Why do multiple miscarriages happen?

Recurrent pregnancy loss can be devastating. We talk about the causes and treatments

Recurrent Pregnancy Loss (RPL) is when a woman has two or more clinical pregnancy losses (miscarriages) before the pregnancy reaches the 20-week mark.

A healthcare worker uses ultrasonography to identify the loss of a clinical pregnancy. Ultrasound can detect a pregnancy as early as five to six weeks gestation in most situations (or one to two weeks after a missed period).

Before disappearing, a 'biochemical pregnancy' loss was diagnosed exclusively by urine or blood hormone monitoring. Biochemical losses are rarely considered while determining an RPL diagnosis.

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Causes of Recurrent Pregnancy Loss

Most pregnancy losses are caused by chromosomal or genetic defects and occur at random. The anomaly could be caused by the egg, sperm, or early embryo.

Approximately 12-15 per cent of all clinically diagnosed pregnancies end in miscarriage; at least 30-60 per cent of all conceptions are expected to end within the first 12 weeks of pregnancy.

Half of the time, the woman is unaware that she is even pregnant. The chance of miscarriage rises with the number of previous miscarriages, but it is usually less than 50 per cent.

Genetics

Random chromosomal abnormalities in the embryo are very common, accounting for 50-80 per cent of all first-trimester losses. However, some chromosomal defects can be handed down numerous times, contributing to multiple pregnancy losses. You and your partner should consider a karyotype to check for a balanced translocation if you've had two or more losses. There is a four per cent probability of detecting a balanced translocation in either parent. Research shows that couples with balanced translocations are more likely to have miscarriages than couples without balanced translocations.

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Infections

In some cases, certain infections could also lead to recurrent pregnancy loss. Infection of the uterus, foetus or placenta or the usage of an intrauterine device with missed infections could lead to RPL. Infections in the vagina, bacterial or viral, could also result in RPL. Though all infections cannot be ruled out, some infections can be detected through vaginal testing.

Endocrine issues

Thyroid and pituitary gland illness, diabetes, and polycystic ovarian syndrome are all endocrine concerns that should be investigated. Luteal Phase Defect (LPD) is an ovulatory disorder where your ovaries do not produce enough progesterone and may lead to miscarriage. Ovulation induction drugs like clomiphene citrate are the first line of treatment for patients with an LFD. Progesterone therapy was once popular; however, few, if any, studies show that empiric progesterone medication is beneficial. When examining potential endocrine concerns, being well-informed is always the best strategy.

Uterine malformations

A uterine structural issue is responsible for about 15 per cent of all miscarriages. Abnormalities of the uterus can be congenital (present at birth), such as a double uterus, a uterus divided by a wall (septate uterus), or other less common genetic issues. For some women, fibroids or polyps are also a concern. These growths can appear anywhere in the uterus and may or may not create issues during pregnancy. Miscarriages can also be caused by intrauterine scarring. The good news is that most of these issues may be treated surgically before conception, enhancing your chances of a healthy pregnancy.

Managing recurrent pregnancy loss

RPL is frequently a natural process. Almost two-thirds of women with RPL will have a healthy pregnancy in the end, typically without any additional treatment. Only about half of all miscarriages have a clear or treatable aetiology. Given below are a few suggested treatments to help reduce the risk for miscarriage.

Blood thinning medicines

Low-dose aspirin and heparin may be used to treat women with autoimmune or clotting (thrombophilia) issues. These medications can be used to reduce the chance of miscarriage when pregnant. Before using these medications, consult your doctor because they raise the risk of significant bleeding problems (such as stomach ulcers).

Surgery

Correcting the shape of the uterus can significantly reduce the risk of miscarriage. Extra tissue that splits the uterus (septum), certain fibroids (benign tumours), and scar tissue can all be fixed with surgery in the uterus (womb). The surgeon utilizes an instrument with a camera (hysteroscope) that is passed through the vagina to repair the inside of the uterus.

Other medical conditions

RPL could be linked to a variety of medical issues like high amounts of prolactin, an overactive or underactive thyroid gland, and irregular blood sugar levels. Diabetes, thyroid dysfunction, and excessive prolactin levels can all be treated to increase the odds of a healthy, full-term pregnancy.

(Dr Vanajakshi Shivkumar is Senior Consultant, obstetrician and gynaecologist, Milann Fertility & Birthing Hospital, Kumarapark, Bangalore.)