The Evaluation and Treatment of Recurrent Miscarriage
Miscarriage is a very common and emotionally troubling outcome of many early pregnancies. Studies show that about 8 to 20 percent of women who know they are pregnant have a miscarriage some time before 20 weeks of pregnancy; 80 percent of these occur in the first 12 weeks. But the actual rate of miscarriage is even higher since many women have very early miscarriages without ever realizing that they are pregnant.
If you have had two or more miscarriages before the pregnancies reach 20 weeks it is considered recurrent miscarriage or recurrent pregnancy loss (RPL). You deserve an evaluation for a possible recurring problem and if one is found, treatment to prevent future losses.
The most common causes of recurrent pregnancy losses are:
- Chromosomal- Chromosome abnormalities occur for no known reason in up to 60% of first-trimester miscarriages. These abnormalities typically do not allow development into a healthy baby. They may be recurrent because one of the couple is a translocation carrier (some healthy people have differences in the way their chromosomes are arranged which can increase their risk for genetically unbalanced pregnancy losses). As women age, the miscarriage risk due to these genetic abnormalities increases — from 10%-15% in women younger than 35 years old to more than 50% in women over 40 years old and may be related to poor ovarian reserve.
- Structural- Abnormalities in the shape of a woman's uterus might be a cause for pregnancy loss, such as a band of tissue inside the uterus, called a septum. Fibroids, polyps and scar tissue in the uterus can also be factors.
- Infectious- Carriers of an organism called ureaplasma has been linked with repeated losses.
- Hormonal- Deficiency in the production of progesterone to support the endometrium and placental development could result in pregnancy loss.
- Lifestyle/Medical- Smoking increases the risk for RPL. Using certain recreational drugs, such as cocaine, can also lead to miscarriage. Being overweight has been linked with RPL as well as other pregnancy complications. Excessive alcohol or caffeine intake might be linked with RPL. Untreated medical conditions, such as thyroid disease or diabetes, can increase the risk for miscarriage. Some believe that abnormalities of the immune system or blood-clotting system (thrombophilia) can also cause RPL.
The evaluation of RPL would include tests to detect the potential causes. The exact tests and their order will vary among physicians but may include:
- Testing the chromosomes of both partners (karyotype)
- Testing the ovarian reserve of the female partner
- Tests to determine the anatomic configuration of the uterus such as HSG, sonohysterogram or hysteroscopy
- A culture for ureaplasma
- Blood tests to detect medical and hormonal issues
- A timed endometrial biopsy to detect problems in endometrial development
Treatment will be designed to correct any problems found in the testing phase and then careful monitoring of the next pregnancy with blood tests and ultrasounds to detect and correct any correctable problems. Treatments may include:
- Hormone supplementation (progesterone)
- Hysteroscopic surgery to correct anatomic issues in the uterus
- Antibiotics if infection is an issue
- Medical treatment of medical issues
- If chromosomes are the issue, IVF with PGS can select chromosomally normal embryos to transfer
If no recurrent issues are found in the testing, careful monitoring and support of the next pregnancy may help avoid another miscarriage and result in the birth of a healthy baby. The encouraging news from the American Society for Reproductive Medicine is that even after having three miscarriages, a woman has a 60%-80% chance of conceiving and carrying a full term pregnancy.
If you have suffered two or more early losses, make an appointment for a consultation with one of our RPMG physicians.