Recurrent

Pregnancy
Loss
Recurrent pregnancy loss
three or more consecutive pregnancy losses < 20 weeks' gestation or with a fetal weight <
500 g
Two or more failed pregnancies confirmed by sonographic or histopathological examination

Primary PL
to multiple losses in a woman who has never delivered a liveborn

Secondary PL
to multiple pregnancy losses in a patient with a prior live birth
Etiology
parental chromosomal abnormalities
antiphospholipid antibody syndrome
structural uterine abnormalities

Genetic factors usually result in early embryonic losses

autoimmune or uterine anatomical abnormalities more likely cause second-trimester losses

*approximately 40 to 50 percent of women have idiopathic RPL

Parental Chromosomal Abnormalities
account for only 2 to 4 percent of RPL cases
Chances of carrier status for balanced structural chromosome abnormality are
dependent on maternal age at which the second miscarriage took place, number
of miscarriages and whether or not the parents or siblings of the couple with the
recurrent miscarriage have had two or more miscarriages
Anatomical Factors
Congenital or acquired uterine anomaly

acquired abnormalities
uterine synechiae-Asherman syndrome

usually result from destruction of large areas of endometrium. This can follow uterine curettage
Uterine leiomyomas are common and may cause miscarriage,
especially if located near the placental implantation adversely
affected by submucous but not subserosal or intramural leiomyomas
Congenital genital tract anomalies
-they are associated with recurrent miscarriages
-often originate from abnormal mullerian duct
formation
*Septate uterus is associated with early
miscarriages
Immunologic factors
-Miscarriages are more common in women with systemic lupus erythematosus
APAS
-recurrent pregnancy loss, pregnancy related morbidity (Preeclampsia and
growth retardation) and or venous thrombosis in combination with presence of
LAC lupus anticoagulant or antibodies to cardiolipin (ACA, IgG, IgM)
- 1st blood sampling atleas 12 weeks after the latest miscarriage and to confirm
the the laboratory abnormalities after at least 12 weeks
 Endocrine Factors
-8 to 12 percent of recurrent miscarriages are caused by endocrine factors
Corpus Luteum Insufficiency
-polycystic ovarian syndrome
*
Thyroid dysfunction
- assessment of thyroid status is not indicated
-prevalence of thyroid dysfunction among women with thyroid disease is low (1-2%)
Diabetes mellitus

-screening of DM in asymptomatic women because of RPL is not recommended

-the prevalence of DM in women with RPL is low <1%

-those whose HbA1c concentrations were > 12 percent or whose preprandial glucose
concentrations were persistently > 120 mg/dL had an elevated risk and that the risk for well
controlled patients is not increased
Maternal Infections
Infection of reproductive tract has been linked theoretically to pregnancy loss

*prospective trial has demonstrated a link between the detection of bacterial vaginosis and history of second
trimester pregnancy loss

-infection associated pregnancy loss may result from immunologic activation that occurs is response to
pathologic organism

HSV and CMV

-can directly infect the fetus and placenta

-villitis and related tissue destruction may disrupt pregnancy

-Mechanism that protect the fetus from autoimmune rejection also may protect virally infected cellplacental cells
from recognition and clearance
Lifestyle
lifestyle modification is advised: weight loss, smoking cessation, healthy food
Unexplained miscarriages
Premature Rupture
of Membrane
M A X I M A V ER A P I N A L G A N , MD
labor is induced soon after admission when ruptured membranes are
confirmed at term

lower rates of chorioamnionitis, metritis, and neonatal intensive care

unit admissions for women with term ruptured membranes whose
labors were induced compared with those managed expectantly.
Rupture of the membranes is significant for three reasons.
1. if the presenting part is not fixed in the pelvis,
the umbilical cord can prolapse and be compressed
2. labor is likely to begin soon if the pregnancy is at or near term
3. if delivery is delayed after membrane rupture, intrauterine and
neonatal infection is more likely as the time interval increases
 Diagnosis
• amnionic fluid pools in the posterior fornix or clear fluid lows
from the cervical canal

• pH determination of vaginal fluid

• indicator nitrazine to identify ruptured membranes is a simple

and fairly reliable method.

• amnionic fluid include arborization or ferning of vaginal fluid,

• specific amnionic fluid protein s can be sought using point-of-

care assays
“It’s one small step for man, one
giant leap for mankind.”

- NEIL ARMSTRONG