Recurrent Miscarriage – Causes, Diagnosis And Treatment

However, it may be of some relief that most women who have experienced recurrent miscarriages go on to become happy mothers under medical supervision. The chance of a woman with a history of recurrent miscarriages, having a baby is a good 60%, especially if the reason of the miscarriage cannot be concluded. About half the cases of recurrent miscarriages go without the cause being ascertained by doctors.

What Causes Recurrent Miscarriage?

Increasing maternal age or paternal age, multiparty or repeated pregnancies, chromosomal abnormalities, untreated hypothyroidism, and untreated diabetes are the main risk factors of recurrent abortions (1A). Sometimes the cause is unknown as well (1B).

As sad as it is, a miscarriage does increase the chances of a subsequent miscarriage may also add to the problem. Please bear in mind that these causes are not common.

Top 13 Reasons For Recurrent Miscarriage

Various factors are accountable for recurrent miscarriages. Here are the top 13 reasons that could bring about this condition.

1. Uterine Conditions

Abnormalities in the uterus are often responsible for recurrent miscarriages (2). Uterine malformations are responsible for a significant number of recurrent miscarriages. A septate uterus (uterus having septum internally hence divided in cavity by a partition) is the most common uterine abnormality and can cause repeated pregnancy loss (3). Combined laparoscopy or MRI may help diagnose this condition.

Common uterine conditions that can cause recurrent miscarriages (2A) include

• Unicornuate uterus
• Bicornuate uterus
• Septate uterus
• Didelphys uterus
• Intrauterine adhesions
• Submucosal myomas

2. Cervical Incompetence

Conditions such as cervical incompetence or weak cervix are the next common conditions resulting in recurrent abortions. Cervical incompetence can lead to preterm deliveries or miscarriages (4).

3. Chromosomal Abnormalities

Chromosomal abnormalities or genetic disorders are one of the major contributing factors for repetitive abortions (5). Here are a few genetic or chromosomal reasons for recurrent abortions.

a. Translocations

Robertsonian translocation in either of the partners can cause a non-viable fetus and abortion (1C). Karyotyping helps identify this genetic defect.

b. Aneuploidy

Aneuploidy chromosomal disorder is frequent with increasing reproductive age and depicts germ cell quality (6).

4. Endocrine Disorders

Various endocrine disorders contribute to about 20% of all recurrent pregnancy losses (1D). Hypothyroidism, untreated diabetes mellitus, and luteal phase defects can also cause miscarriages. Females affected with PCOS or polycystic ovarian syndrome experience a higher risk of untimely termination of pregnancy.

5. Thrombophilia

 Thrombophilia or tendency for blood clotting is another risk for miscarriages and is responsible for recurrent miscarriages in about 40 to 50% of the cases. (7).

6. Immune Factors

Lowered maternal immune tolerance for the fetus is another factor causing miscarriages (8).

7. Antiphospholipid Syndrome

This is an autoimmune disease and accounts for 15 percent of all recurrent miscarriages (9). Usually, aspirin or heparin is given to women having antiphospholipid syndrome.

8. Thyroid Antibodies

The presence of serum antithyroid antibodies may increase the risk of recurrent miscarriages (10).

9. Ovarian Factors

The susceptibility to miscarriage increases with advancing age as the ovarian reserves are also depleted with increasing age and they become vulnerable to miscarriages (11). The actual cause is the poor quality of maternal eggs.

10. Luteal Phase Defect

Luteal phase defects can cause implantation failures and is often responsible for miscarriages (12). Progesterone is released during the luteal phase and if it is produced in insufficient quantities from the corpus luteum. The inadequate amount of progesterone does not sustain pregnancy and miscarriage is the obvious outcome.

11. Lifestyle Factors

Excessive exposure to toxins, smoking or consuming alcohol can also cause recurrent miscarriages (13).

12. BMI

Maintaining a healthy BMI is essential to ensure a proper pregnancy. Lower BMIs (being underweight) and having BMIs over 25 (being overweight significantly contribute to recurrent pregnancy losses (14).

13. Infection

Many infections such as toxoplasmosis, listeriosis, and viral infections (rubella, measles, herpes, cytomegalovirus), etc. are also among the notorious causes of miscarriages (15).

Diagnosis Of Recurrent Miscarriage

A thorough clinical examination is done to find out the underlying cause. After that,

• Blood tests such as karyotype testing of both partners are done to rule out the presence of any chromosomal abnormalities. If anything is detected, you will be sent for genetic counseling.
• Ultrasound scans are done to assess the condition of the uterus and ovaries.
• Specialized tests like TORCH are done to find out any underlying viral or bacterial infection. Tissues from the placenta may also be tested for signs of a problem.

Sometimes, the tests do not yield any results. If the miscarriages cannot be explained, chances are that you will get through your pregnancy the next time.

Treatment For Recurrent Miscarriage

Treatment depends upon the identification of the cause, but unfortunately, there is no actual treatment for unexplained recurrent pregnancies.

a. Genetic Counseling

Abortion counseling is done with the primary objective of empowering the woman (1E). Do not force the decision and allow the couple to make their decision. Restrict rigorous activities and exercises. Intercourse is not advised while you are expecting particularly in the first trimester and third trimester.

b. Medication

Some experts advise progesterone medication to reduce miscarriage rates (1F).  Progesterone should only be used if there is a luteal phase defect or if your obstetrician is sure about the use. Doctors may suggest aspirin medication too (1G).

