Couples with recurrent pregnancy loss (RPL) require empathy and understanding as early pregnancy loss is an emotionally traumatic experience, similar to that associated with stillbirth or neonatal death. In addition, evaluation can be frustrating and difficult because the etiology of their RPL may not be determined and there are few evidence-based diagnostic and treatment strategies [1,2].
CANDIDATES FOR EVALUATION
RPL is classically defined as the occurrence of three or more consecutive losses of clinically recognized pregnancies prior to the 20th week of gestation (ectopic and molar pregnancies are not included). (See "Definition and etiology of recurrent pregnancy loss".)
There is a general consensus that healthy women should not undergo extensive evaluation after a single first trimester or early second trimester spontaneous miscarriage, given these are relatively common, sporadic events: miscarriage occurs in about 10 to 15 percent of clinically recognized pregnancies under 20 weeks of gestation . In prospective studies, the overall risk of miscarriage in the next pregnancy remains about 15 percent after one miscarriage, but rises to 17 to 31 percent after two consecutive miscarriages and to 25 to 46 percent after three or more miscarriages. Based on these and similar data, most experts initiate evaluation and treatment of RPL after either two or three consecutive miscarriages [3-5].
It is important to remember that most women with RPL have a good prognosis for eventually having a successful pregnancy, even when a definitive diagnosis is not made and no treatment initiated. In one representative study, the overall live birth rates after normal and abnormal diagnostic evaluations for RPL were 77 and 71 percent, respectively . In another study, 8 of 17 women with six or more consecutive unexplained miscarriages subsequently achieved a successful pregnancy outcome .
HISTORY AND PHYSICAL EXAMINATION
The minimum diagnostic workup of couples with RPL consists of a complete medical, surgical, genetic, and family history and a physical examination.