Recurrent miscarriages – A distressing but treatable problem
Miscarriage (abortion or pregnancy loss) is the most common complication of pregnancy. Approximately 15% of all pregnancies end in a miscarriage and 25% of women suffer at least one miscarriage. Recurrent pregnancy loss is preceded by distinct pregnancy symptoms, and is usually defined as the loss of three or more consecutive pregnancies. Fortunately, only 1% of couples fall into this group. A woman who has suffered a single abortion has an 80% chance of successful outcome as compared with one with three losses, as she would have 60% chances of successful pregnancy outcome in future.
What causes miscarriage?
There is no single cause for recurrent miscarriages.
- Genetic – It is one of most common causes of miscarriage. Even if parents are genetically normal fetus can be genetically abnormal and miscarriage is nature’s way of getting rid of chromosomally abnormal pregnancies. The chromosomes carry the genetic information, and the fetus inherits one half of its chromosomes from the mother and one half from the father. Errors in transmission and division of chromosomes can occur and lead to abnormalities incompatible with life and lead to miscarriage. In 3 to 5 percent of couples, one partner possesses abnormal chromosomes which are passed on to the fetus, owing to which the chance of recurrent miscarriage definitely increases. In isolation, this is one of the most prominent causes of miscarriage.
- Hormonal – Earlier, hormonal imbalances and low levels of progesterone were considered to be one of the causes of miscarriage. Recent studies have shown that low progesterone is in fact the effect and not the cause of the miscarriage. Polycystic ovaries have been associated with abnormal hormonal status, and it has been associated with recurrent miscarriages in few studies.
- Blood clotting disorders – The importance of blood clotting disorders and recurrent miscarriage has now been firmly established. It is well established that women’s blood becomes thicker during pregnancy, which stands among the most visible pregnancy symptoms. Well, it has been recently shown that this effect is more in few women. If blood clots occur in the blood vessels of the placenta, the blood flow to the baby is decreased and this can lead to miscarriage. The Antiphospholipid Syndrome is seen in 15% of women with recurrent miscarriages, and if not treated, it can lead to repeat abortion in more than 90% cases. If properly diagnosed and treated during pregnancy, then there is more than 80% chance of having successful pregnancy in future. This condition leads to increased clotting tendency in women, and requires treatment with especial blood thinning agents (Aspirin and low molecular weight Heparin).
- Infection – Repeated vaginal infections may be responsible for late (more than 14 weeks) losses in few cases, making them another major cause of miscarriage.
- Structural abnormalities – Cervical incompetence (weakness of neck of womb) is among the causes of miscarriage that is responsible for late losses (more than 14-15 weeks). Applying stitches to the cervix is beneficial in such cases. There is typical history of painless and quick abortion and cervical ultrasound is definitely helpful in identifying such cases where pregnancy symptoms clearly show. Other rare uterine abnormalities like unicornuate uterus, uterine septum, etc. are also known to cause recurrent abortions.
- Smoking, drinking alcohol and cocaine intake by mother are also linked to recurrent miscarriages.
- Rh negative women with history of isoimmunisation suffer from repeated abortions.
- Stress can seriously affect our health and though there is no clear cut evidence that stress causes miscarriages but distressed mothers may be more susceptible to illness or medical problems in pregnancy.
- There is no evidence that sex, physical activity or transvaginal scanning in pregnancy are causes of miscarriage.
What tests could be considered when there is recurrent miscarriage?
There are a very large number of tests that can be considered when there have been repeated abortions.
- Chromosomal analysis of parents
- Rubella screening – TORCH is not a cause of recurrent abortions and rubella is done to rule out susceptibility for future pregnancy.
- Antiphospholipid antibody screening- lupus anticoagulant and anticardiolipin antibodies to be done twice at least at a difference of 6 weeks in non-pregnant state.
- Pelvic scan to rule out uterine malformation
Treatment of recurrent miscarriages
- It is based on the proper evaluation of cause.
- It has been seen that early evaluation and regular follow up by dedicated recurrent miscarriage clinics can achieve as high as 90% success rate in these cases.
- Tender loving care of women and repeated early scanning and counseling by recurrent miscarriage specialists has very soothing effect on parents and can help in achieving successful outcome.
Men and Miscarriage
The experience of pregnancy loss, and that too after pregnancy symptoms, can be very devastating and lonely not only for a woman but also for her partner. The person who is most commonly forgotten in a family bereaved by a miscarriage is father. It has been seen that counseling of the partners, repeated meetings with both, and involvement of husband with wife’s treatment and care can provide support in such circumstances, and help in successful outcomes in the future.
Some commonly asked questions after miscarriage?
Why did I have miscarriage?
The first thing many women ask is – Could I have prevented this miscarriage?
What you should know is that it is highly unlikely that anything you did could have caused this miscarriage. But you definitely need support and careful evaluation to avoid preventable causes of miscarriage.
What will happen now?
There are medical and surgical ways of getting rid of miscarried pregnancy and now-a-days, the medical options are much safer and less interventional.
When can I try for another baby?
Once you and your partner are ready mentally and physically, you can try for pregnancy. It is advisable that you get properly evaluated by recurrent miscarriage specialist in non-pregnant state to achieve the best outcomes in the future.
Dr Preeti Jindal
Consultant, Gynaecology and Obs
Fortis Hospital Mohali