The couple usually feels lost; they seek help and advice from various consultants, all with conflicting recommendations. In Egypt unfortunately there are no specialized clinics for looking after women suffering from recurrent miscarriages. Recurrent miscarriage clinics are available is in many countries, like the United Kingdom. These clinics are usually run by obstetricians who have the skills and interest in managing recurrent pregnancy loss.
In this article I will try to address the various causes and investigations for recurrent miscarriages and the different ways of managing these problems. All the tests and treatments mentioned are available in Egypt.
What is recurrent miscarriage?
Habitual abortion (recurrent pregnancy loss or recurrent miscarriage) is the occurrence of 3 consecutive spontaneous miscarriages (spontaneous abortions). The majority of women who have had two miscarriages will conceive and carry normally afterwards. There are various causes for habitual abortions, and some are treatable. Some couples never have a cause identified, often after extensive investigations.
Causes of recurrent miscarriages
Womb malformations are considered to cause about 15% of recurrent miscarriages. Women who have serious anatomical abnormalities and do not have treatment for them seem to be more likely to miscarry or give birth early.The most common abnormality is the presence of a partition of the uterine cavity. The diagnosis is made by ultrasound or hysteroscopy (inserting a telescope into the womb). Also the presence uterine fibroids which are benign could result in pregnancy loss.
Weak cervix In some women the entrance of the womb (the cervix) opens too early in the pregnancy and causes a miscarriage in the third to sixth month. This is known as having a weak (or ‘incompetent’) cervix.
Chromosomal disorders For around three to five in every 100 women who have recurrent miscarriages, they or their partner have an abnormality on one of their chromosomes (the genetic structures within our cells that contain our DNA and the features we inherit from our parents). Although such abnormalities may cause no problem for the woman or her partner, they may sometimes cause problems if passed on to the baby.
Endocrine disorders Women with thyroid disorders, both under or overactive, are at increased risk for pregnancy losses. Unrecognized or poorly treated diabetes mellitus leads to increased miscarriages. Women with a condition known as polycystic ovary syndrome also have higher loss rates. In this condition the ovaries are slightly larger and produce more small follicles than normal. This may be linked to an imbalance of hormones. Just under half of women with recurrent early miscarriages have polycystic ovaries; this is about twice the number of women in the general population. Many women with polycystic ovaries and recurrent miscarriage have high levels of a hormone called luteinising hormone (LH) in their blood. Reducing the level of LH before pregnancy, however, does not improve the chances of a successful birth.
Thrombophilia Certain inherited conditions mean that the blood may be more likely to clot than is usual. These conditions are known as thrombophilia. They do not, though, mean that a serious blood clot will inevitably develop. Although thrombophilia has been thought to play some part in miscarriages, we do not yet know enough about how or why that is. Recent studies confirm that anticoagulant medication may improve the chances of carrying pregnancy to term. It explains about 15% of recurrent miscarriages.
Immune factors Antibodies are substances produced in our blood in order to fight off infections. Around 15 in every 100 women who have had recurrent miscarriages have particular antibodies, called antiphospholipid antibodies (aPL), in their blood; fewer than two in every 100 women with normal pregnancies have aPL antibodies. Some people produce antibodies that react against the body’s own tissues; this is known as an autoimmune response and it is what happens to women who have aPL antibodies.
Reduced ovarian reserve The risk for miscarriage increases with age, and women in the advanced reproductive age who have a reduced ovarian reserve are prone to higher risk of repeated miscarriages. Such miscarriages are due to decreased egg quality.
Luteal phase defect Inadequate amount of a certain hormone known as progesterone, this hormone is produced to maintain the early pregnancy. Studies about the value of progesterone supplementation remain deficient; however, such supplementation is commonly carried out on an empirical basis.
Lifestyle factors While lifestyle factors have been associated with increased risk for miscarriage in general, and are usually not listed as specific causes for recurrent pregnancy loss, every effort should be made to address these issues. Of specific concern are chronic exposures to toxins including smoking, alcohol, and drugs.
