Recurrent Recurrent MiscarriageMiscarriage

GuidelinesGuidelines Dr Muhammad El HennawyDr Muhammad El Hennawy

Ob/gyn ConsultantOb/gyn ConsultantRass el barr central hospital andRass el barr central hospital and dumyat specialised hospitaldumyat specialised hospitalDumyatt Dumyatt –– EGYPT EGYPTwww. mmhennawywww. mmhennawy .co.nr.co.nr

DefinitionDefinition

A recurrent miscarriage is A recurrent miscarriage is 3 or 3 or more consecutive, more consecutive, spontaneous pregnancy lossesspontaneous pregnancy losses, , under 20 week gestation from the under 20 week gestation from the last menstrual period , by the last menstrual period , by the same partner. same partner.

Primary recurrent pregnancy lossPrimary recurrent pregnancy loss" " refers to couples that have never refers to couples that have never had a live birth, had a live birth,

while while "secondary RPL""secondary RPL" refers to refers to those who have had repetitive those who have had repetitive losses following a successful losses following a successful pregnancy pregnancy

a woman who had a a woman who had a miscarriage,instead of getting miscarriage,instead of getting sympathy and support, is made to sympathy and support, is made to feel that it is somehow her fault feel that it is somehow her fault

It is all too common to find It is all too common to find recurrent miscarriges leading to recurrent miscarriges leading to divorce divorce

TerminologyTerminology The medical term 'spontaneous The medical term 'spontaneous

abortion' should be replaced with the abortion' should be replaced with the term 'miscarriage'term 'miscarriage'

Other names : recurrent pregnancy loss Other names : recurrent pregnancy loss (RPL), (RPL),

habitual abortions ,habitual abortions , habitual miscarriages, habitual miscarriages,

recurrent abortions ,recurrent abortions , recurrent miscarriages. recurrent miscarriages.

IncidenceIncidence 1010––15%15% of all clinically recognised of all clinically recognised

pregnancies end in a miscarriage pregnancies end in a miscarriage the theoretical risk of three consecutive the theoretical risk of three consecutive

pregnancy losses that expected by chance pregnancy losses that expected by chance alone is alone is 0.34%.0.34%.

This incidence is greater than that expected This incidence is greater than that expected by chance alone---Recurrent miscarriage by chance alone---Recurrent miscarriage affects affects 1%1% of all women ---Hence, only a of all women ---Hence, only a proportion of women presenting with proportion of women presenting with recurrent miscarriage will have a persistent recurrent miscarriage will have a persistent underlying cause for their pregnancy losses underlying cause for their pregnancy losses

Risk factorsRisk factors Advanced maternal ageAdvanced maternal age adversely affects ovarian function, giving adversely affects ovarian function, giving

rise to a decline in the number of good rise to a decline in the number of good quality oocytes, resulting in quality oocytes, resulting in chromosomally abnormal conceptions chromosomally abnormal conceptions that rarely develop further. that rarely develop further.

. . previous number of miscarriagesprevious number of miscarriages

possible causespossible causes

Recurrent miscarriage is a Recurrent miscarriage is a heterogeneous condition that has heterogeneous condition that has many possible causes; many possible causes; more than more than oneone contributory factor may underlie contributory factor may underlie the recurrent pregnancy losses.the recurrent pregnancy losses.

each may have had each may have had a differenta different cause. cause.

Geneticfactors

Anatomicalfactors

EndocrineInfectiveagents

Immunefactors

InheretedThrombophilic

defect

Explained Un-explained

RecurentMiscarriage

Enviromentalfactors

Body Cervix

Paternalkaryotyping

CytogeneticOf miscarriage

C I

Uterineanomalies

APS

BacterialVaginosis

Investigations and treatmentsInvestigations and treatmentsRecent information indicates that women should look into RPL Recent information indicates that women should look into RPL

testing after two losses when it used to be common to wait testing after two losses when it used to be common to wait until three. This is especially important for women in their 30s until three. This is especially important for women in their 30s

and 40sand 40s

Diagnosis and investigationDiagnosis and investigation EPAUs should use and develop diagnostic and EPAUs should use and develop diagnostic and

therapeutic algorithms of care.therapeutic algorithms of care. In particular, these should include management of In particular, these should include management of

'suspected ectopic pregnancy' (including serum 'suspected ectopic pregnancy' (including serum hCG) and the 'indeterminate' ultrasound scan.hCG) and the 'indeterminate' ultrasound scan.

