A 35-year-old woman, gravida 4 para 1 aborta 2, comes to the office for her first prenatal visit. Her last menstrual period was 7 weeks ago, and she is concerned about a recent episode of vaginal bleeding and cramping. A home pregnancy test was positive a few days after the patient's missed menstrual period. Around that time, she had nausea that has since subsided. She has had 1 prior full-term delivery followed by 2 early first-trimester losses requiring dilation and curettage procedures. Six months ago, she had an isolated episode of sudden right arm weakness and slurred speech, which resolved spontaneously 2 hours later. The patient takes a daily prenatal vitamin but no other medications. BMI is 34 kg/m². Blood pressure is 130/80 mm Hg. Pelvic examination shows a closed cervix; no vaginal bleeding; and a slightly enlarged, irregularly shaped uterus. Ultrasound reveals an empty uterus with a single subserosal fibroid that is 2 cm in diameter. β-hCG is 23 IU/L. Which of the following maternal factors is the most likely cause of this patient's miscarriage?

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11ec25c8_da1d_6923_bc81_8ba837946ee0_MD0003_00 This patient has now had 3 consecutive spontaneous abortions consistent with recurrent pregnancy loss (RPL). There are multiple etiologies for RPL, including structural (eg, uterine anomaly), genetic (eg, aneuploidy), and endocrine (eg, diabetes mellitus) causes. However, in this young woman who has also had a prior episode of sudden weakness and slurred speech (suggesting a transient ischemic attack), the most likely etiology of her RPL is antiphospholipid antibody syndrome (APS). APS is an autoimmune disorder caused by antiphospholipid antibodies (eg, lupus anticoagulant, anticardiolipin antibody) that create a hypercoagulable state leading to venous and/or arterial thrombosis (eg, transient ischemic attack). During pregnancy, APS can cause placental vessel thrombosis, which may result in RPL (as in this patient) or in other pregnancy complications (eg, preeclampsia, placental insufficiency). Due to the high risk of venous and/or arterial thrombosis, patients with APS require chronic anticoagulation. Nonpregnant patients are anticoagulated with warfarin; pregnant patients receive low molecular weight heparin. (Choice A) Multiple sclerosis causes multiple, focal, demyelinating lesions of the CNS and may present with arm weakness and slurred speech. However, multiple sclerosis is not a cause of RPL, making this diagnosis less likely. (Choice B) Submucosal and intracavitary uterine fibroids may cause RPL due to interference with implantation. Subserosal fibroids are located outside the uterine cavity and therefore typically do not interfere with implantation or cause miscarriage. Subserosal fibroids (Choice D) Patients with insulin resistance (eg, type 2 diabetes mellitus) are at increased risk of miscarriage, particularly those with high glucose levels (due to congenital anomalies and/or placental hypoperfusion). Patients with pregnancy loss due to insulin resistance typically have known poorly controlled diabetes mellitus, in contrast to this patient with no known medical conditions. (Choice E) A subclinical uterine infection (eg, chronic endometritis, pelvic inflammatory disease) can cause infertility by interfering with implantation. It is not associated with RPL or arm weakness and slurred speech. Educational objective: Patients with recurrent pregnancy loss plus an unprovoked venous and/or arterial thrombosis (eg, transient ischemic attack) may have antiphospholipid antibody syndrome, an autoimmune disorder that causes a hypercoagulable state. Management is with chronic anticoagulation. References: The antiphospholipid syndrome: still an enigma. (http://www.ncbi.nlm.nih.gov/pubmed/26637701)

A 35-Year-Old Woman, Gravida 4 Para 1 Aborta 2, Comes