- Definition. The occurrence of repeated (three or more consecutive) pregnancies that end in miscarriage of the fetus, usually before 20 weeks of gestation.
- Prevalence. One percent of women of reproductive age who conceive.
Diagnostic evaluation of couples (Figure 24.1)
- History. The pattern, trimester, and characteristics of prior pregnancy losses should be reviewed. Exposure to environmental toxins and drugs, prior gynecologic or obstetric infections, and excluding the possibility of consanguinity are important.
- Physical examination may reveal evidence of maternal systemic disease or uterine anomalies.
- Laboratory tests and imaging studies should be individually utilized.
Etiology (Figure 24.2)
Most couples will have no clear explanation for their recurrent pregnancy loss (RPL). Several alleged causes are controversial and anxious patients/physicians often explore empiric or alternative treatments with dubious benefit.
Idiopathic (>50%)
- Many couples never have a cause identified, even after extensive investigations. Informative and supportive counseling serves an important role because 60–70% of women with at least one previous live birth will have a successful next pregnancy.
Anatomic factors (10–15%)
- Uterine anomalies are most often associated with second-trimester loss. Congenital malformations (see Chapter 10) result from müllerian tube fusion abnormalities and acquired lesions have a more controversial impact. Surgical revision may be helpful in some circumstances.
- Incompetent cervix (see Chapter 58) also accounts for mainly second-trimester losses. Cerclage placement may be beneficial in selected patients.
Endocrine factors (10–15%)
- Luteal phase deficiency
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