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Recurrent pregnancy loss affects about 5% of couples and it's associated with a huge emotional burden. As you would expect, there is some evidence that vaginal progesterone supplementation may be considered in patients with recurrent pregnancy loss who are now experiencing vaginal bleeding during the first trimester. But what about prophylactic dose aspirin in the first trimester or preconceptionally for unexplained recurrent pregnancy loss as a therapeutic intervention? Is this evidence based? Well, there's a new publication from the Society of Maternal Fetal Medicine from their new journal Pregnancy that looked at this. So in this episode we're going to tackle prophylactic low dose aspirin for otherwise unexplained recurrent spontaneous pregnancy loss. Is this a thing? Should we be offering this? What does the data say? We're going to get into it in this episode. Sam Sappa's OBGYN no Spin Podcast.

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Podcast Family we have covered recurrent pregnancy loss on this show several times before. We've Talked about the May 2024 Clinical Expert Series from the ACOG on it and we did that in May of that year, 2024 last year. We've talked about antiphospholipid antibody syndrome. We've talked about the various definitions of recurrent pregnancy loss. Is it two losses, Is it three losses? Do they have to be consecutive? No, we've talked about all of that in the past. But recurrent pregnancy loss, regardless of how you define it, regardless of whether they're consecutive or not, well, we cannot argue is the fact that they're devastating. I mean, they're an emotional burden. Everyone carries it differently. Some are much more bothered than others, but they shouldn't be ignored. That's a take home message. And you should do the appropriate evaluation for it, which we have covered in the past. Remember, that's antiphospholipid antibody. You should look for that. You should look for uterine structural abnormalities. We should look for parental genetic information. So parents need a karyotype to look for perhaps balanced translocations that become unbalanced in the child. So we need to do a formal evaluation for this. Okay? And remember that thrombophilia evaluation outside of antiphospilipin antibody syndrome is not part of that evaluation. We covered that not long ago on this show. But here's the issue, all right? You do your evaluation, you do the chromosomes, you do all this eval, you do a 3D ultrasound of the uterus and it looks normal. And, or an HSG, whatever. 3D ultrasound is, really replace an HSG for uterine cavity defect effects or even for some alluring anomalies, because 3D ultrasound of uterine structure is just so good now that very few actually need an hsg, unless you're looking for tubal blockage. So let's say you do all the work up and you find nothing. I mean, there's nothing like. I don't find anything. I mean, you know, you're not a diabetic. Your thyroid is, seems to be normal, uterine cavity seems to be fine. You don't have antipathy antibody syndrome. Genetically, you're well. All right, well, let's keep going. But the next question becomes this. Is there anything possible that I can take, like aspirin, Would that help? Because that's gone around and round into the literature. Now, let me just start off right off the bat, right at the beginning, aspirin plus low dose heparin is absolutely the recommendation for, for recurrent pregnancy loss in the presence of antiphospholipid antibody syndrome. We get that. That's not an issue. That's absolutely the standard of care which has been for a long time. And for patients with known antiphospholipid antibody syndrome, aspirin should begin before they get pregnant. All right, so if you have a patient with aps, they should be on low dose aspirin if they're trying to conceive so that it's already on board by the time implantation happens. To avoid a faulty implantation, then you add the heparin in its usual dosages once pregnancy is confirmed. All right, so aspirin is absolutely a thing for antiphospholipid antibody syndrome to prevent recurrent pregnancy loss in those patients. But what about unexplained? It's otherwise normal, yet you do a workup and there's nothing. Right now the ACOG does not recommend low dose aspirin for the prevention of early pregnancy loss in women with unexplained recurrent pregnancy loss. Very similar, of course, to asrm. We just don't do it. And that goes all the way back to a very large study that was done back in 2014 that found no significant difference in live births or in cases of recurrent pregnancy loss. Of recurrent pregnancy loss between the aspirin and placebo groups in patients who do not have antiphospital antibody syndrome. Right. So that's nothing new. We've known that for over a decade. However, apparently it's still a thing because there's a brand new study out of November of 2025 in SMFM's new online journal, Pregnancy now. This just came out, officially published on November 22, 2025. Guys, recent, because we're doing this on the 25th of November. So this came out three days ago and the title of this meta analysis is Low Dose Aspirin in Unexplained Recurrent Pregnancy A Systematic Review and Meta Analysis. Now, the fact that authors took the time out to do this systematic review and meta analysis and publish this November of 2025, even though we've known since 2014 that unexplained recurrent pregnancy loss and aspirin doesn't make a difference, apparently still a thing because this is still being explained and studied. Okay, so once again, aspirin right now for antiphospholipid antibody syndrome. Absolutely. That's a check to prevent recurrent pregnancy loss and absolutely gets the check mark. Of course, for preeclampsia or hypertensive disorders or pregnancy prevention. And while some are advocating based on emerging data that maybe it might help with preterm labor, ACOG says yes, we realize that data is out there. But as of right now, there's not enough high quality data to really move the needle, so it doesn't recommend it for that. So right now, outside of antiphospholipid antibody syndrome and recurrent pregnancy loss and hypertensive disorder or pregnancy prophylaxis, no other real indication for low dose aspirin in pregnancy. All right, so that's where we stand. However, once again, this issue does keep coming around and I have periodically received questions through our social media channel. Hey, this lady, she's just devastated. She had her third pregnancy loss several months ago. Now she's pregnant again. Is there anything I do? What about aspirin? No. I mean, you can give her aspirin. It's just not gonna do anything and it's false hope and it's not in line with current OBGYN guidance or standards. All right, so short of it is, even