Evaluation and Management of Recurrent Pregnancy Loss

Initial Evaluation

The American College of Chest Physicians recommends screening for antiphospholipid antibodies (APLAs) in all patients with recurrent early pregnancy loss (three or more miscarriages before 10 weeks) 1
Parental karyotyping should be performed on both partners to identify chromosomal rearrangements that could cause recurrent losses, as recommended by the American Society for Reproductive Medicine 2
Thyroid function tests (TSH, free T4) are essential, as thyroid dysfunction contributes to pregnancy loss and requires optimization before conception, according to the Endocrine Society 2
Evaluate for polycystic ovary syndrome (PCOS), which is associated with higher rates of pregnancy loss, as stated by the American College of Obstetricians and Gynecologists 2

Transvaginal ultrasound (TVUS) is the initial screening tool for uterine cavity abnormalities, as recommended by the American Institute of Ultrasound in Medicine 2
Sonohysterography (SIS) provides superior assessment of the uterine cavity compared to standard ultrasound, according to the Society of Radiologists in Ultrasound 2
Hysterosalpingography (HSG) is an alternative imaging modality to identify structural abnormalities, as stated by the American College of Radiology 2

Evaluate the male partner in all couples with two or more pregnancy losses, as this is now a guideline recommendation by the American Society for Reproductive Medicine 2
Consider karyotype testing of the male partner to identify chromosomal abnormalities, as recommended by the American College of Medical Genetics and Genomics 2
Sperm DNA fragmentation testing should be considered, as increasing evidence links elevated sperm DNA fragmentation with recurrent pregnancy loss, according to the Society for Male Reproduction and Urology 2

For patients with recurrent complete hydatidiform moles, consider genetic testing for mutations in NLRP7 and KHDC3L genes, which cause familial recurrent hydatidiform mole (FRHM), an autosomal recessive condition, as recommended by the American College of Medical Genetics and Genomics 2

Do NOT routinely screen for inherited thrombophilias (factor V Leiden, prothrombin G20210A mutation, protein C/S deficiency) in women with recurrent pregnancy loss, as stated by the American College of Chest Physicians 1
The only exception is if a woman has homozygous factor V Leiden or prothrombin 20210A mutation AND a positive family history for VTE, she should receive antepartum prophylaxis with LMWH, but this is for VTE prevention, not pregnancy loss prevention, according to the American College of Chest Physicians 1

For women who meet laboratory criteria for APLA syndrome, treatment with unfractionated heparin or LMWH plus low-dose aspirin is recommended, as stated by the American College of Chest Physicians 1

Counsel on smoking cessation, alcohol avoidance, and elimination of recreational drugs, as these are modifiable risk factors, according to the American College of Obstetricians and Gynecologists 3
Regular physical activity within guidelines is safe and unlikely to increase pregnancy loss risk; it may actually benefit insulin resistance and obesity, which increase miscarriage risk, as recommended by the American College of Sports Medicine 2
Optimize nutrition and maintain healthy weight before attempting conception, as stated by the Academy of Nutrition and Dietetics 3

Confirm viable intrauterine pregnancy with early ultrasound as soon as pregnancy is detected, as recommended by the American Institute of Ultrasound in Medicine 2
Provide regular prenatal visits with serial ultrasound monitoring throughout the pregnancy, according to the American College of Obstetricians and Gynecologists 2
Screen for gestational diabetes in current pregnancies, as glucose intolerance may contribute to pregnancy loss, as stated by the American Diabetes Association 3