EPAUs should have access to transvaginal EPAUs should have access to transvaginal ultrasound with staff appropriately trained in its ultrasound with staff appropriately trained in its use.use.

Non-sensitised rhesus (Rh) negative women Non-sensitised rhesus (Rh) negative women should receive anti-D immunoglobulin in the should receive anti-D immunoglobulin in the following situations: ectopic pregnancy, all following situations: ectopic pregnancy, all miscarriages over 12 weeks (including miscarriages over 12 weeks (including threatened), all miscarriages where the uterus is threatened), all miscarriages where the uterus is evacuated, and for threatened miscarriages under evacuated, and for threatened miscarriages under 12 weeks when bleeding is heavy or associated 12 weeks when bleeding is heavy or associated with pain.with pain.

Genetic factorsGenetic factors

All couples with a history of recurrent All couples with a history of recurrent miscarriage should have peripheral miscarriage should have peripheral blood karyotyping performed. The blood karyotyping performed. The finding of an abnormal parental finding of an abnormal parental karyotype should prompt referral to a karyotype should prompt referral to a clinical geneticist.clinical geneticist.

33––5% of couples with recurrent 5% of couples with recurrent miscarriage, one of the partners carries a miscarriage, one of the partners carries a balanced structural chromosomal anomaly balanced structural chromosomal anomaly

55––10% chance of a pregnancy with an 10% chance of a pregnancy with an unbalanced translocation. unbalanced translocation.

In all couples with a history of recurrent miscarriage cytogenetic analysis of the products of conception should be performed if the next pregnancy fails.

an abnormal embryo, which is incompatible with life, e.g. chromosomal abnormalities or life, e.g. chromosomal abnormalities or structural malformations. structural malformations.

If the karyotype of the miscarried pregnancy If the karyotype of the miscarried pregnancy is abnormal, there is a better prognosis in is abnormal, there is a better prognosis in the next pregnancy the next pregnancy

Cytogenetic testing is an expensive tool and should be reserved for patients who have undergone treatment in the index pregnancy or have been participants in a research trial

Fetal chromosomal Fetal chromosomal abnormalitiesabnormalities

This may be due to abnormalities in This may be due to abnormalities in the egg, sperm or both. Thethe egg, sperm or both. The   most most common chromosomal defects are common chromosomal defects are

Trisomy:Trisomy: Monosomy:Monosomy:   Polyploidy:Polyploidy:

Chromosome Testing on Fetal (Miscarriage) Chromosome Testing on Fetal (Miscarriage) TissueTissue

This can only be done right at the time of This can only be done right at the time of miscarriage.miscarriage.

It is an analysis of the genetic makeup of the fetus. It is an analysis of the genetic makeup of the fetus. It can indicate genetic problems that lead to RPL. It can indicate genetic problems that lead to RPL. Many miscarriages are caused by chromosomal Many miscarriages are caused by chromosomal

abnormalities that are unlikely to repeat. To know if abnormalities that are unlikely to repeat. To know if the problem is likely to recur, it is necessary to the problem is likely to recur, it is necessary to study the genetics of both parents as well.study the genetics of both parents as well.

Karyotyping of ParentsKaryotyping of Parents each Chromosome analysis of blood of both parents.each Chromosome analysis of blood of both parents. It can show if there is a potential problem with one It can show if there is a potential problem with one

of the parents that leads to miscarriage, but often of the parents that leads to miscarriage, but often has to be done in conjunction with fetal testing to has to be done in conjunction with fetal testing to provide answers.provide answers.

