Recurrent pregnancy loss — structured SAQ (15 marks)

(a) Definition and the decision to investigate now (2 marks)

• Two or more intrauterine losses up to 20 weeks, whether or not consecutive. Both ESHRE and RANZCOG trigger investigation at two losses; RANZCOG specifies they need not be consecutive and must be confirmed intrauterine. Ectopic and molar pregnancies do not count.^[1][2]
• Investigate her now. A systematic review found abnormal findings for uterine anomalies and antiphospholipid syndrome are no different after two losses than three — with less certainty for chromosomal, thrombophilia and thyroid testing — so waiting for another loss delays diagnosis without clear gain. She meets the definition.^[3]

(b) The investigation panel and three refusals (6 marks)

Three marks for the panel, three for the refusals with evidence. ^[1][2]

Routinely recommended: ^[21]

• Lupus anticoagulant (acquired thrombophilia).
• Anticardiolipin antibodies, IgG and IgM.
• Thyroid function with thyroid peroxidase antibodies.
• A 3D pelvic ultrasound of the uterus.^[21]

Three refusals, with the evidence: ^[1][6]

• Heparin for inherited thrombophilia — ALIFE2 found no benefit (live birth 72 per cent heparin versus 71 per cent standard care) and advises against screening for inherited thrombophilia.^[6]
• Levothyroxine for euthyroid antibody-positive women — TABLET found no benefit (37.4 per cent versus 37.9 per cent live birth).^[7]
• Septum resection — TRUST found hysteroscopic septum resection did not improve reproductive outcomes.^[8]
• (Also acceptable: natural killer cells, cytokines, HLA typing, vitamin D, ovarian reserve — not routinely recommended.)^[1]

(c) Confirming antiphospholipid syndrome and the treatment (4 marks)

Two marks for confirmation, two for treatment with doses. ^[4][5]

• Do not diagnose on one result. Definite antiphospholipid syndrome needs at least one clinical criterion and at least one laboratory criterion, the laboratory criterion present on two or more occasions at least 12 weeks apart. Repeat the lupus anticoagulant at least 12 weeks later — confirm the timing with the laboratory.^[4][21][22]
• Treatment if confirmed: low-dose aspirin 75 to 150 mg daily, started before conception or from the positive pregnancy test, plus low-molecular-weight heparin from the positive test continued until at least 34 weeks. RANZCOG grades this a strong recommendation on moderate evidence.^[5][21]

(d) Levothyroxine for euthyroid antibody-positive women (3 marks)

• Do not offer levothyroxine. She is euthyroid with a TSH of 1.8 mIU per litre and positive antibodies. TABLET randomised 952 euthyroid antibody-positive women and found a live birth rate of 37.4 per cent with levothyroxine versus 37.9 per cent with placebo — no benefit.^[7]
• ESHRE upgraded its recommendation accordingly: euthyroid women with thyroid antibodies should not be treated with levothyroxine. If untreated, check TSH in early pregnancy at 7 to 9 weeks and monitor as clinically indicated.^[1][21]
• Offer levothyroxine only for overt hypothyroidism. Name TABLET as the trial that closed the question.^[7]