It can be heartbreaking to miscarry one baby after another. Each new pregnancy brings both hope and anxiety. And each new loss may be harder to bear, especially if you feel that time is running out. The experience can place great strain on even the strongest relationships. You and your partner might react differently from each other and that can cause great tension. Family and friends may find it harder to support you with each miscarriage; they may even think you’re getting used to loss and able to cope. And all the time there may be a sense that your life is on hold while you try – and try again – for a baby.
Miscarriage is defined as the spontaneous loss of pregnancy before the fetus reaches viability. The term therefore includes all pregnancy losses from the time of conception until 24 weeks of gestation.
Recurrent miscarriage, defined as the loss of three or more consecutive pregnancies, affects 1% of couples trying to conceive. It has been estimated that 1–2% of second-trimester pregnancies miscarry before 24 weeks of gestation. It affects about one in every hundred couples trying for a baby. Sometimes a treatable cause can be found, and sometimes not. But in either case, most couples are more likely to have a successful pregnancy next time than to miscarry again.
Risk factors for recurrent miscarriage (What are the causes of recurrent first trimester miscarriage and second trimester miscarriage?)
1. Maternal age and number of previous miscarriages : these are two independent risk factors for a further miscarriage. Advancing maternal age is associated with a decline in both the number and quality of the remaining oocytes. The risk of miscarriage is highest among couples where the woman is ≥35 years of age and the man ≥40 years of age. The risk of a further miscarriage increases after each successive pregnancy loss ,reaching approximately 40% after three consecutive pregnancy losses, and the prognosis worsens with increasing maternal age.
2. Antiphospholipid syndrome : Antiphospholipid syndrome is the most important treatable cause of recurrent miscarriage. Antiphospholipid syndrome refers to the association between antiphospholipid antibodies – lupus anticoagulant, anticardiolipin antibodies and anti-B2 glycoprotein-I antibodies – and adverse pregnancy outcome or vascular thrombosis. The mechanisms by which antiphospholipid antibodies cause pregnancy morbidity include inhibition of trophoblastic function and differentiation, activation of complement pathways at the maternal–fetal interface resulting in a local inflammatory response and, in later pregnancy,thrombosis of the uteroplacental vasculature. In women with recurrent miscarriage associated with antiphospholipid antibodies, the live birth rate in pregnancies with no pharmacological intervention has been reported to be as low as 10%.
3. Genetic factors : In approximately 2–5% of couples with recurrent miscarriage, one of the partners carries a balanced structural chromosomal anomaly: most commonly a balanced reciprocal or Robertsonian translocation. Although carriers of a balanced translocation are usually phenotypically normal, their pregnancies are at increased risk of miscarriage and may result in a live birth with multiple congenital malformation and/or mental disability secondary to an unbalanced chromosomal arrangement.
4. Embryonic chromosomal abnormalities : In couples with recurrent miscarriage, chromosomal abnormalities of the embryo account for 30–57% of further miscarriages. The risk of miscarriage resulting from chromosomal abnormalities of the embryo increases with advancing maternal age.
5. Congenital uterine malformations : The reported prevalence of uterine anomalies in recurrent miscarriage populations ranges between 1.8% and 37.6%. The prevalence of uterine malformations appears to be higher in women with second-trimester miscarriages compared with women who suffer first trimester miscarriages,but this may be related to the cervical weakness that is frequently associated with uterine malformation.
6. Cervical weakness : Cervical weakness is a recognised cause of second-trimester miscarriage. The diagnosis is usually based on a history of second-trimester miscarriage preceded by spontaneous rupture of membranes or painless cervical dilatation.
7. Endocrine factors : Systemic maternal endocrine disorders such as diabetes mellitus and thyroid disease have been associated with miscarriage. Women with diabetes who have high haemoglobin A1c levels in the first trimester are at risk of miscarriage and fetal malformation. Polycystic ovary syndrome (PCOS) has been linked to an increased risk of miscarriage but the exact mechanism remains unclear. The increased risk of miscarriage in women with PCOS has been recently attributed to insulin resistance, hyperinsulinaemia and hyperandrogenaemia.
