A 30-year-old woman, gravida 3 para 0 aborta 3, comes to the office due to a history of recurrent spontaneous abortions. The patient has had 3 first trimester spontaneous abortions in the past 2 years that did not require medical or surgical management. Her menses occur every 30 days and consist of 4-5 days of moderate bleeding and mild cramping. Her Pap tests have been normal, and she has never had a sexually transmitted infection. The patient has no chronic medical conditions and takes no medications. She had a laparoscopic right ovarian cystectomy at age 18 for a large, benign cyst. She drinks alcohol on special occasions, but does not use tobacco or illicit drugs. She practices yoga 4-5 times a week. Blood pressure is 120/70 mm Hg and pulse is 74/min. BMI is 26 kg/m². Bimanual examination reveals a smooth, normal-sized, nontender uterus and no adnexal masses or tenderness. Speculum examination shows minimal physiologic cervical discharge and a cervix with no visible lesions. Laboratory evaluation is normal. A hysterosalpingogram shows a filling defect in the middle of the uterine cavity and bilaterally patent fallopian tubes. Her husband has a healthy daughter from a prior relationship and recently had a semen analysis that was normal. The patient asks what can be done to prevent another miscarriage. Which of the following is the most appropriate response?

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Explanation: 11ec2b69_bede_deac_8f63_bbb64e3b847c_MD0005_00 Recurrent pregnancy loss (RPL) refers to >3 consecutive spontaneous abortions at <20 weeks gestation. Although the etiology of RPL is often idiopathic, it can be secondary to a variety of causes (eg, chromosomal, structural, immunologic, endocrine; hypercoagulability). Determining the etiology of RPL can guide future recommendations and treatment options to help prevent another spontaneous abortion. This patient's hysterosalpingogram shows a filling defect due to either an intracavitary leiomyoma, intrauterine adhesions (eg, Asherman syndrome), or a uterine anomaly (eg, septum, bicornuate, didelphys). This patient's smooth, normal-sized uterus and regular menses suggest the filling defect on hysterosalpingogram is due to a uterine septum, the uterine anomaly most commonly associated with RPL. Uterine septa have a relatively low blood supply; therefore, when an embryo implants on a septum, the implantation is abnormal and poorly vascularized, typically leading to pregnancy loss. Hysteroscopic resection of the uterine septum is the first-line treatment for patients with RPL and a uterine septum, and decreases the recurrence risk of spontaneous abortion (Choice E). intracavitary leiomyoma (eg, septum (Choice A) Vaginal progesterone supplementation is indicated for prevention of preterm delivery in patients diagnosed with a short cervix (<25 mm) via transvaginal ultrasound at 18-24 weeks gestation. It does not decrease the risk of pregnancy loss in patients with RPL.(Choice C) Antiphospholipid antibody syndrome can present with RPL and/or thrombosis. Aspirin is indicated as prophylaxis for thrombosis in patients with the syndrome but does not decrease the risk of pregnancy loss in these (or any) patients. (Choice D) Ovulation induction is indicated for anovulatory infertility, not RPL. This patient has regular menstrual cycles (eg, ovulatory) and no difficulty becoming pregnant; therefore, ovulation induction is not required. Educational objective: Recurrent pregnancy loss is defined as >3 consecutive spontaneous abortions (eg, <20 weeks gestation). Uterine septum, a uterine anomaly associated with recurrent pregnancy loss, can be treated with hysteroscopic resection to decrease the risk of another spontaneous abortion. References: Uterine septum: a guideline. (http://www.ncbi.nlm.nih.gov/pubmed/27235766) Uterine factors. (http://www.ncbi.nlm.nih.gov/pubmed/24491984)

A 30-Year-Old Woman, Gravida 3 Para 0 Aborta 3, Comes