Traditionally recurrent miscarriage is called if the patient has aborted more than 2 times before 20 weeks of the pregnancy. Some authorities tell the definition of recurrent miscarriages as previous 3 abortions before 20 weeks of pregnancy.
We generally don’t wait for second miscarriage to happen. For ladies who had first pregnancy failed, we are more aggressive and start evaluation and treatment before and during next pregnancy.
For any pregnant lady chances of spontaneous abortion / Spontaneous pregnancy loss is very common. Approximately 15% of all pregnancies result in spontaneous abortion. Spontaneous pregnancy loss can be physically and emotionally taxing for couples, especially when faced with recurrent losses.
About one woman in 100 experiences recurrent miscarriage.
What causes recurrent miscarriage?
The exact cause of the abortion is difficult to find out. In more than 90% of the recurrent abortion cases cause is unknown or cannot be found out. We are enlisting important causes as below:
• APLA syndrome: Anti Phospho Lipid Antibody Syndrome (APLA) is also known as sticky blood syndrome or Hughes syndrome. As the name suggest, there is abnormal tendency of blood clot formation in side patient’s blood vessel. It makes blood flow to stop completely or partially in various organs. If blood flow to growing pregnancy stops, growth of the pregnancy also stops which leads to abortion.
APLS has been found in between 15 per cent and 20 per cent of recurrent miscarriages.
• Thrombophilias: An inherited or acquired blood-clotting disorder, called thrombophilia. Thrombophilia means that abnormal tendency of the patient to clot the flowing blood in the blood vessels. This could cause recurrent miscarriage.
• Genetic problems: Abnormal genetic makeup of any of the couple (Wife or husband) may lead to transmission of the same genetic defect to the developing embryo. Many times this genetically abnormal fetus is not fit to survive and it gets aborted. Recurrent miscarriage is thought to be linked to chromosomal abnormality for between two per cent and five per cent of couples.
• Anatomical abnormalities of the uterus or cervix:Uterus is the place where the embryo gets implanted. After implantation it gets blood supply, nourishment so as to grow up to next 9 months and deliver thereafter. In some patient shape and or size of the uterus is abnormal. Uterus may have septum-curtain in between. Uterus may be separate in two halves or only half of the uterus is developed and many other abnormalities are seen. In such cases the developing embryo will not get sufficient blood supply or space to grow and it will get aborted. Surgical correction of the abnormal shape of the uterus will lead to positive outcome.
• Vaginal Infection: Bacterial vaginosis is a vaginal infection, increases the risk of late miscarriage and premature birth. Some viral infections known as TORCH were blamed for recurrent abortions but they can lead to single abortion, not multiple.
• Hormonal abnormalities in pregnant mother: A problem with hormones as in some conditions, such as polycystic ovaries, Luteal phase defect have been linked to recurrent miscarriage. It may be due to abnormal hormones are not sufficient to support the pregnancy.
• Age of the pregnant lady:It may simply be that age is having an effect. The older the patient is, the more likely she is likely to experience miscarriage. The age of your baby's father may also increase the risk of miscarriage.
• Endocrine or metabolic conditions: Conditions such as Thyroid problems, diabetes are also blamed of recurrent pregnancy loss. If patient has undergone one pregnancy loss previously, we start hormonal support, low dose aspirin, vitamins for such patients. For patients having multiple abortions generally we prefer to get all the tests done before pregnancy only. Following are some tests which we do:
1. Blood tests for thyroid, diabetes, urine test for infection, vaginal swab test for vaginal infection.
2. Ultrasound scan
3. Blood test for APLA syndrome and thrombophilias
4. HSG (Hysterosalphingography) an X ray to see the shape and size of the uterus can be done in between pregnancy.
If the patient is diagnosed to have APLS, with the proper treatment, she will have a good chance of a successful pregnancy. The treatment consists of blood-thinning medicines such as aspirin and low molecular weight heparin to treat APS.
If no other abnormality is detected, we do both husband and wife’s blood test to check for chromosomal abnormalities. This is called karyotyping. If an abnormality is discovered, the couple is referred to a clinical genetics specialist and for genetic counselling.
Sometimes, though, tests don't provide answers. If we can't find a reason for patient’s miscarriages, Patient has to see it as a reason for better luck next time, and to keep trying.
Sometimes we do karyotyping of the products /tissue which was aborted to diagnose chromosomal abnormalities.
Ultrasound scans: An ultrasound scan to check uterus and ovaries is done for all the patients as a baseline investigation. Ultrasound scan may show abnormalities like septum Curtain) in side uterus, Fibroids, nature of inner lining of the uterus etc; which can lead to recurrent miscarriages.
In some patient the cervix-mouth of the uterus is weak or open leading to repeated abortions. This is called as cervical incompetence. Timely diagnosis of this condition and a minor operation to put a stitch in the cervix saves pregnancy many times. The cervical stitch or stitch at the mouth of uterus is usually taken from vagina and it is absolutely pain free without any scar on patient’s tummy. If cervical stitch is taken to prevent an abortion or premature delivery, it is removed few weeks before due date of delivery and normal delivery is possible after the removal of the stitch. Removal of the stitch is a small procedure, for which patient need not to get admitted in the hospital. Rarely patient aborts or deliver prematurely in spite of the cervical stitch is taken. In such cases we offer laparoscopic cervical stitch early phase of the next pregnancy. During laparoscopic cervical stitch we tie the cervix at much higher level and that’s the reason that it prevents abortion or premature delivery.
If miscarriages are unexplained then patient have a good chance of having a successful pregnancy in the future. She will need to be looked after very carefully and given extra support and scans from the beginning of her pregnancy.
This close care and support in itself can increase chances of a successful pregnancy. About three quarters of women who have unexplained recurrent losses have a healthy baby eventually with the right support and care.