8. Infective agents : Any severe infection that leads to bacteraemia or viraemia can cause sporadic miscarriage.The role of infection in recurrent miscarriage is unclear. The presence of bacterial vaginosis in the first trimester of pregnancy has been reported as a risk factor for second-trimester miscarriage and preterm delivery
9. Inherited thrombophilic defects : Both inherited and acquired thrombophilias, including activated protein C resistance (most commonly due to factor V Leiden mutation),deficiencies of protein C/S and antithrombin III, hyperhomocysteinaemia and prothrombin gene mutation, are established causes of systemic thrombosis. In addition, inherited thrombophilias have been implicated as a possible cause in recurrent miscarriage and late pregnancy complications with the presumed mechanism being thrombosis of the uteroplacental circulation.
10. Smoking and alcohol : Maternal cigarette smoking and caffeine consumption have been associated with an increased risk of spontaneous miscarriage in a dose-dependent manner. Heavy alcohol consumption is toxic to the embryo and the fetus. Even moderate consumption of five or more units per week may increase the risk of sporadic miscarriage
If you have had three miscarriages in a row, you should be offered tests to try to find the cause. This should happen whether or not you already have one or more children. Testing is not usually offered after one or two early miscarriages (up to 14 weeks) because these are often due to chance. But you might be offered tests after two early miscarriages if you are in your late 30s or 40s or if it has taken you a long time to conceive. If you had a late (second trimester) miscarriage, where your baby died after 14 weeks of pregnancy, you should be offered tests after this loss.
Some important investigations that are required are are:
If you have suffered two or more miscarriages, you should talk with your gynaecologist. Often, women decide to continue trying to get pregnant naturally. However, in certain situations, your doctor might suggest treatments to help reduce your risk for miscarriage.
Surgery : Surgery can fix some problems in the uterus (womb), like extra tissue that divides the uterus (septum), some fibroids (benign tumors), or scar tissue. Correcting the shape of the inside of the uterus can often lower the chance for miscarriage.
Blood-thinning medicines : Women with autoimmune or clotting (thrombophilia) problems may be treated with low-dose aspirin and heparin. These medicines can be taken during pregnancy to lower the risk of miscarriage.
Correcting other medical problems : Recurrent pregnancy loss may be related to some medical problems. These include abnormal blood sugar levels, an over- or underactive thyroid gland, or high levels of the hormone prolactin. Treating medical conditions such as diabetes, thyroid dysfunction, or high prolactin levels can improve the chances of having a healthy, full-term pregnancy.
Genetic screening : In about 5% of couples with RPL, one of the parents has a rearrangement (translocation) of their chromosomes. If a chromosomal problem is found, the doctor might recommend genetic counselling or fertility treatments, such as in vitro fertilization (IVF). During IVF, eggs and sperm are mixed outside of the body in a laboratory. After IVF, before the embryos are returned to the uterus, they can be tested (preimplantation genetic screening). This allows embryos without translocations to be chosen to increase the chance of a healthy pregnancy.
Lifestyle Choices : In general, whatever is healthy for a woman improves the chance of a healthy pregnancy. Stopping cigarette smoking and stopping illicit drug use (such as cocaine) will lower the risk for miscarriage.
Limiting alcohol and caffeine intake may also help. Being overweight has been linked with increased risk of miscarriage, so healthy weight loss might also help pregnancy outcomes. Psychological support and counselling can help couples cope with the emotional pain of miscarriage and create a healthy environment for a pregnancy.
Get in touch with Dr. Shweta Mishra at her Crossings Republik, Ghaziabad (Crossings Republik Clinic Location & Direction) clinic for Recurrent Miscarriage Treatment in Ghaziabad, or either at Amrapali Icon Leisure Valley, Greater Noida West (Noida Extension Clinic Location & Direction) clinic for Recurrent Miscarriage Treatment in Noida Extension. Also, you could make a wellness appointment at any clinic location convenient to you.
Disclaimer: The content on this website is only intended for educational purposes and to create knowledge amongst masses about women's health and obstetrics & gynaecology. Hence, no information issued on this website shall be treated as an alternative to consultation from a certified obstetrician & gynaecologist. The results can vary from women to women depending on their specific health conditions.