These tests help rule out the 3% or so of partners These tests help rule out the 3% or so of partners that carry a "hidden" chromosomal problem called a that carry a "hidden" chromosomal problem called a balanced translocation.balanced translocation.

KARYOTYPING , HOWKARYOTYPING , HOW?? It is A display of an individualIt is A display of an individual’’s chromosome s chromosome

pairs.pairs. Process : Sample of cells is taken, usually blood Process : Sample of cells is taken, usually blood

cells. cells. Cells are chemically stimulated to undergo Cells are chemically stimulated to undergo

mitosis. Mitosis is stopped at mitosis. Mitosis is stopped at metaphasemetaphase.. Chromosomes are separated out, Chromosomes are separated out, viewed with a microscope viewed with a microscope and photographed. and photographed. The photograph is then rearranged to show the The photograph is then rearranged to show the

paired chromosomes. paired chromosomes. SizeSize, , shapeshape and and banding banding patternpattern are used to pair up the chromosomes are used to pair up the chromosomes. .

Anatomical factorsAnatomical factors

One in six to ten women with One in six to ten women with recurrent miscarriages has a recurrent miscarriages has a structural defect like uterine structural defect like uterine

septum or adhesions septum or adhesions

HysterosalpingogramHysterosalpingogram (HSG) (HSG) two dimensional pelvic ultrasound two dimensional pelvic ultrasound

with (or without) with (or without) SonohysterographySonohysterography

3D3D UltrasoundUltrasoundLaparoscopyLaparoscopy HysteroscopyHysteroscopy

The reported prevalence of uterine anomalies in The reported prevalence of uterine anomalies in recurrent miscarriage populations range between recurrent miscarriage populations range between 1.8% and 37.6%. 1.8% and 37.6%.

The prevalence of uterine malformations appears to The prevalence of uterine malformations appears to be higher in women with be higher in women with late miscarriageslate miscarriages compared compared with women who suffer early miscarriages but this with women who suffer early miscarriages but this may be related to the cervical weakness that is may be related to the cervical weakness that is frequently associated with uterine malformation. frequently associated with uterine malformation.

untreated uterine anomaliesuntreated uterine anomalies has a term delivery rate has a term delivery rate of only 50%. of only 50%.

Open uterine surgeryOpen uterine surgery is associated with is associated with postoperative infertility and carries a significant risk postoperative infertility and carries a significant risk of uterine scar rupture during pregnancy. These of uterine scar rupture during pregnancy. These complications are less likely to occur after complications are less likely to occur after hysteroscopic surgery but no randomised trial hysteroscopic surgery but no randomised trial assessing the benefits of surgical correction of assessing the benefits of surgical correction of uterine abnormalities on pregnancy outcome has uterine abnormalities on pregnancy outcome has been performed. been performed.

Congenital anomaliesCongenital anomalies an abnormal or irregularly shaped uterus.an abnormal or irregularly shaped uterus. Sometimes Sometimes the uterus has an extra wall down

its centre, which makes it look as if it is divided it is divided intointo

two (bicornuate or septate uterus) (bicornuate or septate uterus) a septate uterus Where as a partial septum a septate uterus Where as a partial septum

increases the risk to 60%-75%; a total septum increases the risk to 60%-75%; a total septum carries a risk for loss of up to 90%. carries a risk for loss of up to 90%.

Today a relatively simple surgical procedure can Today a relatively simple surgical procedure can remove a uterine septum remove a uterine septum

or it may or it may have only developed one half (unicornuate uterus)(unicornuate uterus). .

