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Getting a positive pregnancy test result brings tremendous joy to couples who are trying for a baby. However, losing the pregnancy in the first 20 weeks - known as a miscarriage - can be equally hard on couples. Up to 15% of pregnancies end in a miscarriage and eight out of 10 miscarriages occur in the first trimester of pregnancy, from weeks zero to 13.

Distressing as a  miscarriage can be, one to two out of 100 women also run the risk of having recurrent miscarriages. Having two or more consecutive miscarriages prior to 20 weeks of pregnancy is known as recurrent pregnancy loss or miscarriage. Also known as repeated spontaneous abortion or habitual abortion, this type of miscarriage can be a cause of concern and distress for women who are trying to have a baby.

According to a study published in the Journal of Obstetrics and Gynecology of India in 2015, Indian women are more likely to suffer recurrent spontaneous miscarriage (RSM) than Westerners. According to the study, "age, (blood) clotting disorders, immunological factors, infections, and genetic disorders were the significant risk factors associated with RSM". Further, the study authors added, the chances of subsequent miscarriage go up by 24.97% after the first miscarriage, 34.04% after the second miscarriage and 21.88% after the third miscarriage.

Usually, a woman who has had recurrent miscarriages is advised to undergo a number of tests to figure out the underlying issue that is causing the miscarriages. These tests include a pelvic exam and blood tests to identify any uterine, genetic or immunological anomalies behind the recurrent miscarriages. 

If and when the underlying causes of the recurrent miscarriage is identified, it can be treated accordingly. Since this type of repeated loss of pregnancy is rare, identification of the causes and treatments can vary from person to person.

  1. Causes of recurrent miscarriage
  2. Risk factors for second or third miscarriage
  3. Diagnosis of recurrent miscarriage
  4. Treatment of recurrent miscarriage
  5. Doctors for Recurrent Miscarriage

If you have had a recurrent miscarriage, your obstetrician will conduct a number of tests to figure out any underlying cause. The doctor will ask for your and your spouse’s medical history, conduct a pelvic exam and ask you to get blood tests done. Based on the results of these tests, the cause behind recurrent miscarriage can be understood and then treated. The causes can vary from person to person. The following are some of the leading causes of recurrent miscarriage as noted by a 2009 study published in the journal Review in Obstetrics & Gynecology.

  1. Genetic causes of recurrent miscarriage
  2. Anatomical causes: uterus abnormality, fibroids, polyps, placenta problems
  3. Endocrine or hormonal causes of recurrent miscarriage
  4. Infectious causes of recurrent miscarriage
  5. Immunologic causes of recurrent miscarriage
  6. Blood clotting problems cause repeated miscarriage
  7. Environmental causes of recurrent miscarriage
  8. Unexplained causes of recurrent miscarriage

Genetic causes of recurrent miscarriage

About 2-4% of recurrent miscarriages occur due to genetic factors in either one or both parents. If there are any structural chromosomal aberrations - due to breaking and abnormal reconstitution of chromosomes - this could cause recurrent miscarriage. Chromosomal inversions and mosaicism and numerical abnormalities are other structural chromosomal damages that can cause this problem. However, single-gene defects associated with cystic fibrosis or sickle-cell anaemia are not linked in any way to recurrent miscarriage.

According to a study published in Clinical Chemistry in 2019, recurrent miscarriages are also linked to poor sperm quality, specifically if the sperm of the male partner shows high levels of chromosomal damage. The study reveals that apart from low serum testosterone and estrogen levels, the damaged sperm of the male partner will show reduced total and progressive sperm motility, atypical sperm morphology, and high levels of reactive oxygen species (ROS). High ROS-induced sperm damage is usually linked to chromosomal damage in the embryo, which can lead to recurrent miscarriages.

Read more: Low Sperm Count: Symptoms, causes, treament

Anatomical causes: uterus abnormality, fibroids, polyps, placenta problems

Approximately 10-15% of recurrent miscarriage cases are linked to abnormalities in the uterus like

These can lead to interrupted vascular (blood) supply to the endometrium (the innermost lining of the uterus). This, in turn, can cause inadequate and abnormal creation of the placenta. The placenta is an organ that develops in the uterus during pregnancy, and it provides nutrition and oxygen to the growing foetus while also getting rid of waste from the foetus' body. Without the placenta functioning normally, a pregnancy cannot be sustained, and a miscarriage is inevitable.

