Referral Patterns and Outcomes for Women with for Recurrent Pregnancy Loss Managed At a Multidisciplinary Thrombosis Program,

Recurrent pregnancy loss (RPL) can affect up to 5% of couples who are trying to conceive. In addition to the mental anguish, miscarriages are accompanied by the physical component of pain with the potential need for hospitalization and medical or surgical intervention. While, the recommended evaluation of RPL includes an assessment of multiple variables, including disorders of thrombophilia, the definition of RPL remains vague. Because no explicit definitions exist for RPL, we undertook an analysis of patients referred to a large, tertiary care center specifically for the evaluation and treatment of RPL.

We utilized data from the Duke University site of the Thrombosis and Hemostasis Centers Research and Prevention Network established by the Division of Blood Disorders of the Centers for Disease Control and Prevention (CDC). Patients referred to Duke University with a diagnosis of RPL were followed prospectively and their data regarding the diagnostic evaluation, prescribed treatments, and subsequent maternal-fetal outcomes were recorded. Information from the initial intake included demographic data, reason for referral, number and sequence of pregnancy losses, thrombophilia assessment, as well as the additional recommendations. Results of clinical evaluations performed at Duke, including coagulation assays, autoimmunity testing, examination of uterine anatomy, and parental chromosomal analysis were recorded, as well as any prescribed treatments of the current/subsequent pregnancy. Where follow-up data was available, results of the current and subsequent maternal and fetal outcomes were noted.

As of March 2010, 2566 participants were enrolled in the CDC Patient Registry at Duke University, of which 62 were referred specifically for RPL. We found that almost 30% of referred patients (18/62) had undergone no prior testing, whereas at least 25% of referred patients came with a diagnosis that could not be confirmed. The most common misdiagnosis was of a thrombophilic marker, particularly with low-titer anti-phospholipid antibodies. Our evaluation found no discernible cause for RPL in 38% (23/62) of the women referred; our most common identified factor was a thrombophilic disorder (32%, 20/62) (Table 1 ). We found that analysis of the uterine cavity and assessment of parental chromosomes was infrequently performed prior to referral. The most common treatment recommendation was low molecular weight heparin, followed by observation alone. For patients who subsequently became pregnant, an overwhelming majority of women had no adverse maternal outcomes (86%), and a 72% live birth rate was recorded. Fortunately, no maternal deaths were observed.

Women with underlying thrombophilia who are interested in having a successful pregnancy can be effectively diagnosed, counseled, and treated. These results show that for women with RPL, a coordinated, multi-disciplinary approach can be beneficial to achieving a safe pregnancy and healthy baby. Furthermore, the CDC Thrombosis and Hemostasis Centers Research and Prevention Network is enrolling a broad and robust patient population with thrombotic disorders and provides a national registry for tracking and evaluating pregnancy outcomes.

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