In patients having antiphospholipid syndrome (APS), heparin administration can increase the birth rate by up to 70 percent. According to some experts, the administration of metformin in pregnancy can lower the risk of abortion, especially in patients having polycystic ovarian syndrome

c. Surgical Management

McDonald stitches or cervical cerclage (a procedure in which stitches are used to close the cervix during pregnancy to help prevent pregnancy loss or premature birth) is done for cervical incompetence patients. The cerclage, however, poses a potential threat of inducing uterine contractions. The process is beneficial to women with having cervix less than 25 mm.

How to Cope With Repeated Miscarriages

Having to experience repeated miscarriages can be quite traumatic with the uncertainty of the future looming over. However, with advanced medical technology available and access to various tests and treatments, pregnancy is possible in most cases.

The first step to dealing with repeated miscarriages is healing. While physical healing can happen within a few weeks, psychological healing takes time. It is important to give yourself and your partner time to heal and recover completely so that you are strong enough to give it another try.

Lean on your partner or close circle of family and friends through the process of healing and trying again. Take the help of counselors to help you heal through the journey.

Talk to fertility specialists who will be able to run the necessary tests and find out the reason behind these repeated miscarriages. Once the root cause is identified and treated, you can successfully get pregnant and have a healthy baby.

Will I Be Able To Have A Healthy Baby?

Unexplained miscarriages do carry a good chance of having a successful pregnancy in the future. Though your pregnancy will be very closely monitored, it will be this close care that will boost your chances of having a healthy baby. Some causes of recurrent miscarriage are treatable, your gynecologist is the best person to answer you.

There cannot be complete certainty in such cases, but you will be closely ascertained. If you have been emotionally drained because of repeated losses and are feeling low and scared to lose another baby, it would be wise to seek support and help from family, friends, and support groups. Keeping a positive mind and an optimistic attitude can help you have a normal pregnancy.

Recurrent miscarriages are common but identifying the cause of these miscarriages and getting treated is important. Rely on doctors, specialists, therapists, family, and friends to help you through this tedious journey and help you achieve pregnancy and a healthy delivery.

FAQ’s

1. What is The Cause of Repeated Miscarriage?

The most common causes of recurrent miscarriages include uterine abnormalities, genetic abnormalities, thyroid imbalances, endocrine dysfunctions, and hormonal disturbances.

2. Can I Have a Baby After 3 Miscarriages?

It is possible to have a baby after 3 miscarriages but it is important to have a complete medical evaluation with a fertility specialist to see what the root cause of these miscarriages is. You can undergo blood tests, ultrasound tests, and genetic counseling depending on the results. The doctor will then suggest a future course of action to help you achieve a successful pregnancy.

3. What to Do After a Recurrent Miscarriage?

If you are experiencing recurrent miscarriages, it is important to get medical help. Consult with a fertility specialist and get the necessary tests done as per the suggestions of the specialist. This will help determine the underlying cause of the repeated abortions. Follow the suggestions and treatment given by the doctors.

4. Does 3 Miscarriages Mean Infertility?

Three consecutive miscarriages may or may not mean infertility. To confirm infertility, you will need to get the relevant tests done. A doctor or a fertility specialist will guide you in this aspect.

References

1. Recurrent Pregnancy Loss: Etiology, Diagnosis, and Therapy – PMC – [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2709325/]
2. Uterine factor in recurrent pregnancy loss – PubMed – [https://pubmed.ncbi.nlm.nih.gov/30683511/]
3. The septate uterus: a review of management and reproductive outcome – ScienceDirect – [https://www.sciencedirect.com/science/article/pii/S001502829900480X]
4. Cervical stitch (cerclage) for preventing pregnancy loss in women – PMC – [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6991153/]
5. Genetic Considerations in Recurrent Pregnancy Loss – PMC – [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4355257/]
6. Aneuploidy in Early Miscarriage and its Related Factors | Chinese Medical Journal – [https://mednexus.org/doi/full/10.4103/0366-6999.167352]
7. Thrombophilia and Recurrent Pregnancy Loss – PMC – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3916273/]
8. Immunologic causes and thrombophilia in recurrent pregnancy loss – ScienceDirect – [https://www.sciencedirect.com/science/article/pii/S0015028221000388]
9. Antiphospholipid Syndrome during pregnancy: the state of the art – PMC – [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279165/]
10. Thyroid Antibodies and Miscarriage: Where Are We at a Generation Later? – PMC – [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3112530/]
11. Association between diminished ovarian reserve and recurrent pregnancy loss: a comparative study – JOG – [http://www.gynaecology-obstetrics-journal.com/association-between-diminished-ovarian-reserve-and-recurrent-pregnancy-loss-a-comparative-study/]
12. Luteal insufficiency in first trimester – PMC – [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3659905/]
13. Recurrent Pregnancy Loss Etiology, Risk Factors, Diagnosis, and Management. Fresh Look into a Full Box – PMC – [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10298962/]
14. Systematic review and meta-analysis of female lifestyle factors and risk of recurrent pregnancy loss – PMC – [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007745/]
15. The role of infection in miscarriage – PMC – [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4664130/]