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Recurrent Miscarriage
What is recurrent miscarriage?
Recurrent miscarriage is three or more consecutive pregnancy losses and it affects 1%-2% of couples worldwide. Most miscarriages happen during the first trimester (within 12 weeks of pregnancy), and only a few are during the second trimester (within 13 to 24 weeks of pregnancy). If a woman has recurrent miscarriage or a miscarriage in the second trimester, she should seek advice from a gynaecologist as soon as possible.
Causes of recurrent miscarriage and the treatment options
The risk of having a miscarriage will be greater when a woman gets older, mainly because egg aging increases embryo chromosomal abnormalities. More than 1 in 3 pregnancies in women aged over 40 would end in a miscarriage. Besides, obese women would have a higher risk of miscarriage as well. Miscarriages may also be more common if the father is older. More than half of the couples have no clear reason for their miscarriages and they are likely to have a successful pregnancy again in the future.
Causes of recurrent pregnancy loss
Less than half of recurrent miscarriages have a special cause.
The identified causes and treatment options include the following:
Uterine Abnormality
Cause
It may result in impaired implantation and hinder embryo growth, leading to infertility or miscarriage. Congenital uterine abnormalities include septate uterus, bicornuate uterus and unicornuate uterus.
Specific Investigation
Assessment of Uterus Structure:
- 3D transvaginal ultrasound scan
- Hysterosalpingogram or hysteroscopy
- Magnetic resonance imaging
Treatment
Surgery to correct the problems in the uterus, e.g., division of uterine septum.
Cervical Weakness (also known as incompetent cervix)
Cause
Less than one in a hundred women has a weakness in the cervix that allows it to dilate too early. This is a known cause of late (second trimester) miscarriage.
Specific Investigation
Regular scan of your cervix in your next pregnancy
Treatment
Some women could be treated with progesterone, ring pessary or a ‘cervical stitch’ to keep the cervix closed during pregnancy. The stitch is normally inserted under anaesthesia at 12 to 14 weeks, then removed at term or at the end of the pregnancy.
Autoimmune Disease (e.g., antiphospholipid syndrome (APLS))
Cause
The immune system makes abnormal antibodies that attack cells called phospholipids in blood. This makes the blood more ‘sticky’ and likely to clot.
It is not clear why these antibodies cause miscarriage. They may stop the pregnancy to continue properly in the uterus (womb) or they may interfere with blood flow to the placenta, which supports the baby.
Specific Investigation
Blood Tests
- Test for APLS: to detect an immune system abnormality
- Lupus anticoagulant
- Anticardiolipin antibody
- Anti-B2 glycoprotein 1 antibody
Treatment
Women who fulfill the laboratory criteria of APLS may be prescribed with low-dose aspirin (75 mg to 100 mg/day) before conception, and a prophylactic dose of heparin starting on the day of their positive pregnancy test to dilute the blood and prevent blood clots.
Endocrine Disease (e.g., abnormal thyroid function)
Cause
Thyroid dysfunction in pregnancy has consequences for both mother and baby. Women with hypothyroidism or presence of thyroid antibodies are associated with increased risk of miscarriage.
Specific Investigation
Blood Tests for Thyroid Function and Thyroid Antibody:
- Thyroid stimulating hormone
- Anti-thyroid peroxidase (if needed)
Treatment
Levothyroxine should be prescribed because of possible maternal and fetal complications associated with untreated hypothyroidism.
Chromosomal Abnormalities
Cause
In less than five in one hundred couples with recurrent miscarriage, one partner carries a chromosomal defect called a ‘balanced translocation’. This doesn’t cause a problem for the parent, but it can be passed on to the baby as an ‘unbalanced translocation’. This means that some genetic information is duplicated and some is missing and may result in miscarriage or fetal anomalies.
Specific Investigation
- Getting Tissue from the Aborted Fetus to Test for Chromosomal Abnormalities
- Chromosomal Analysis of Couples to Diagnose Genetic Defects
Treatment
Couples will be referred to a clinical geneticist for genetic counselling. Fertility treatment with preimplantation genetic testing or donor gametes may be considered.
Thrombophilia
Cause
Such as inherited clotting disorders, this is a very rare condition in which there is an imbalance in naturally occurring blood clotting proteins or clotting factor. This can put women at risk of developing blood clots and cause abnormal blood flow to uterus and make miscarriage more likely.
Specific Investigation
Blood Tests
- Doctors will assess the need of testing for thrombophilias.
Treatment
Women may be prescribed with low-dose aspirin (75 mg to 100 mg/day) before conception, and a prophylactic dose of heparin starting on the day of their positive pregnancy test.
Summary
More than half of the couples who have investigations for recurrent miscarriage don’t come out with an answer as to why they have miscarried. About 70% of recurrent miscarriage will have a successful future pregnancy again. Couples should maintain a healthy lifestyle, including abstaining from smoking and alcohol, maintaining normal weight and doing exercise, before planning for pregnancy.
Finding help and support
It’s difficult to deal with the emotional stresses and grief after pregnancy loss. We encourage you to share your feelings with your partner or others who have similar experience. Also, seek professional advice from gynaecologists as soon as possible if you are worried.
Looking ahead
Pregnancy loss may have a big impact on you and your partner. It is very normal to feel a range of emotions at this time but they will pass by with time.