Recurrent Miscarriage & Recurrent Pregnancy Loss

Recurrent miscarriage & recurrent pregnancy loss at a glance

• Recurrent miscarriage, also called recurrent pregnancy loss, is two or more consecutive miscarriages.
• While normal miscarriages happen in about 25 percent of pregnancies, recurrent miscarriage occurs in about 2 percent of pregnancies.
• The most common causes of recurrent miscarriage are age of the mother and genetic defects, according to the American Society for Reproductive Medicine.
• Treatment for recurrent miscarriage may involve medications, surgery or use of in vitro fertilization (IVF) to achieve pregnancy.
• About two-thirds of women who have suffered recurrent miscarriage have a successful pregnancy in subsequent efforts.

What is recurrent miscarriage?

Recurrent miscarriage, also known as recurrent pregnancy loss (RPL), is defined as two or more consecutive miscarriages. A miscarriage is defined as the spontaneous loss of a clinically-recognized pregnancy before the 20th week. Clinically recognized means the fetus has been identified with ultrasound or through tissue after the pregnancy loss.

In general, 15 percent of all pregnancies between 4 and 20 weeks will undergo clinically recognized spontaneous miscarriage. About 25 percent of known pregnancies result in miscarriage, but the true miscarriage rate is closer to 50 percent due to miscarriages that happen before a woman may even know she is pregnant.

The U.S. Department of Health and Human Services estimates that less than 5 percent of pregnant women experience two consecutive miscarriages. About 1 percent experience three or more consecutive miscarriages. After three or more consecutive losses there is a 40 percent chance for a fourth loss.

Before week 20, women may have a chemical pregnancy, when hormone levels indicating pregnancy are present but an ultrasound does not confirm the fetus. This may mean it is an ectopic pregnancy, in which the embryo implants outside the uterus and the pregnancy must be ended.

About two-thirds of women who have suffered recurrent pregnancy loss have a successful pregnancy in subsequent efforts. A healthy lifestyle can help improve those odds: getting moderate exercise, controlling weight, quitting smoking and reducing alcohol and caffeine intake may be beneficial in avoiding RPL.

Even though the percentage rate is in favor of a successful pregnancy after recurrent miscarriage, the psychological impact on the woman and couple can be significant. Therefore, our choice is to begin a recurrent pregnancy loss evaluation after two losses to help avoid a third if possible.

Symptoms of recurrent miscarriage

Symptoms for recurrent miscarriage are not more severe than those for a single miscarriage. If a woman experiences any of the following symptoms while pregnant, she should seek medical attention immediately:

• Vaginal bleeding
• Passing fetal tissue
• Cramping and pain in the abdomen
• Fever.

Causes of recurrent miscarriage

Pinpointing the cause of repeated miscarriages can be difficult. In more than half of couples with recurrent pregnancy losses doctors are unable to find a specific reason. Yet there are a number of factors at play. Below are causes of RPL and their related diagnosis and treatment options.

Age

Age increases the chance of a miscarriage. Age-related pregnancy loss is associated with poor egg quality, which leads to genetic abnormalities. More than one-third of all pregnancies after age 40 end in miscarriage.

The best available technique for assessing the quality of a woman’s eggs is measuring what’s known as ovarian reserve, determined by levels of follicle stimulating hormone (FSH) and estradiol. In some cases a clomiphene challenge test is performed in women over the age of 38 who have a solitary ovary or have had a prior poor response with fertility medications. These tests will determine if aggressive therapy is indicated and how successful we will be at attaining a pregnancy using a woman’s own eggs.

Genetic factors

Chromosomes play a factor in such cases of advanced maternal age, as most embryos that end in miscarriage for these women carry an abnormal number of chromosomes.

