Reccurent Pregnancy Loss (RPL)

To rule out antiphospholipid syndrome

1. Anticardiolipin antibodies
   1. Ig G (0-15 GPL) – better predictor of fetal outcome;
   2. Ig M (0-15 MPL);
   3. Ig A;
   Positive in medium or higher titer or >= 2 occasions six weeks apart;
2. Lupus anticoagulant; Sample must be taken uncuffed and to be centrifuged within 1 hour
   1. dRVVT ( dilute Russel Viper venom test);
   2. Activated partial thrombin time;
   3. Kaolin coagulation time.
   A panel of assays should be done; If single test is to be done, it should be dRVVT. Thrombotic complications are more with lupus anticoagulant positive than patients with positive anticardiolipin antibodies.
3. To rule out polycystic ovarian disease:
   1. LH:FSH ratio (>3:1);
   2. Hyperinsulinemia
   3. Fasting glucose: fasting insulin < 4.5 indicated insulin resistance;
   4. S.testosterone (may be increased or normal)
   5. Total testosterone – 20-80ng/ml, free testosterone – 100-200 pg/dl;
   6. Serum androstenedione (increased in PCOD, normal 60-300 ng/dl);
   7. DHEAS (increased in 50-60% patients, normal 80-350μg/dl).
4. Rule out luteal phase defect (in early loss)
   1. Serum progesterone level (< 10mmolL) - done 3 days before;
   2. Endometrial biopsy expected period in 2 consecutive cycles;
   3. Basal body temperature – luteal phase lasting < 10days.
5. To rule uterine malformations (2nd trimester losses)
   1. Hysterosalpingography;
   2. Hysteroscopy / laparoscopy;
   3. Transvaginal ultrasound.
6. To rule out cervical incompetence (2nd trimester losses)
   1. Passage of No.8 Hegar’s dilator without resistance;
   2. Passage of No.16 Foley’s catheter without resistance;
   3. Wide of funnel shape internal os on HSG.
7. Rule out other thrombophilias
   1. Antithrombin III;
   2. Protein C and S deficiency;
   3. Activated protein C resistance.

Other tests

1. Thyroid function tests – Serum TSH, T3, T4; Worthwhile but not recommended;
2. Parental karyotype;
3. Karyotype of abortus – Abortus should be collected in sterile container with Hartman’s solution/ or solution provided by the laboratory.