Recurrent Pregancy losses --How to empirically mange ?

 

Recurrent Pregancy Losses:  1. History:- What to ask for : family tree –Pedigree tracing : Geneticist opinion of –both partners ,Smoking, Alcohol intake, & other Addictions , Environmental pollutants including Workplace toxins, Regular ingestion of teratogens for some systemic diseases including drugs for depression & Psychiatric diseases Diabetes mellitus, Hypothyroidism, etc.. , Abnormal sperm morphology, Food habits,

 

 

 An aberrant immune response – either auto- or alloimmune – has been postulated to underlie some cases of ‘unexplained’ infertility, in vitro fertilisation (IVF) failure and recurrent miscarriage. Despite a paucity of evidence, a variety of immune tests and treatments for reproductive failure have been introduced into clinical practice.

 Sadly, in some cases the etiology even if diagnosed are not always modifiable-!! Such unfortunate causes of preg loss are genetic, emotional, endocrinological, anatomic (partly modifiable) most importantly, immunologic causes !!

 

 

 

 Rationality of Investigation?? Wil such investiagtuions help the couple?  Benefit & loss balance sheet: What will happen if one does not investigate this particular unfortunate couple at all!!! The logic behind not investigating is that in as many cases >50% of similar cases - no etiology could be established.

 • Then what shall we do the practicing obstetrician?? What is then Standard (?) “Recurrent Preg Loss work up”:-( triaging is, therefore important. ).

Low cost investigations should be initiated as the first step and immunological tests and tests for coagulation to be deferred initially.

 

Additionally, lifestyle modifications like avoidance of stress (Yoga, exercise), control of Obesity & Hyperandrogenism if there be any. .

 • Step 2:-Most people prescribe progesterone supplement after LH surge is detected and continuing for -10-12 weeks after LH surge. LDA(Low dose aspirin 150 mg at bed time)  from preconceptionally and after the cardiac activities are demonstrated one can opt for UFH (if financially weak).
• What one can do  ideally(?) is to “combine LDA(150 mg HS )  with UFH (better than LMWH) at the dosage of 5000-10,000 better 12 hourly depending on the body weight and titre of aPL and any past H/O of VTE if there be any.

But many  prefer to initiate heparin as soon as UPT is +ve. Others initiate after demonstration of cardiac activity, Unfractionated heparin is cheaper than Low Molecular weight heparin but warrants weekly or latest fortnightly by platelate count and INR .Heparin induced  thrombocytopenia may ensue may be combated with Inj protamine sulphate .