Recurrent Pregnancy Loss
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Direct answer
Recurrent pregnancy loss is the loss of two or more consecutive pregnancies (many Indian texts still define it as three), affecting roughly one per cent of couples trying to conceive. Although chance alone explains some recurrences, a systematic search identifies antiphospholipid syndrome, parental balanced translocation, uterine anomalies, cervical insufficiency and untreated endocrine disorders as the treatable or actionable causes. The cornerstone of care is a structured workup — parental and fetal karyotyping, antiphospholipid antibodies, thyroid function and uterine imaging — followed by cause-directed treatment such as low-dose aspirin with heparin for antiphospholipid syndrome.
What you must remember
- Definition: two or more failed clinical pregnancies per ESHRE and ASRM usage, with the classical three-loss definition persisting in Indian textbooks; document loss gestation and sequence.
- Genetic causes: parental balanced reciprocal or Robertsonian translocations (found in a small but important minority) and recurrent fetal aneuploidy; options include prenatal diagnosis or preimplantation genetic testing in selected couples.
- Antiphospholipid syndrome — the treatable flagship: lupus anticoagulant, anticardiolipin (IgG or IgM) or anti-beta2 glycoprotein-I antibodies in clinically significant titre, present on two occasions at least 12 weeks apart, plus characteristic pregnancy morbidity; treatment is low-dose aspirin plus low molecular weight heparin during pregnancy.
- Uterine factors: septate uterus and other müllerian anomalies (saline sonography, three-dimensional ultrasound or hysteroscopy), intrauterine adhesions and submucous fibroids; hysteroscopic septum resection is the classic corrective surgery.
- Endocrine factors: uncontrolled diabetes, overt hypothyroidism, thyroid autoimmunity with borderline function and hyperprolactinaemia; correct before conception. Inherited thrombophilias are weakly and controversially linked to late loss — routine screening is not advised and treatment is not established.
- Cervical insufficiency produces painless second-trimester losses; history plus a short cervix on transvaginal ultrasound guide cerclage decisions.
- Supportive care: the great majority of couples with unexplained recurrent loss have a good prognosis (a future live birth chance of well over half in most series) — reassurance plus close early scanning is itself therapeutic.
Common confusion
Over-investigation and over-treatment are the real-world errors: ordering exhaustive TORCH panels and treating empirical "immunotherapy" or progesterone without cause has weak evidence, whereas missing antiphospholipid syndrome deprives the couple of the one clearly effective regimen — aspirin plus heparin. The second distinction is antibody persistence: a single positive antiphospholipid test means nothing; the diagnosis requires a second confirmation 12 or more weeks apart.
Exam-focused takeaway
Stems pair a woman with recurrent losses plus a finding — a lupus anticoagulant, a septate uterus, a TSH of 8, a partner with a balanced translocation — and ask for the next or most effective step. The triple requirement for antiphospholipid diagnosis (clinical criteria plus two antibody tests 12 weeks apart) and the two-versus-three loss definition are frequent one-liners. Prognosis counselling in unexplained cases is a newer style of question.
Frequently asked questions
How many losses define recurrent pregnancy loss?
Two or more consecutive pregnancy losses in current international usage; classical Indian teaching retains three consecutive losses.
Which cause has the clearest effective treatment?
Antiphospholipid syndrome — low-dose aspirin plus low molecular weight heparin measurably improves live birth rates.
What first-line workup is advised?
Parental karyotyping, antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, anti-beta2 glycoprotein-I), thyroid function with prolactin as indicated, and uterine imaging by sonography or hysteroscopy.
Are inherited thrombophilias a major cause?
They are weakly associated, screening is not routine, and heparin treatment for recurrent early loss is not evidence-supported.
What is the outlook in unexplained recurrent loss?
Favourable — most series report subsequent live birth chances well above half, supporting reassurance with supportive early surveillance.