Modified from Branch, 2010; ETkan, 201s1; Miyakis, 2006.
2001; Ramzy, 1998). s discussed in Chapter 63 (p. 1197), most agree that excision of submucosal leiomyomas in women with RPL can be considered.
Congenital genital tract anomalies often originate from abnormal mlillerian duct formation. These have an overall incidence of approximately 1 in 200 women (Nahum, 1998). Depending on their anatomy, some may raise risks for early miscarriage, whereas others may cause midtrimester abortion or preterm delivery. Unicornuate, bicornuate, and septate uteri are associated with all three types of loss (Reichman, 2010). A fuller discussion of these anatomical abnormalities and their reproductive efects is found in Chapter 3 (p. 41).
Miscarriages are more common in women with systemic lupus erythematosus (Clowse, 2008). Many of these women, as well as some without lupus, carry antiphospholipid antibodies, a family of autoantibodies that bind to phospholipid-binding plasma proteins (Erkan, 201 1). Women with RPL have a higher frequency of these antibodies compared with normal controls (Branch, 2010). As shown in 1 able 18-5, the antiphospholipid antibody syndrome APS) is deined by these antibodies in combination with various forms of reproductive loss and substantively increased risks for venous thromboembolism (American College of Obstetricians and Gynecologists, 20 17b,i). Mechanisms that cause pregnancy loss are discussed along with treatment in Chapter 59 (p. 1144).
Regarding alloimmunity, one provocative theory suggests that normal pregnancy requires formation of blocking factors that avert maternal rejection of foreign fetal antigens that are paternally derived (Chap. 5, p. 95). Factors that prevent this tolerance may underlie RPL (Berger, 2010). However, proposed therapies using paternal or third-party leukocyte immunization or intravenous immunoglobulin (IlG) have not proved beneicial in aAt least one clinical and one laboratory criteria must be present for diagnosis. bThese tests must be positive on two or more occasions at least 12 weeks apart.
women with idiopathic RPL (Christiansen, 2015; Stephenson, 2010).
According to Arredondo and Noble (2006), 8 to 12 percent of recurrent miscarriages are caused by endocrine factors. Studies to evaluate these have been inconsistent and generally underpowered. Two examples, both controversial, are progesterone deficiency caused by a luteal-phase dect and poycystic ovarian syndrome (Bukulmez, 2004; Cocksedge, 2008).
In contrast, the well-known abortifacient action of uncontrolled diabetes mellitus is detailed in Chapter 57 (p. 1099). Optimal periconceptional glycemic control will mitigate many of these losses.
Likewise, the efects of overt hypothyroidism and severe iodine deficiency on early pregnancy failure are well known and discussed in Chapter 58 (p. 1124). Correction with supplementation reverses these actions. Also, the influence of subclinical hypothyroidism and antithyroid antibodies are sporadic, and thus any efects on recurrent miscarriage rates have been debated (Garber, 2012). That said, two metaanalyses reported convincingly positive associations between these antibodies and a greater risk for sporadic and recurrent miscarriages (Chen, 2011; Thangaratinam, 2011). One ongoing randomized trial regarding potential beneits of treatment will help guide future management (Vissenberg, 2015).