before this systematic review and meta analysis came out, all of the data do not support low dose aspirin in the first trimester for unexplained recurrent pregnancy loss. Actually, there's one study that showed it may actually increase spontaneous pregnancy loss outside of antiphospholipid antibody syndrome, but that was one study and it kind of freaked people out. So, like, the short of it is it doesn't help and maybe potentially could hurt. So let's not do that, okay? Unless you have antiphospholipid antibody syndrome. Now, there was a bigger trial that looked at low dose aspirin that showed a small maybe, and that's the key word there, maybe. In other words, a modest improvement in live birth rates in those patients who use low dose aspirin after one or two previous losses. So I don't want you to say, hey, what about the Eager trial? That's E A, G, E, R. Yes, I know the Eager trial, thank you very much. And yes, it did say that maybe it could help. However, that study had a lot of limitations. That was in 2021 and the EGR trial. Actually, the full name of this study is quote, the effect of preconception initiated low dose aspirin on human chorionic gonadotropin detected pregnancy, pregnancy loss and life birth per protocol analysis of a randomized trial. End quote. Yeah, that's all the title. And oddly enough, guess what journal that was in that was in the Annals of Internal Medicine. I can bet you that no internist is gives a damn about low dose aspirin and HCG levels and pregnancy loss. That's just not their lane. All right? But whatever hey, good for these authors who got it published in the annals of internal Medicine. That was called the Eager Trial. And yes, it did show maybe it might could help with live birth rate in those with one or two prior losses, but it had a lot of issues. All right, so even though that was out there, and yes, I know there is this one study that maybe could help. The majority of the data show no, it doesn't do anything in cases of unexplained recurrent pregnancy loss. Which, which brings us to this New publication now 72 hours ago from when we're recording this. Now, I want to do this very quickly because as I said in the intro a little while ago, we're doing this on November 25th. We're getting close to Thanksgiving. I don't want to bore anybody with a bunch of data because everyone's mind is on turkey and gravy, okay? Including my own. Although I'm going to be very thankful. I'm very thankful, thank God that I am. I get to be with my family on Thanksgiving, although I'm working in the weekend, so I'll take what I get. Any time off that I can be with family is wonderful. And I'm very thankful for many things. I'm thankful my kids are healthy. I'm thankful, you know, no one's in jail. I can be honest, thankful, you know, we all have our wits about us. You know, we're not suffering with some kind of severe mental illness because, you know, my family had been, has been previously affected by that. I'm thankful for that. We have a house. I'm thankful I get a job that I love. Guys, there's so many things to be thankful for when you consider the basic necessities. So I just want us to really concentrate on that. But if you're driving to Thanksgiving and you're listening to this, happy Thanksgiving to you. And that's why I want this to be relatively brief, relatively brief in this. Plus, I promised our producer that I wouldn't take forever. Short answer is because, again, this is nothing new. Guys, how many times have we said this? There's really nothing new under the sun. Things get repackaged and then, you know, a new author comes up and goes, oh, look what we have found about low dose prophylactic aspirin and unexplained recurrent pregnancy loss. It doesn't work. You don't say again. We've known that since 2014 with a large trial that came out and even the Cochrane review showed outside of antipilate antibody syndrome. Yeah, it just doesn't do anything. This new publication from the journal Pregnancy took a look at three. That's it, three RCTs that met their inclusion criteria with an n of about 656 pregnancies. That's it, 656. Short answer. There was no significant improvement in continuation of pregnancy with aspirin. Now to be fair, even though there was no benefit of using low dose aspirin in those with unexplained recurrent pregnancy loss, it does require a special mention here. And the special mention is that the dose used was 50 to 80 milligrams. Yo, super low dose. I mean, damn. I mean even a baby aspirin is 81 milligrams. So this was exceptionally small. All right, so they realize that and they say, hey, maybe, maybe 150 milligrams or two baby aspirins at 162 milligrams, maybe that could help. But as of right now, further studies, specifically randomized controlled trials using 150 milligrams of aspirin in unexplained recurrent pregnancy loss are needed to clarify the efficacy of acetyl salicylicylic acid in preventing placental insufficiency related pregnancy loss. End quote. So even though this study has limitations of only doing three RCTs of only including 656 pregnancies and of using a dose that is super super small of 50 to 80 milligrams as of white right now, ACOG and ASRM and even SMFM does not recommend low dose acetyl salicylic acid asa otherwise known as aspirin for the prevention of early pregnancy loss in women with otherwise unexplained recurrent pregnancy loss. So if you got aps, please use it. If you got some other condition that requires aspirin use, keep using it. But to give false hope that recurrent pregnancy loss somehow is going to be better by giving low dose aspirin in cases when you haven't found anything else. It's just not evidence based. So let's stick right now with national guidance, even though it may change later. But as of right now, there is no benefit outside of antiphospholipid antibody syndrome or for whatever other medical condition that that may require aspirin use for women with unexplained miscarriage as a way to increase pregnancy longevity. Podcast Family I think we've done what we're supposed to do. I wanted this to be relatively quick because again, we're getting close to three Thanksgiving. I don't believe we're going to do another one before Thanksgiving because that's just two days away. So we send you our best regards. We thank you for your partnership, we thank you for your faithful support. And we will be back sometime after Thanksgiving to bring you another hot off the press episode and or at least a summary of some kind of ob GYN topic when we come back. So as always, podcast family, we're thankful for you. Spend time with family and enjoy one another. And now that we've done all that, it let's take it home. This has been Dr. Chapa Zobichyn, no Spin Podcast Podcast Family. Thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin Podcast.