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Written by: Kathryn Danzey

What is recurrent miscarriage?

Generally speaking it refers to three or more consecutive spontaneous miscarriages.

How often does it happen?

A history of three or more consecutive spontaneous miscarriages occurs in about 1 % of women.

What causes recurrent miscarriage?

Current medical literature suggests that causes are identified in only half of the cases. The identifiable causes include the following:

1. Lupus anticoagulant syndrome
This is a condition with abnormal clotting tendency, so that the small vessels in the placenta may be prone to blockage, leading to miscarriage.

2. Structural anomalies of the uterus (womb)
Structural uterine anomaly occurs in up to 10% of women with a history of recurrent pregnancy loss. The mechanism of the pregnancy loss in these patients is uncertain, it may be related to impaired implantation. The abnormalities include fibroid, septum (a partition) or scar tissue (adhesions) present within the uterine cavity.

3. Parental chromosomal anomalies
Parental chromosomal anomalies are found in -4% of couples with recurrent pregnancy loss, compared with 0.2% in the normal population.

4. Cervical weakness
Cervical weakness commonly causes pregnancy loss in the second trimester (14-28 weeks) but not in the first trimester (up to 13 weeks) of pregnancy. The typical history is that of a sudden leakage of fluid in the second trimester; followed by a painless miscarriage. There is no truly diagnostic tests for cervical weakness. The diagnosis is most commonly based on past obstetric history and, to a lesser extent, clinical assessment of the cervix during pregnancy by vagina! examination or serial ultrasound examination.

5. Polycystic ovarian syndrome
There appears to be some evidence of association between polycystic ovarian syndrome and recurrent miscarriages. In our own experience, this condition is found in about 10% of women with recurrent miscarriage.

6. Other coagulation disorders
Apart from lupus anticoagulant syndrome, several other coagulation disorders have also been associated with recurrent miscarriages including anti thrombin III deficiency, protein C or S resistance. There is no significant increase in risk of spontaneous miscarriage in carriers of factor V Leiden, but there may be an increased risk of still birth. Thrombocythaemia (high platelet count) has been also reported to be a cause of recurrent miscarriage.

7. Immunological factors
It is debatable if immunological factors contribute to recurrent miscarriage. There is conflicting scientific data in this area.

8. Infections
Infections appear not to play a significant role in first trimester recurrent miscarriage. However, infection may be a cause of premature labour and mid trimester loss. Bacterial vaginosis (BV), is increasingly recognised as a possible cause of premature labour and second trimester loss.

9. Unexplained recurrent miscarriage
In approximately 50% of women with recurrent miscarriage, no cause is found despite thorough investigations. A number of possible causes have been proposed to explain the occurrence of recurrent pregnancy losses in these patients:

1. Suboptimal development of the endometrium (lining of the uterus): the lining is a very important structure because it is where implantation occurs and through which nutrition is delivered to the embryo. It is an area of active research interest at the Jessop Hospital.
2. Fetal chromosomal anomalies: it is possible that repeated fetal chromosomal anomalies, occurring by chance, may be responsible for recurrent miscarriage. Women over the age of 37 years are more likely to have miscarriages associated with fetal chromosomal anomalies.

What investigations are necessary?
The most important step is to find out if there is any underlying cause for the recurrent miscarriage. As there are several possible underlying causes, a number of tests are necessary.

• Blood test – Chromosome analysis
– Hormone tests
– Clotting study

• Hysterosalpingogram – a special x-ray which can identify abnormalities within the uterus. It is also used to determine if the fallopian tubes are open. This procedure involves injecting a solution through the cervix so that the uterus is visible by x-ray. As the solution travels through the uterus and the fallopian tubes, x-rays are taken to reveal the inner shape of these organs. Moderate cramping usually results and can be eased with medication. The hysterosalpingogram is performed just after the menstrual period stops and before ovulation (often between day 5 and 10 of the cycle).

• Hysteroscopy – it is a procedure which employs a telescope and camera system to examine the. uterine cavity. A long, narrow, lighted telescope-like instrument called a hysteroscope is inserted through the cervix into the uterus so that the surgeon can view the uterine cavity. This procedure is usually conducted on an outpatient basis or as a day case with either general or local anaesthesia. It helps to exclude fibroid protruding into the cavity of the uterus, septum or adhesions (scar tissue).

• Ultrasound – to exclude fibroids or polycystic ovarian disease

• Endometrial biopsy – it is carried out as an outpatient procedure. A small sample of the lining of the uterus is obtained around day 21 of the cycle

What treatments are available?

The treatment of recurrent miscarriage is directed at the cause.

1. Lupus anticoagulant and clotting disorders: Women in this category will benefit from aspirin at a dose of 75 mg/day and daily subcutaneous injection of heparin or clexane throughout the pregnancy.

2. Uterine anomalies: Treatment of structural uterine anomalies usually involves surgical reconstruction.

3. Hormone treatment:
Progestogens: Progestogens were used some years ago to treat women with recurrent miscarriage. However, recent data show that such a treatment confers no benefit.
HCG: HCG injections are of benefit in women with recurrent miscarriage and irregular cycles prior to conception.

4. Polycystic ovarian disease: Preliminary data suggests that laparoscopic ovarian drilling (diathermy) of women with this condition may reduce the incidence of miscarriage.

5. Cervical weakness: Cervical suture can be inserted to strengthen the cervix.

6. Chromosome anomalies: In patients with chromosomal problems genetic counselling and referral to a clinical geneticist will be offered. In suitable cases, the possibility of donor gametes (eggs or sperm) will also be discussed.

7. Immunological therapy: Immunotherapy had been tried in the past. Current evidence, however, suggests that there is no benefit from this treatment. Immunotherapy is no longer offered in Sheffield.

Facts and fallacies

If you’ve had a previous miscarriage, it is very normal to be frightened and worried during your next pregnancy. It is important to understand that gentle exercise does not increase the risk of pregnancy loss. Video display terminals and computers do not increase the risk of miscarriage; neither does hair spray or hair colour. However, smoking and drinking can increase the risk of pregnancy loss, so you should discontinue these activities during pregnancy.

Monitoring and support during your next pregnancy

Clinical studies have consistently shown that women who have recurrent miscarriage are more likely to have a successful pregnancy if they feel well cared for, attend a specialised miscarriage clinic, and are closely monitored by weekly or alternate week ultrasound examination.

Further reading

A paper on “Recurrent miscarriage: principles of management” by Mr T C Li, published in Human Reproduction, 13: 478-482, 1998. A copy could be obtained from Mr Li’s secretary.

Prof T C Li
Consultant Gynaecologist
7 Williamson Road
Sheffield S119AR
Tel: 0114 2550365
March 2007

About the Author

Kathryn Danzey
I have a passion to bring to you what really works in the beauty industry, from a moisturiser to the latest advanced treatment for anti ageing. After almost 4 decades in the industry I'm packed with info to share but never tire of looking for new things and would love you to share your experiences with us too. We're here to help you find that treatment or product that will make a change for you. Can't do without My Collagen Shots and H3O Night Repair. Love a great serum and UV protection

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