Recurrent Miscarriage

CONDITION

What is recurrent miscarriage?

Recurrent miscarriage is the loss of two or more consecutive pregnancies that have involuntarily ended before 20 weeks. To be called a miscarriage, these pregnancies should have been clinically-recognised on an ultrasound or pregnancy tissue found after the loss.

What are the common names for recurrent miscarriage?

Recurrent miscarriage can also be referred to as recurrent pregnancy loss, habitual abortion or multiple miscarriages.

What is the percentage of population affected by recurrent miscarriage?

Recurrent miscarriage is about 15-20%. Early losses that occur even before a missed period may be as high as 30-50%. In women who have a history of two or more previous losses, the risk increases to about 40%. The risk of miscarriage is increased with advancing maternal age. Evaluation should be instituted after 2 losses especially in the infertility population.  About 5% of women will have at least 2 consecutive miscarriages while only 1% experience 3 or more.

How does recurrent miscarriage affect you?

If you are trying to get pregnant, recurrent miscarriages can be physically and emotionally difficult for you and your partner to handle.

Which part of the body is affected?

The female reproductive system is made up of the following parts:

  • Vagina: opening of the reproductive system, which allows the entry of sperm
  • Cervix: narrow region that connects the vagina to the uterus
  • Uterus or womb: where a fertilised egg implants and grows to develop into a baby
  • Ovaries: organs on either side of the uterus, which release an egg each month in the prospect of a pregnancy
  • Fallopian tubes: narrow tubes that open out at the ovaries to pick up the released egg for fertilisation

Each month an egg is released from an ovary and is taken up by the fallopian tube. If it gets fertilised by sperm, the embryo travels to the uterus and implants in the uterine membrane. From here, it develops into a baby.

How does recurrent miscarriage affect you?

Recurrent miscarriages can take a toll on your physical and emotional wellbeing. It is usually associated with eager anticipation, hope and disappointment, followed by uncertainty, fear, anxiety and grief. You will also have to face the physical and emotional consequences of intense hormonal ups and downs.

What are the causes of a recurrent miscarriage?

Some of the causes of a recurrent miscarriage are:

  • Genetic factors: chromosomal abnormalities in the foetus
  • Structural abnormalities: structural defects in the uterus, polyps and submucous fibroids and Asherman’s syndrome.
  • Antiphospholipid syndrome: autoimmune disease associated with recurrent thrombosis (clot formation) in veins and arteries
  • Hormonal imbalance: diabetes, abnormal thyroid function, high prolactin levels and decreased progesterone
  • Placenta: defects in the formation of the placenta and microthrombi in the placental blood supply
  • Severe infections: rare cause
  • Lifestyle factors: alcohol, cigarette smoking, cocaine use and increased caffeine intake

Who is at risk of recurrent miscarriage?

Increasing maternal age is an independent risk factor for recurrent miscarriage. While you can have a 15% risk between ages 30 to 34 years, your risk can increase to 51% and 93% between the ages of 40 to 44 years and ≥45 years, respectively.

The number of previous miscarriages is another determining factor for recurrent miscarriages; with the risk increasing to about 40% following three earlier pregnancy losses.

What are the signs and symptoms of recurrent miscarriage?

The symptoms of a miscarriage are:

  • Light or heavy vaginal bleeding that is irregular or constant
  • Pain, including abdominal pain, pelvic cramps, or a dull persistent ache in your lower back
  • Passing of blood clots or greyish foetal tissue from your vagina

What are the types of miscarriage?

Miscarriage can be of many types such as:

  • Threatened abortion: early symptoms such as vaginal bleeding occurs, without any other symptoms
  • Inevitable abortion: broken membranes or dilated cervix
  • Incomplete abortion: only a part of the pregnancy tissue comes out, with some of it still in the uterus
  • Complete spontaneous abortion: complete expulsion of the pregnancy tissue
  • Missed abortion: foetus has died or not developed, but there are no symptoms of a miscarriage, and the pregnancy tissue remains in the uterus
  • Septic abortion: foetal material has been infected before, during or after a miscarriage

How is the recurrent miscarriage diagnosed?

Your doctor may first review your medical, genetic, surgical and family history, and perform a thorough physical examination. If you have a high risk of genetic abnormalities, your doctor may order karyotyping of both parents. An ultrasound, saline ultrasound, MRI, hysteroscopy or hysterosalpingogram X-ray may be ordered to evaluate your uterus for abnormalities. Further tests such as amniocentesis (testing of the amniotic fluid), chorionic villus sampling (testing of the placenta) or preimplantation genetic diagnosis or PGD (egg and sperm are extracted, allowed to fuse in the lab and one cell of embryo is tested) may be ordered.

TREATMENT

What are the consequences of not treating recurrent miscarriage?

Left untreated, you may not be able to get pregnant.

What are the treatment options for recurrent miscarriage?

Treatment is centred around the underlying cause of recurrent miscarriage and may include:

  • Medication to treat antiphospholipid syndrome
  • Surgery for structural abnormalities
  • Hormone therapy to treat conditions characterised by hormonal imbalances
  • Treatment for couples with chromosomal abnormalities:
    • Genetic counselling on future risks for recurrent miscarriage
    • Preimplantation genetic diagnosis along with IVF
    • Egg or sperm donation
    • Adoption

What are the lifestyle recommendations to prevent recurrent miscarriage?

The lifestyle recommendations to prevent recurrent miscarriage are:

  • Avoid smoking cigarettes
  • Avoid cocaine
  • Reduce alcohol intake
  • Reduce excess caffeine intake

What is the current research regarding recurrent miscarriage?

Extensive research is being done to find better treatment options for recurrent miscarriage. Some of the recent studies are listed below:

  • Matjila MJ, Hoffman A, van der Spuy ZM. Medical conditions associated with recurrent miscarriage-Is BMI the tip of the iceberg? Eur J Obstet Gynecol Reprod Biol. 2017 May 3;214:91-96.
  • Ebina Y, Nishino Y, Deguchi M, Maesawa Y, Nakashima Y, Yamada H. Natural killer cell activity in women with recurrent miscarriage: Etiology and pregnancy outcome. J Reprod Immunol. 2017 Apr;120:42-47.
  • Promberger R, Walch K, Seemann R, Pils S, Ott J. A Retrospective Study on the Association between Thyroid Autoantibodies with β2-glycoprotein and Cardiolipin Antibodies in Recurrent Miscarriage. Iran J Allergy Asthma Immunol. 2017 Feb;16(1):72-76.
  • Tur-Torres MH, Garrido-Gimenez C, Alijotas-Reig J. Genetics of recurrent miscarriage and fetal loss. Best Pract Res Clin Obstet Gynaecol. 2017 Mar 27.