Recurrent Miscarriage
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RECURRENT   MISCARRIAGE

DR. S. Kalaichandran, MBBS, MD, FRCSC,FSOGC (Canada), FRCOG

Lecturer University of Ottawa
Obstetrics and Gynaecology

Introduction:

It is a sad commentary on our society and its ignorance when a woman who had a miscarriage, instead of getting sympathy and support, is made to feel that it is somehow her fault. It is all too common to find recurrent miscarriges leading to divorce. This article is written to give basic information about miscarriages. The reader is adviced to consult the Family Doctor or the Gynaecologist for specific problems.

Definition:

A miscarriage is a pregnancy loss under 20 week gestation from the last menstrual period. A recurrent miscarriage is a term traditionally applied after 3 successive miscarriages.

 Incidence:

Early pregnancy loss is much more common than the average person understands. Using the very sensitive pregnancy tests that are available now, we know that 1 in 2 pregnancies end in very early miscarriage. In the past the majority of these would have been passed off as late or heavy menses. Even after a clinically diagnosed pregnancy, 1 in 5- 6 pregnancies end in a miscarriage between 4 & 20 week gestation.

 

 

 

1.Chromosomal abnormalities in the conceptus

7 out  of 10 miscarriages under 12 week gestation are due to chromosomal abnormalities in the conceptus. This is more common with increase in maternal age. In women over 40 years of age, 1 in 3 will have a miscarriage  on this account. If we include the very early miscarriages too, 3 out of 4 pregnancies end in miscarriages in this age group.

 2. Genetic factors in the couple

In a small number of recurrent miscarriages, genetic defects (translocation) in the parents may be responsible. One has to consider this when there is a family history of recurrent miscarriages.

 3. Environmental factors

Exposure to noxious or toxic substances are known to be associated with recurrent miscarriages. Social(!) drugs , cigarettes, alcohol and caffeine are implicated.   Anaesthetic gases, dry cleaning fluids, petroleum products and Isoteretinon (for acne) are known causes.

4. Medical conditions

Uncontrolled  Diabetes and Thyroid disease   may cause miscarriages. In a developing country,  chronic diseases, like Malaria or Tuberculosis may be responsible for a significant number of miscarriages.

 5. Auto immune disease

One in ten women with recurrent miscarriages  show  evidence  of  auto immune  factors  on   investigation. They  may have  overt  auto immune diseases like  diabetes, thyroid disease, lupus, colitis, skin and joint diseases or develop these conditions later.

 6. Structural defects

One in six to ten women  with  recurrent  miscarriages  has  a  structural  defect  like uterine  septum or adhesions.

Management:

Miscarriages, like  infertility, is  a  problem  of  a  couple  and  they  should  be  seen  together.  The  majority  can  be  reassured. Of  those who had  a  successful  pregnancy  before  3  miscarriages, 70%  will  have  a  successful  pregnancy.  Of  those  who  had  no  previous  successful  pregnancy,  a  full  60%  will  have  a  successful pregnancy.

Education  and  reassuarance  with  these  good  statistical  odds  may  be  all  that  is  needed. Education  about  smoking, alcohol and drug abuse is  also important ; fortunately  this  is  not  a  problem  among  Indian  women  at  present. Counselling  is needed on  pre-conceptual  folate  prophylaxis  to  prevent  neural tube defect  and  miscarriages.   

Karyotyping  may  be  useful  if  there  is  a  family  history  of  recurrent  miscarriages  or  the couple  are  closely  related  to  each  other  before  marriage  as  is  often  the  case  in  India.

Screening  for  diabetes, thyroid disease and  auto immune  factors  will  rule  out  these  conditions.

  Hystersalpingogram,  hystroscopy and  laparoscopy  will  be  useful  to  assess  the  anatomy  of  the  uterus  and  tubes.

  Ovum tracking  with  serial  ultrasound scans  and  serial serum progestrone  assays  will help  in  diagnosing  ovulatory  factors (corpus luteum failure).

  After  all  these  investigations  50%  of  recurrent  aborters  will  be  found  to  have  no  abnormalities  and  these  should  be  attributed  to  chromosomal defect  in  the  conceptus.      

Copyright © 1999 [Dr. Kalaichandran]. All rights reserved.
Revised: May 12, 2003 .