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Recurrent Pregnancy Loss

Maternal pregnancy complications


Description

Spontaneous abortion, usually referred to as miscarriages, are quite common and can occur once during every women’s reproductive life. In the general population, the risk of miscarriage is 1 in 5 pregnancies. This increases to 1 in 3 pregnancies when women are over 40. When pregnancy loss becomes recurrent, an investigation is a good idea.

Note that an investigation will only be initiated after 2 consecutive miscarriages or more. It is also necessary that the pregnancy was confirmed by an ultrasound or a pathology examination of the products of conception was performed. Pregnancies confirmed only via a positive pregnancy test are not counted. After 2 or more successive miscarriages, the risk of recurrence is estimated to be 30% for women under 35 years of age.


Causes

The most common cause of spontaneous abortion is aneuploidy, commonly known as chromosomal abnormalities, in the embryo or ovum. This happens more frequently with women of advanced reproductive age.

Causes of recurrent miscarriages include:

  • Abnormalities of the uterus: uterine septum, uterine scarring or Asherman’s syndrome, submucous fibroma
  • Endocrine diseases: diabetes, thyroid disorder, hyperprolactinemia
  • Coagulation disorders: antiphospholipid syndrome
  • Genetic abnormalities in men or women: balanced translocation
  • Low ovarian reserve

Research into whether or not other immunological or infectious causes are responsible for recurrent pregnancy loss is ongoing. Unfortunately, in half of the cases of recurrent miscarriages, a cause is not found.


Counselling 

Although the risk of miscarriage seems high at 30% of women under 35 with a history of recurrent pregnancy loss, there is still a 70% chance of giving birth to a healthy child in a woman’s reproductive years.

It is important to space pregnancies at least 2 menstrual cycles apart to have better implantation of a fertilized egg. It is also necessary to lead a healthy lifestyle, maintain a healthy weight, exercise, quit drinking and smoking, and finally, stay hydrated. A daily dose of 1 mg of folic acid and 1000 IU of vitamin D is recommended as well. 


Tests and procedures

Investigations into this issue are directly related to the known causes of recurrent pregnancy loss for which an effective treatment is available.

To identify abnormalities of the uterus, hysterosonography or hysteroscopy is prescribed. This test is used to identify the presence of a septum, scars, or fibroids inside the uterine cavity.

Blood is taken to test fasting glucose, glycated hemoglobin, TSH and prolactin to identify the presence of diabetes, hypothyroidism, or hyperprolactinemia.

Further blood tests looking for anti-beta 2 glycoprotein, IgM and IgG anticardiolipin, and lupus anticoagulant are needed to identify the presence of antiphospholipid syndrome.

Parental karyotype tests are used to identify if either member of the couple has a balanced translocation.

The ovarian reserve is assessed using a pelvic ultrasound designed to count antral follicles and a blood test done to assess FSH, AMH, and estradiol levels between day 2 and day 5 of the menstrual cycle.

Sometimes an IgA anti-transglutaminase blood test will be requested to check for an intolerance to gluten.

Although often used, there is no evidence that prescribing progesterone improves the chances of live pregnancy, except perhaps in cases where a hematoma has been diagnosed in the first trimester.


Treatment and follow-up care

In cases of recurrent pregnancy loss, targeted treatment is recommended depending on the results of the investigations. In most cases, specialists in reproductive endocrinology and infertility are your best choice to provide any required treatments.

If a uterine abnormality is discovered, a hysteroscopic surgery is the treatment favoured.

In cases of hormonal disorders, consultation and management by an endocrinologist may be required for the treatment of diabetes, hypothyroidism, or hyperprolactinemia. Optimal control over these conditions is necessary before becoming pregnant.

If antiphospholipid syndrome is identified, the treatment of choice is the daily intake of low-dose aspirin and low molecular weight heparin from when the positive pregnancy test is documented to the week 36 of the pregnancy.

If a chromosome abnormality is discovered in one of the parents, a preimplantation diagnosis followed by in vitro fertilization can be considered.

In cases of low ovarian reserve, stimulation of ovulation is necessary.

Sometimes a gluten-free diet is effective if the anti-transglutaminase IgA test is abnormal.


Resources and useful links

  • Kutteh W. Novel Strategies for the Management of RPL. Sem Repro Med 2015 ;33-3.
  • Pluchino N. Hormonal Causes of RPL. Hormones 2014.
  • RCOG Guideline on Recurrent Pregancy Loss, 2011.
  • Jeve, Y. Evidence-based Management of Recurrent Miscarriage. J Hum Reprod Science 2014.
  • Coomarasamy, A. A randomized Trial of Progesterone in Women with Recurrent Miscarriage. NEJM 2015.
Fiche par

Dre Camille Sylvestre et Dre Lucie Morin

About this page
Updated on 12/20/2017
Created on 12/18/2017
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