What is it?
Recurrent miscarriage (RM) is the consecutive loss of three or more pregnancies through miscarriage. These miscarriages typically occur after the pregnancy has been detected by ultrasound but might also occur at much earlier stages following only positive pregnancy tests.
This is a common condition as about 1% of pregnant women are affected by recurrent miscarriage.
What causes it?
RM can be caused by a number of conditions but we do not find any underlying cause in 50% of women investigated. The currently recognized causes include: Antiphospholipid syndrome: this is the single most common cause of RM. It denotes the presence of two substances (anticardiolipin antibodies and lupus anticoagulant) in blood that increase its stickiness.
- Acquired thrombophilias: these also increase the stickiness of blood and include diminished levels of some blood components (Protein C, Protein S, Antithrombin III and Factor V Leiden).
- Uterine abnormalities: the presence of a uterine septum, submucosal fibroids or uterine synechiae (adhesions) can cause repeated miscarriages.
- Chromosomal disorders: the presence of a balanced chromosomal translocation in either partner can predispose to RM. This is a condition where there is a re-arrangement of the chromosomes without loss of any chromosomal material and so does not produce any effects in those affected. It only becomes problematic at the time of conception when the splitting and joining of chromosomes from both partners can result in loss of some genetic material resulting in miscarriage.
- Genital tract infections: some infections like bacterial vaginosis have been implicated in miscarriage.
What problems can RM lead to?
This condition is one of the most frustrating that most sufferers will come across. It is even more so if investigations reveal no underlying cause for it. RM has been known to adversely affect personal and family relationships in the long-term and so affected couples need to have access to counseling if required.
How is it investigated?
The investigation of RM aims to uncover the reason in the 50% of affected couples with an underlying cause. The list below details the principal investigations that are usually undertaken:
- Haematological investigations: these are blood tests that measure the levels of the substances that affect blood stickiness in the female.
- Hormonal investigations: these are blood tests that measure the levels of ovarian hormones in the female.
- Genetic investigations: these are blood tests that look at the gentic make-up of both partners.
- Ultrasound investigations: this will usually be a transvaginal (internal) ultrasound to examine the whole of the genital tract. It could sometimes entail injecting some fluid into the womb during the scan for a more detailed examination (a procedure called hydrosonography).
How is RM treated?
The treatment that is offered for RM depends on whether an underlying cause is found and what that cause is.
Where there is no underlying cause: affected couples will be reassured that there is no underlying cause for the miscarriages and that in such situations their chances of achieving a live birth in future are about 70%. We would offer such couples ultrasound surveillance (1-2 weekly scans up to 12 weeks of pregnancy) in future pregnancies as this has been found to improve the chances of achieving a live birth. The role of aspirin and progesterone in these situations is controversial as there is no robust evidence of their effectiveness. Anyone interested in any of these should discuss it with the doctor.
Where there is an underlying cause: couples are offered the recognized treatment for that problem if it exists. Women with antiphospholipid syndrome and acquired thrombophilias are treated with a combination of two blood thinning substances (aspirin and heparin) and this has been proven to significantly improve their chances of live birth. Women with uterine septa or synechiae are treated by surgical correction through a hysteroscopic procedure. Submucosal uterine fibroids are treated by excision through a hysteroscopic procedure. Genital tract infections are treated with the appropriate antibiotics. There is no cure for genetic abnormalities but we arrange detailed genetic counseling for affected couples and provide avenues for genetic testing of the pregnancy (fetus) at an early stage of future pregnancies.
Is there a role for complimentary therapies?
There is no scientific evidence for the effectiveness of any complimentary therapy. However, we do know that stress plays a role (albeit unquantifiable) in RM and any measures that help to reduce stress might benefit the woman. Therefore, although we would not recommend taking any non-traditional medicines for this condition, some women might find that techniques like acupuncture help to reduce their stress levels.
Please follow this link for patient information about recurrent miscarriage https://www.rcog.org.uk/en/patients/patient-leaflets/recurrent-and-late-miscarriage/