Recurrent Early Pregnancy Loss

Recurrent pregnancy loss (RPL) represents a disheartening and distressing loss for couples, as well as a complex clinical challenge for physicians. Clinically recognised pregnancy loss is common, occurring in over 15% of pregnancies, whilst recurrent pregnancy losses are a distinct disorder defined by two or more recognised pregnancy losses (ESHRE Guideline Group on RPL et al., Hum Reprod Open 2018(2):hoy004, 2018; Practice Committee of the American Society for Reproductive Medicine, Fertil Steril 98:1103–1111, 2012). It is estimated that less than 5% of women experience two consecutive miscarriages and only 1–2% experience three or more (Stirrat, Lancet 336:673–675, 1990; Rai and Regan, Lancet 368:601–611, 2006). A comprehensive evaluation may include investigations into anatomic, genetic, endocrine, autoimmune and iatrogenic causes of recurrent pregnancy loss. The psychological impact that may result from repeated pregnancy losses should also not be underestimated, and supportive psychological care should also be offered to couples (ESHRE Guideline Group on RPL et al., Hum Reprod Open 2018(2):hoy004, 2018; Gibbins and Porter, Clin Obstet Gynecol;59(3):456–463, 2016). The investigations and management of RPL are unsolved problems, and there is no clear aetiology found in up to 50% of es. However, despite this, women with unexplained recurrent first trimester miscarriage have an excellent pregnancy outcome if offered supportive care and conceive a subsequent pregnancy with 50–60% success rate (Royal College of Obstetricians and Gynaecologists, Scientific Advisory Committee, Guideline No. 17. The Investigation and treatment of couples with recurrent miscarriage, 2011). Assessment of RPL should focus on screening for genetic factors, antiphospholipid syndrome and assessment for uterine malformations, endocrine disorders and optimising healthy lifestyle behaviours (ESHRE Guideline Group on RPL et al., Hum Reprod Open 2018(2):hoy004, 2018; Practice Committee of the American Society for Reproductive Medicine, Fertil Steril 98:1103–1111, 2012). Overall, evidence-based and up-to-date clinical practice guidelines are required to inform the effective management of couples with RPL, and the goal remains to optimise value and adhere to evidence-based care (Branch and Silver, Clin Obstet Gynecol 59(3):535–538, 2016).