SPORADIC AND RECURRENT SPONTANEOUS-ABORTION

Human pregnancy is an inefficient process; only 30% of conceptions attain viability. Spontaneous abortion is the most common complication of pregnancy and is responsible for significant distress among couples and individuals desiring children. Recurrent spontaneous abortion, traditionally defined as three prior pregnancy losses before 20 weeks of gestation, occurs in 1 of 300 pregnancies. This definition should be reexamined to allow search for causation after two consecutive losses, especially in childless women in whom fetal cardiac activity had been ultrasonically detected, in women older than 35 years of age, and in couples having difficulty in conceiving. Many causes have been proposed for both sporadic and recurrent abortion, including chromosomal and other genetic anomalies, anatomic abnormalities, endocrine factors, infections, immunologic aberrations, and other miscellaneous factors. After conventional investigation, up to 60% of cases remain unexplained. Many hypotheses have been proposed to explain these otherwise unexplained losses. Many of these hypotheses are controversial, and most have been disproved. Unfortunately, the lack of scientific rationale has not stopped the implementation of many unsubstantiated therapies driven in part by patient demand and physician frustration. The ethical duty of every physician is to ensure that the tests and procedures he or she uses are worth the money, inconvenience, and risks. Understanding the potential mechanisms involved in spontaneous abortion, together with a caring, empathetic attitude of the clinician toward the couple experiencing reproductive failure, will enable amelioration of the emotional distress these couples encounter and will facilitate a rational, scientific assessment leading to appropriate consultation and ultimately effective therapy.