Of a secret grief

Recurrent pregnancy losses or miscarriages can leave a woman exhausted, physically and emotionally. But all hope's not lost...

Pregnancy is a very exciting time for every woman, but at the same time, it can also be a time of deep uncertainty and great psychological stress. Very often, the stress and uncertainty stems from fears over the normalcy of your baby. Being pregnant with the most-awaited little bundle of joy, spending weeks hiding the regular nausea until tested positive, the growing cup size and constant fatigue — pregnancy is definitely not an easy time for women. The last thing that they want is an unfortunate miscarriage.

Recurrent abortions are frustrating and disheartening to the couple as well as the treating clinician. It is believed that 15-20% of all pregnancies end up as early pregnancy losses. These figures, however, are for clinically recognised pregnancies i.e., those pregnancies which are confirmed around four to five weeks after conception. There is now evidence that the pregnancy loss rate before this period i.e., during the two to three weeks following conception may be as high as 50%.

What do the numbers say?
The occurrence of recurrent miscarriage in the general population is believed to be around 0.8-1%. This is an adverse life event and a frustrating and heart-wrenching experience for both the patient and the physician. Despite continued research, the management of recurrent pregnancy loss (RPL) seems to be as elusive as ever. 

RPL, habitual abortion or recurrent miscarriage, is defined as the failure of pregnancy before the foetus is 20 weeks old. It can be due to various reasons including anatomical factors, chromosomal abnormalities, antiphospholipid syndrome, hormonal or metabolic factors, or very often due to unidentified causes. The abnormality may be caused by the egg, the sperm, or the early embryo.

Looking at the reasons
Apart from medical reasons, even a mother’s psychological condition can also result in a miscarriage of the foetus. This condition can make the woman depressed and tremendously deprive her of any hope. However, it is of considerable relief that most women who have experienced recurrent miscarriages can certainly go on to become happy mothers under medical supervision. Here are some other causes:

Uterine conditions: Around 15% of recurrent miscarriages are caused by uterine malformations. A septate uterus (uterus having septum on the inside and hence divided in cavity by a partition) is the most common uterine irregularity and is diagnosed by combined laparoscopy or MRI. This is also a type of congenital uterine malformation, which results in the formation in the woman’s uterus during her prenatal development.

Cervical conditions: Cervical conditions such as cervical incompetence or weak cervix is the next common condition resulting in recurring miscarriage. In pregnancy, with the baby’s growth, there is a certain amount of pressure in the cervix. If the cervix starts to open before the birth of the baby, it is called as a weakened cervix or an incompetent cervix. 

Chromosomal disorders: Most spontaneous miscarriages are caused by an abnormal (aneuploid) karyotype of the embryo. At least 50% of all first-trimester spontaneous abortions (SABs) are cytogenetically abnormal.

Ovarian factors: The susceptibility to miscarriage increases with an advancing age as the ovarian reserves are also depleted with advancing age, and they become vulnerable to miscarriages. The actual cause is the poor quality of maternal eggs.

Lifestyle factors: Excessive exposure to toxins, smoking or consuming alcohol can also cause recurrent miscarriages.

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

Diagnosis & treatment
A thorough clinical examination should be done to find out the underlying cause. Ultrasound scans can be done to review the condition of the uterus and ovaries. Blood tests of both the partners are done to rule out the presence of any chromosomal abnormalities. If an abnormality is detected, the patient will be sent for genetic counselling. Specialised tests like TORCH (toxoplasmosis, rubella cytomegalovirus, herpes simplex, and HIV) are done to find out any underlying viral or bacterial infection. Tissues from the placenta may also be tested for signs of a problem.

Proper treatment can only begin when the cause of recurrent miscarriage can be identified. But in some unfortunate circumstances, there is no actual treatment for inexplicable recurrent miscarriage. Here are some treatments:

Genetic counselling: Abortion counselling is done with the primary objective of empowering the woman. One should not force the decision and allow the couple to decide this on their own. Restrict rigorous activities and exercises. Sexual intercourse is generally not advised while you are pregnant, especially in the first trimester and third trimester. Some experts might advise progesterone, but it is a bit controversial. Progesterone should only be used if there is a luteal phase defect, or if your obstetrician is sure about the use.

Surgical management: McDonald stitches or cervical cerclage (procedure in which stitches are used to close the cervix during pregnancy to help prevent pregnancy loss or premature birth) is done for cervical-incompetent patients. The process is beneficial to women having cervix less than 25 mm.

An unexplained miscarriage, sometimes, holds a good chance of having a perfectly 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. If you have been emotionally exhausted because of repeated loss and are feeling extremely low and scared to lose another baby, it would be a wise decision to seek support and help from family and friends. Keeping a positive attitude can help you have a normal pregnancy without any glitch.

(The author is medical director, Milann)