HyperprolactinaemiaProlactin is a hormone which prepares a pregnant woman’s breasts to produce milk. When a woman produces too much prolactin, this is known as hyperprolactinaemia. It is not yet clear whether this condition plays a role in recurrent miscarriage because the evidence is conflicting.
InfectionsIf a serious infection gets into the bloodstream it may lead to a miscarriage, vaginal infection called bacterial vaginosis early in pregnancy may increase the risk of having a miscarriage around the fourth to sixth month or of giving birth early. It is not clear, though, whether infections cause recurrent miscarriage; for this to happen, the bacteria or virus would need to be able to survive without causing enough symptoms to be noticed. This rules out illnesses like measles, herpes, listeria, toxoplasmosis and cytomegalovirus. Therefore there is no need to undergo these investigations.
Management of recurrent pregnancy loss
Supportive antenatal care Women who have supportive care from the beginning of a pregnancy have a better chance of a successful birth. There is some evidence that attending an early pregnancy clinic can reduce the risk of further miscarriages.
Screening for abnormalities in the structure of the womb Ultrasound examination is usually sufficient to pick up any abnormalities. Hysteroscopy may be needed in some cases if ultrasound fails to make a diagnosis. Hysterosalpingography (an X-ray of the fallopian tubes using fluid injected through the entrance of the womb) has no advantages over pelvic ultrasound and causes more discomfort, so it is not usually necessary.
Screening for genetic problems The couple should be offered a blood test to check for chromosome abnormalities; the test is known as karyotyping. In case of any abnormality, patients should be informed of the chances for future pregnancies and available choices explained. Some members of the family might have the same problem.
Screening for abnormalities in the embryo Checking the chromosomes of the embryo through karyotyping, although it is not always possible to get a result. The placenta may also be examined through a microscope. The results of these tests may help them to identify causes and thus possible treatment options.
Screening for vaginal infection By taking vaginal swabs to pick up certain infections as bacterial vaginosis Treatment with antibiotics may help to reduce the risks of miscarriage or of premature birth. There is not enough evidence to be sure that it makes any difference to the chances of a baby surviving.
Treatment for aPL antibodies There is some evidence that if in the presence of aPL antibodies and a history of recurrent miscarriages, treatment with low-dose aspirin tablets and low-dose heparin injections in the early part of pregnancy may improve the chances of a live birth up to about seven in ten (compared to around four in ten if you take aspirin alone and just one in ten if you have no treatment).
Steroids (certain sorts of natural or synthetic hormones) have been used to treat aPL antibodies in recurrent miscarriage, but they do not seem to improve the chances of a successful delivery and they carry significant risks for mother and baby compared with aspirin and heparin.
Treatment for thrombophilia Although there is a higher risk of miscarriage in the presence of an inherited tendency to blood clotting (thrombophilia). At present there is no test available to identify whether miscarriage will take place. However, in the presence of thrombophilia patients will be offered treatment to reduce the risk of a blood clot.
Treatment for a weak cervix A vaginal ultrasound scan during pregnancy may indicate the likelihood of pregnancy loss. In case of a weak cervix an operation will be offered to put a stitch in the cervix, to make sure it stays closed. It is usually done through the vagina, but occasionally it may be done through a ‘bikini line’ cut in the abdomen, just above the line of the pubic hair.
Hormone treatment It has been suggested that taking progesterone hormones( known as hormones to support the pregnancy) early in pregnancy could help prevent a miscarriage. There is not yet enough evidence to prove whether this works. However, it is a very common practice in Egypt.
Immunotherapy Treatment to prevent or change the response of the immune system (known as immunotherapy) is not recommended for women with recurrent miscarriage. It has not been proven to work, does not improve the chances of a live birth and it may carry serious risks (including transfusion reaction, allergic shock and hepatitis).
Often, in spite of careful investigations, the reasons for recurrent miscarriages cannot always be found. However, if the couple feels able to keep trying, they still have a good chance of a successful birth in future. It is important to have a positive attitude and to stay optimistic because successful pregnancies do occur after many miscarriages. I hope the scientific content is not too difficult but I am happy to clarify any bits in the article that seem vague or difficult to understand.