Recurrent Abortion/Pregnancy Loss
Recurrent miscarriage, habitual abortion, or recurrent pregnancy loss (RPL) is classically defined as the occurrence of three or more consecutive pregnancy loss; however, the American Society of Reproductive Medicine (ASRM) has recently redefined recurrent pregnancy loss as two or more pregnancy losses. A pregnancy loss is defined as a clinically-recognized pregnancy involuntarily ending before 20 weeks. A clinically-recognized pregnancy means that the pregnancy has been visualized on an ultrasound or that pregnancy tissue was identified after a pregnancy loss.
Causes:
Chromosomal Abnormalities
Mismatched chromosomes account for at least 60 percent of miscarriages. Chromosomes are the tiny structures in each cell that carry our genes; we each have 23 pairs of them, one set from our mother and one set from our father. Sometimes, when the egg and sperm meet, one or the other is faulty and then the chromosomes can’t line up properly. In that case, the resulting embryo has a chromosomal abnormality and the pregnancy usually results in a miscarriage. Couples who experience two or more miscarriages in a row sometimes learn, through medical testing, that they have chromosomal anomalies that don’t affect them, but do prevent a pregnancy from taking hold.
If you have one miscarriage, be patient. The odds are strongly in your favor that you will get pregnant again and deliver a healthy baby. If you miscarry again, however, consider preserving the tissue you pass (if possible, save it in a sterile saline contact-lens solution) and take it to your physician to be sent to a lab for chromosomal testing. If it’s chromosomally normal, we can immediately start looking for other issues that may be responsible for the miscarriages and may be treatable.
Uterine Abnormalities and Incompetent Cervixes
If you have a uterus that is “abnormally” shaped or divided-called uterine septum–miscarriage occurs because the embryo either can’t implant or once it does implant, can’t get the nourishment it needs to survive. “Uterine anomalies account for about 10 percent of miscarriage. A weakened or incompetent cervix is another problem that can lead to miscarriage, because toward the end of the first trimester the fetus has grown large enough that the cervix starts to bulge. If the cervix is weakened, it can’t hold the fetus in.
Your physician may not discover this problem until you have had recurrent miscarriages, or until your pregnancy is well under way. The good news is that, Uterine septum can be corrected with surgery. And if you have an incompetent cervix, your physician will put a stitch in the cervix to keep it closed, a procedure called a cerclage. You may also require bed rest or hospitalization for part of your pregnancy.
Immunologic Disorders
When you consider that a woman’s body views sperm as a foreign object, it’s a wonder that pregnancy happens at all. But most of the time, a fertilized egg sends a message to the mother that says ‘don’t treat me like a germ, and pregnancy proceeds without incident. In some cases, though, the embryo isn’t accepted by the woman’s body. Antiphospholipid antibodies—antibodies that attack one’s own tissue, including embryos-account for many miscarriages that physician used to think were unexplainable.
There hasn’t been much research done in this area yet. While the treatments are still considered experimental.
Untreated Illnesses Such as Thyroid Problems (Both Hyper- and Hypo-Thyroidism) and Uncontrolled Diabetes
Thyroid conditions and uncontrolled diabetes are both associated with “unfavorable” uterine environments. The effects of these conditions make it difficult for the embryo to survive. Make the lifestyle changes your doctor recommends, and follow any recommended treatment regiments to get your diabetes under control. Thyroid conditions can usually be corrected with medication.
Polycystic Ovary Syndrome (PCOS)
This is now an emerging cause of recurrent miscarriage. Women with PCOS have too-high levels of the male hormone testosterone which, among other things, causes irregular ovulation and menstruation. Even in women who don’t have diabetes, PCOS causes insulin resistance, which prevents the endometrial lining from maturing properly. Treatment with oral antidiabetic drugs, such as metformin (Glucophage), has been successful in reducing miscarriage in women with PCOS.
Bacterial Infections
Many micro-organisms live harmlessly-even helpfully-in the male and female reproductive tracts. But certain bacteria can cause problems, including an increased risk of miscarriage. Two in particular-mycoplasma hominis and ureaplasma urealyticum-live in the genital tracts of healthy men and women, but can raise the risk of miscarriage. In women, infection with these bacteria can inflame the endometrium (the lining of the uterus), making it impossible for an embryo to develop. There are no symptoms, however, so the only way you know if you or your partner is carrying the organism is to be tested. These infections can usually be easily treated with antibiotics.
Lifestyle (Cigarettes, Alcohol, Drugs, Environmental Toxins)
Nicotine crosses the placenta and interferes with blood supply and fetal growth. Smokers have twice the rate of miscarriage as nonsmokers. Drinking more than two alcoholic beverages a day is also associated with miscarriage, using recreational drugs when you’re attempting to get pregnant (or during pregnancy) is foolish. Finally, women who work in certain environments-including farms, operating rooms, dental offices and hospital laboratories-have a higher rate of miscarriage for unknown reasons. Give up all deleterious habits before you try to become pregnant and you increase your odds of enjoying a successful pregnancy. If you’re worried that your workplace may not be healthy for you, tell your doctor about your concerns.
Treatment
The treatment recommendations for patients with recurrent pregnancy loss are based on the underlying cause of recurrent pregnancy loss. No matter what the results of the work-up are, the chance for a successful future pregnancy is high.
Individuals in whom a karyotypic (a chromosomal or genetic) abnormality is found are often referred for genetic counseling. There, a specialist can discuss what the genetic abnormality is and the likelihood of having a chromosomally normal or abnormal pregnancy in the future. Some affected couples may choose to undergo prenatal genetic studies during pregnancy to check the genetic make-up of the offspring with either 1) chorionic villus sampling (CVS), in which a piece of placenta is biopsied late in the first trimester or early in the second trimester, or 2) amniocentesis, which removes some of the amniotic fluid (the fluid that surrounds the baby during pregnancy) for analysis. In vitro fertilization (IVF) with preimplantation genetic diagnosis (PGD) can also be done. With this process, the woman takes shots for several days so that many eggs grow in her ovaries. The eggs are then retrieved from the ovaries in a minor surgical procedure; one sperm is then injected into each egg and the embryo is allowed to grow. One cell of the embryo is then biopsied and the genetic make-up is analyzed to avoid the transfer of an affected embryo.
If a uterine abnormality is found, surgery may be performed depending on the defect. If antiphospolipid syndrome is diagnosed, certain medications that reduce blood clot formation may be given. If thyroid dysfunction or diabetes are diagnosed, specific medications can be prescribed.
Unexplained Recurrent Pregnancy Loss
Over one-half of patients with recurrent pregnancy loss will have unexplained recurrent pregnancy loss, which means that no specific cause could be identified in the work-up. Various treatments may be offered to these patients, but there is no universal recommendation for treatment of these patients. Despite this, the overall chance of pregnancy is good, more than 50%, without any intervention at all.