Read more: Placental abruption: symptoms, causes, prevention, diagnosis, treatment

Endocrine or hormonal causes of recurrent miscarriage

About 17-20% of recurrent miscarriages occur due to problems related to the endocrine system of the body (a network of glands that produce hormones that run the body normally). Luteal phase defect (LPD), polycystic ovary syndrome (PCOS), diabetes, thyroid diseases (hypothyroid or hyperthyroid) and hyperprolactinemia are some health issues linked to the endocrine system, and any of these can cause recurrent miscarriage.

Read more: How to get pregnant with thyroid problems

Infectious causes of recurrent miscarriage

A number of infections are suspected to play a role in recurrent miscarriage, with a 0.5-5% causal rate. These infections include listeriosis, toxoplasmosis, rubella, measles, cytomegalovirus, coxsackieviruses and sexually transmitted infections (STIs) like chlamydia and herpes. Pregnancy loss can occur through the following mechanisms:

  • Direct infection of the uterus, foetus or placenta
  • Placental insufficiency due to chronic infection
  • Chronic endometritis or endocervicitis
  • Amnionitis
  • Infected intrauterine device

Immunologic causes of recurrent miscarriage

Despite the fact that a foetus develops within the mother’s body and depends on her immunity for survival, the immune system of the baby is not identical to that of the mother. This is because genetically, the mother and baby are not the same. The mother’s immune system has to go through a number of compromises so that the foetus is not rejected during the gestation period. However, if these immunological compromises are not made, the mother’s body can reject the foetus, leading to recurrent miscarriage.

Blood clotting problems cause repeated miscarriage

Hypercoagulability, or the condition where a body’s tendency towards blood clotting increases, can occur during pregnancy and a number of women are already at risk of this condition. The risk of thrombophilia, or the occurrence of thrombosis, is also high in women who have antiphospholipid syndrome - an autoimmune disease in which blood coagulation mechanisms of the mother’s body are compromised, and repeated foetus rejection occurs.

Environmental causes of recurrent miscarriage

Occupational and environmental exposure to certain toxins, particularly through food, water and air, can cause recurrent miscarriage. Smoking, alcohol consumption and caffeine consumption have been linked to repeated pregnancy loss. If a mother consumes three to five alcoholic drinks daily during the first trimester or throughout the pregnancy, there is a greater chance of recurrent miscarriage. That the nicotine found in cigarettes is a vasoconstrictor (constricts blood vessels) is well-known - unfortunately, it also to restricts blood flow to the uterus and placenta during pregnancy. Three to five cups of coffee daily is also linked to sporadic as well as recurrent miscarriages.

Read more: How to quit smoking

Unexplained causes of recurrent miscarriage

While the above-mentioned causes account for nearly 50% of recurrent miscarriage cases, no underlying cause can be found in the remaining cases. This makes the treatment of these women more difficult.

That said, progesterone treatment has shown some positive changes in their constitution. More research is needed to understand the mechanisms behind recurrent miscarriage.

There are a number of factors which can put you at an increased risk of recurrent miscarriage. These risks include:

  • If you get pregnant at an older age (above 35 years).
  • If you have chronic conditions like diabetes, high blood pressure, etc.
  • If you have endocrine diseases like hypothyroid, PCOS, etc.
  • If you have uterine abnormalities or growths, like fibroids.
  • If you have cervical issues like a weak cervix.
  • If you smoke, drink alcohol or use illegal drugs before and during pregnancy.
  • Obesity as well as being underweight (malnourished) increase the risk of recurrent miscarriage.
  • Prenatal genetic tests like amniocentesis increase the risk for miscarriage - the reason for this is not known.

Read more: Can I still get pregnant if I have PCOS?

 

Diagnosing any underlying causes is the first step towards proper treatment. While these test can help to determine the underlying causes in some women, it must be noted that some patients don't get a definitive diagnosis despite getting all the tests - in nearly 50% of recurrent miscarriage cases, the underlying causes cannot be identified with certainty.

