prior pregnancy losses the chance of a viable birth is as high as 60%

It is very much important to examine each couple by providing them emotional support along with specific therapy to get the best possible outcome. About The Hospital: Since the inception of Premier Hospital in 1991 till today, we have grown to unprecedented levels, due to our excellence in medical sciences and healthcare. Premier Hospital is the creation of Dr Mahesh Marda and when it was first established, was only a small, 30-bed hospital facility. Back then, we provided only secondary care to patients, but that certainly has changed in the present landscape

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