Review Question - QID 103364

This patient presents with repeated second trimester pregnancy losses in the setting of an anemia (likely microcytic) and a firm, asymmetric uterus which is concerning for a leiomyoma. A hysterosalpingogram can evaluate the uterine cavity.

First trimester miscarriages are typically the result of fetal anomalies (such as aneuploidies) that impair fetal development. Conversely, second trimester miscarriages are typically a result of maternal factors which allow for normal embryonic development through the first trimester; however, as the fetus and placenta increase in size, the uterus cannot support the pregnancy resulting in termination. Leiomyoma uteri present with a firm, enlarged, nontender uterus and can cause menorrhagia and a microcytic anemia. If it affects the uterine cavity, it can potentially alter fertility and lead to recurrent miscarriages. The treatment of leiomyoma uteri is removal of the leiomyomas or a hysterectomy if the patient is not interested in childbearing.

Incorrect Answers:
Answer 1: Anti-cardiolipin antibodies may be indicated in the workup of this patient's recurrent pregnancy loss; however, her concrete symptoms of a microcytic anemia and firm asymmetric uterus suggests a diagnosis of leiomyoma uteri. Anti-cardiolipin antibodies are a marker of antiphospholipid syndrome which can lead to thrombosis and repeat pregnancy losses.

Answer 2: Karotyping may be indicated in the workup of recurrent first trimester pregnancy losses and would be indicated in this patient; however, it would not elucidate her abnormal uterine cavity.

Answers 4-5: Prolactin and TSH levels are typically ordered in the workup of infertility or in patient who is unable to get pregnant. Though both of these labs should be ordered (since conditions like subclinical hypothyroidism can increase the risk of pregnancy loss), they would not further workup this patient's leiomyoma uteri.

Bullet Summary:
A hysterosalpingogram can be used to evaluate the uterine cavity in leiomyoma uteri.