Recurrent pregnancy loss due to chromosomal abnormalities affects approximately 3-8 percent of all pregnancies. For both natural and assisted conception, chromosomally abnormal embryos have a low rate of implantation in the uterus. The most common genetic cause of RPL is aneuploidy, the presence of an extra chromosome or the absence of one in the normal pair of chromosomes. Down syndrome, also known as trisomy 21, is the presence of an additional 21st chromosome and is a common form of aneuploidy.

Environmental factors

Environmental exposures could affect the outcome of a pregnancy. Some anesthetic agents and tetrachoroethylene used in dry cleaning have been associated with miscarriages. If proper precautions are used, including a mask respirator and specialized clothing, then the exposure is minimal and should not cause a problem.

Additionally, several reports have shown a strong association between smoking and pregnancy losses. The risk increases with the number of cigarettes smoked per day.

Exposure to aspartame (an artificial sweetener found in a variety of beverages and used as a sugar substitute in brand name products such as Equal and NutraSweet), heavy caffeine and alcohol intake have all been associated with pregnancy loss. But scientists have not defined the exact amount. Therefore, we advocate limiting the intake of these items while trying to conceive and avoiding these during pregnancy.

Endocrine problems

An endocrine problem is found in 15 percent of women who have RPL. Any hormonal imbalance that affects ovulation could impair normal uterine lining development, and ultimately implantation. Thyroid disease or pituitary dysfunctions are the most common findings associated with RPL due to endocrine issues. Women with an elevated luteinizing hormone (LH) level, as with polycystic ovary syndrome (PCOS), may be at increased risk of miscarriage due to an increased amount of male hormones that adversely affects the uterine lining.

Anatomical causes

Uterine anomalies are found in 12-15 percent of woman with pregnancy losses and also contribute to RPL. These abnormalities include fibroid tumors, derived from the muscle wall of the uterus, or polyps, overgrowths of the uterine lining.

Congenital uterine malformations, such as a uterine septum, are associated with a 60 percent pregnancy loss rate (see below). Surgical correction by operative hysteroscopy has been reported to provide an 80 percent delivery rate.

Incompetent cervix is a condition in which the cervix opens prior to 20 weeks gestation without detectable contractions. In these women, the use of cervical cerclage, a suture placed in the cervix, at the end of the first trimester may reduce the risk of a pregnancy loss.

Uterine anomaly percent risk for a pregnancy loss are as follows:

• Septate – 60 percent
• Unicornuate – 35 percent
• Bicornuate – 33 percent
• Didelphic – 29 percent
• DES exposure – 28 percent.

Blood clotting abnormalities

Abnormalities in blood clotting function resulting from chromosomal anomalies are also a potential cause of pregnancy losses and RPL.

Thrombophilia is the tendency for increased blood clotting, and may be treated with a baby aspirin, heparin anticoagulant injections and/or an increased amount of folic acid.

Antiphospholipid syndrome (APS or APLS) may cause 3-15 percent of RPL in women. APS is also a coagulation disorder that causes thrombosis in both arteries and veins and can lead to miscarriages, pre-term delivery or severe preeclampsia, a serious threat to both maternal and infant health.

Immunologic factors

Blood clots in the small placental blood vessels may be due to the antibodies lupus anticoagulant and anticardiolipin that attach to the wall of the blood vessel and attract clotting factors that can impede blood flow. The result is placental insufficiency and possible miscarriage. Treatment with aspirin and/or heparin anticoagulant injections does not guarantee improvement but studies have reported success rates approaching 85 percent for most women.

Determining treatment for recurrent miscarriage

At RSC New Jersey, if testing after two consecutive miscarriages suggests an underlying problem, then treatment is directed in one or more of several directions: genetic counseling, removal of polyps or fibroids, hormonal correction and anticoagulation. If all of the tests are normal then the diagnosis is recurrent miscarriage of unknown cause.

Repetitive losses are frustrating and can cause depression as well as family discord. One often-overlooked factor of tremendous importance is the psychological impact. Along with medical treatment, we encourage counseling to help cope with the emotional aspects of recurrent miscarriage.