The following tests and exams are done to diagnose the causes behind recurrent miscarriage:

  • Medical history: Your doctor will first take a complete medical history from you and your spouse. This will include all the infections and diseases you have each had, if either or both of you have had any surgeries done, and what diseases run in the family (from heart disease to thyroid problems and diabetes).
  • Genetic testing: A test that includes the karyotype analysis, or the analysis of genetic or chromosomal makeup, of both parents will be done. The purpose of this test is to find out if there are any genetic abnormalities that the parents are passing on to the foetus, which may be leading to the complications.
  • Pelvic exam: The uterus and uterine cavity of the mother also needs to be examined to understand if there are any anatomical abnormalities that are making the woman’s body reject consecutive foetuses. An ultrasound, X-ray, MRI and hysteroscopy can be recommended to delve deeper into this, in addition to a physical pelvic exam by a doctor.
  • Antiphospholipid test: Antibodies related to antiphospholipid syndrome will be tested in the antiphospholipid test to find out if the mother has inherited thrombophilias or abnormally increased blood clotting. The anticardiolipin antibody and lupus anticoagulant will be particularly tested. (Read more: lupus anticoagulant test and cardiolipin antibodies test)
  • Hormone function test: Thyroid function and thyroid antibodies will be tested to see if hormone secretion is taking place normally. The production of hormones like progesterone, prolactin, etc., will also be tested.
  • Ovarian reserve test: This test evaluates how well a woman’s ovaries are functioning. Poor quality ovaries can produce eggs which have abnormalities, and can, in turn, lead to recurrent miscarriage.

The treatment of recurrent miscarriage depends on the diagnosis of any underlying causes. No matter what the diagnosis, treatment for recurrent miscarriage has a high success rate.

Separately, according to the American College of Obstetricians and Gynecologists, 65% of women whose tests did not identify an underlying cause were still able to get pregnant and deliver a healthy baby without any treatment.

In women who have identified causes behind recurrent miscarriage, the following treatments might be suggested by their doctor:

  • Genetic counselling for karyotype abnormalities.
  • In vitro fertilization (IVF) with a pre-implantation genetic diagnosis: the fertilized egg is tested for genetic abnormalities before being implanted in the mom-to-be's uterus.
  • Surgery to correct uterine abnormalities like septate uterus. In septate uterus, a membrane made of muscle and fibres divides the uterus into two parts.
  • Medications like heparin and low-dose aspirin to reduce risks related to thrombophilia and antiphospholipid syndrome may be prescribed.
  • Medications to treat or manage thyroid dysfunctions may be prescribed, based on the diagnosis.
  • Medications to treat diabetes are prescribed for women with high blood sugar levels.

Read more: How to get pregnant if you have a thyroid problem

Dr. Sravanthi Sadhu

Dr. Sravanthi Sadhu

Obstetrics & Gynaecology
7 Years of Experience

Dr. Kavita Singh

Dr. Kavita Singh

Obstetrics & Gynaecology
2 Years of Experience

Dr. Nidhi Bothaju

Dr. Nidhi Bothaju

Obstetrics & Gynaecology
3 Years of Experience

Dr K Supriya

Dr K Supriya

Obstetrics & Gynaecology
4 Years of Experience

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References

  1. Ford, Holly B. and Schust, Danny J. Recurrent Pregnancy Loss: Etiology, Diagnosis, and Therapy. Rev Obstet Gynecol. 2009 Spring; 2(2): 76–83. PMID: 19609401
  2. American College of Obstetricians and Gynecologists. [internet], Bethesda (MD), USA; Repeated Miscarriages
  3. UCLA Health [Internet]. University of California. Oakland. California. US; Recurrent Pregnancy Loss
  4. The Miscarriage Association [Internet]. UK; Recurrent miscarriage
  5. Jeve, Yadava B. and Davies, William. Evidence-based management of recurrent miscarriages. J Hum Reprod Sci. 2014 Jul-Sep; 7(3): 159–169. PMID: 25395740
  6. Duckitt, Kirsten and Qureshi, Aysha. Recurrent miscarriage. BMJ Clin Evid. 2015; 2015: 1409. PMCID: PMC4610348
  7. Kupferminc, Michael J. Thrombophilia and pregnancy. Reprod Biol Endocrinol. 2003; 1: 111. PMID: 14617365
  8. Patki, Ameet and Chauhan, Naveen. An Epidemiology Study to Determine the Prevalence and Risk Factors Associated with Recurrent Spontaneous Miscarriage in India. J Obstet Gynaecol India. 2016 Oct; 66(5): 310–315. PMID: 27486274
  9. World Health Organization, Geneva [Internet]. Why we need to talk about losing a baby.
  10. Jayasena, Channa N. et al. Reduced Testicular Steroidogenesis and Increased Semen Oxidative Stress in Male Partners as Novel Markers of Recurrent Miscarriage. Clinical Chemistry, Volume 65, Issue 1, 1 January 2019, Pages 161–169.
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