Recurrent Pregnancy Loss

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Recurrent Pregnancy Loss — Evaluation & Management

Recurrent pregnancy loss (RPL) is generally defined as two or more consecutive pregnancy losses before 20–24 weeks — some societies still use a threshold of three, and definitions vary, so check which convention your workup pathway follows. Behind the definition sits a couple who deserve a thorough, unhurried evaluation — and the honest reassurance that even without a clear cause, most go on to have a successful pregnancy.

🎯 AT A GLANCE — WHEN TO START A WORKUP

Causes broadly fall into four categories: genetic, anatomic, endocrine, and autoimmune — with a substantial share remaining unexplained even after full evaluation

GREEN — One early loss: common and usually not an indication for formal workup; offer reassurance

AMBER — Two consecutive losses: consider starting evaluation, individualized by age, anxiety, and reproductive history

RED — Three or more losses, or any second-trimester loss: full RPL workup is indicated

Timing is a clue: first-trimester losses point more toward genetic/chromosomal causes; a second-trimester loss shifts suspicion toward an anatomic cause or cervical insufficiency.

🧬 THE FOUR CATEGORIES OF CAUSE

Genetic: a parental balanced translocation (2–4% of couples), or sporadic embryonic aneuploidy — the single most common cause of any individual loss, rising with maternal age

Anatomic: a septate uterus (the anomaly most strongly linked to RPL), intrauterine adhesions, submucosal fibroids, or cervical insufficiency (second-trimester pattern)

Endocrine: poorly controlled diabetes, untreated thyroid dysfunction, hyperprolactinaemia

Autoimmune: antiphospholipid syndrome (APS) — the best-established and most treatable cause in this category

🧪 WORKUP — WHAT TO TEST FOR

1

Parental karyotyping — both partners, looking for a balanced translocation

2

Karyotype of products of conception, where available, especially after a second or third loss

3

Pelvic imaging — 3D ultrasound, saline infusion sonography, or MRI to assess uterine anatomy

4

Antiphospholipid antibodies — lupus anticoagulant, anticardiolipin, and anti-β2-glycoprotein I, each confirmed twice, 12 weeks apart

5

Thyroid function (TSH) and glycaemic screening where risk factors are present

Routine testing for most inherited thrombophilias (beyond APS) is increasingly not recommended by major guidelines — the evidence linking them causally to RPL is weak.

⚕️ ANTIPHOSPHOLIPID SYNDROME — DON'T MISS THIS ONE

Diagnosed with a clinical criterion (pregnancy loss or thrombosis) plus a laboratory criterion (persistent antibody positivity on two occasions, 12 weeks apart)

Of all RPL causes, this is the one where treatment most clearly and consistently improves the live birth rate

Two Different Regimens — Don't Mix Them Up

Obstetric APS only (loss history, no personal thrombosis): low-dose aspirin 75–100 mg daily plus prophylactic-dose LMWH (e.g., enoxaparin 40 mg once daily, or weight-adjusted)

APS with prior venous/arterial thrombosis: low-dose aspirin plus therapeutic-dose anticoagulation throughout pregnancy — these patients need full anticoagulation regardless of pregnancy

Timing

Aspirin: start as soon as pregnancy is confirmed (some start pre-conception); continue until around 36 weeks, or per your obstetric/anaesthesia protocol

LMWH: start once a viable intrauterine pregnancy is confirmed on ultrasound; continue throughout pregnancy

Postpartum: continue anticoagulation for at least 6 weeks — the postpartum period carries the highest thrombotic risk of all

Around delivery: coordinate the last LMWH dose with anaesthesia well in advance — a prophylactic dose is generally held for at least 12 hours, and a therapeutic dose for at least 24 hours, before a neuraxial block. Plan this early, not on the day.

Genetic (Parental Translocation)

Genetic counselling is essential

Options include PGT-SR with IVF, or natural conception with prenatal diagnosis (CVS/amniocentesis)

Anatomic

Hysteroscopic septum resection improves outcomes in a septate uterus

Cervical insufficiency is managed with cerclage in a future pregnancy

Endocrine

Optimize thyroid function before conception

Optimize glycaemic control if diabetic

Unexplained

Supportive, closely-monitored early pregnancy care

Aspirin and progesterone are sometimes used, though evidence is mixed — individualize

For Counselling

Most Go On To Have a Baby

60–75%

LIVE BIRTH RATE
NEXT PREGNANCY

Even after multiple unexplained losses, most women who conceive again will carry a pregnancy to a live birth with supportive care alone. The number of prior losses and maternal age matter more for prognosis than whether a specific cause was ever found.

A full workup finds no clear cause in up to half of couples — this is common, not a failure of testing

Supportive, closely-monitored care in early pregnancy ("tender loving care") is itself linked to better outcomes in trials

Grief and anxiety after repeated loss are normal — pair medical reassurance with genuine emotional support, not just a test result

Reminder: "unexplained" is a description of our testing, not a verdict on the pregnancy ahead.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary for structured teaching and counselling; exact definitions, testing thresholds, and treatment protocols vary by guideline body — follow local and institutional practice.