It is not clear if such problems cause recurrent It is not clear if such problems cause recurrent miscarriage,miscarriage,

fibroidsfibroids If fibroids are detected on the inside If fibroids are detected on the inside

of the uterus (termed submucous of the uterus (termed submucous fibroids) and distort the uterine fibroids) and distort the uterine lining, they are a significant cause of lining, they are a significant cause of reproductive problems and should be reproductive problems and should be removed. It is less clear whether removed. It is less clear whether fibroids in the wall of the uterus fibroids in the wall of the uterus cause reproductive problems cause reproductive problems

scar tissue in the uterusscar tissue in the uterusscar tissue in the uterus which may scar tissue in the uterus which may

hinder implantation or growth of the hinder implantation or growth of the fetus. fetus.

HysterosalpingographyHysterosalpingography The routine use of hysterosalpingography as The routine use of hysterosalpingography as

a screening test for uterine anomalies in a screening test for uterine anomalies in women with recurrent miscarriage is women with recurrent miscarriage is questionablequestionable..

It is associated with patient discomfort, It is associated with patient discomfort, carries a risk of pelvic infection and radiation carries a risk of pelvic infection and radiation

exposure exposure and is no more sensitive than the non-and is no more sensitive than the non-

invasive two dimensional pelvic ultrasound invasive two dimensional pelvic ultrasound assessment of the uterine cavity with (or assessment of the uterine cavity with (or without) Sonohysterography when performed without) Sonohysterography when performed by skilled and experienced personnel. by skilled and experienced personnel.

HysterosonographyHysterosonographyHysterosonography provides a Hysterosonography provides a

sensitive and specific screening tool sensitive and specific screening tool for evaluating the uterine cavity and for evaluating the uterine cavity and it could be an accurate alternative to it could be an accurate alternative to HSG in screening for uterine HSG in screening for uterine abnormalities abnormalities

UltrasoundUltrasound It is sometimes possible to see abnormalities inside the It is sometimes possible to see abnormalities inside the

uterus at the time of a scan, especially auterus at the time of a scan, especially a vaginal scan. A scan will also enable the ovaries to be vaginal scan. A scan will also enable the ovaries to be

examined at the same time. Occasionallyexamined at the same time. Occasionally polycystic ovaries polycystic ovaries are diagnosed by ultrasound scan (see are diagnosed by ultrasound scan (see

above).above). Some units will offer a scan and an examination of the Some units will offer a scan and an examination of the

inside of the uterus at the same time - inside of the uterus at the same time - salinesaline installation sonography (SIS). installation sonography (SIS). A small plastic tube is A small plastic tube is

passed through the cervix and a water-likepassed through the cervix and a water-like solution injected through it. The scan can determine solution injected through it. The scan can determine

whether there is any abnormality inside thewhether there is any abnormality inside the uterus.uterus.

All women with recurrent All women with recurrent miscarriage should have a miscarriage should have a pelvic ultrasound to assess pelvic ultrasound to assess

uterine anatomy and uterine anatomy and morphologymorphology

Two dimensional pelvic ultrasound Two dimensional pelvic ultrasound assessment of the uterine cavity assessment of the uterine cavity with (or without) with (or without) SonohysterographySonohysterography

three-dimensional ultrasoundthree-dimensional ultrasound

The diagnostic value of three-The diagnostic value of three-dimensional ultrasound has been dimensional ultrasound has been explored and appears promising.explored and appears promising.

Since three-dimensional ultrasound Since three-dimensional ultrasound offer both diagnosis and classification offer both diagnosis and classification of uterine malformation its use may of uterine malformation its use may obviate the need for diagnostic obviate the need for diagnostic hysteroscopy and laparoscopy. hysteroscopy and laparoscopy.

HysteroscopyHysteroscopy

This investigation, performed under This investigation, performed under general anaesthetic, examines the general anaesthetic, examines the inside of the uterus with a thininside of the uterus with a thin

telescope (3-5 mm in diameter) . By telescope (3-5 mm in diameter) . By inserting this telescope through the inserting this telescope through the cervix and into the uterus,cervix and into the uterus,

the doctor can see the shape of the the doctor can see the shape of the uterus and examine its lining.uterus and examine its lining.

Cervical weaknessCervical weakness

Cervical cerclage is associated with potential Cervical cerclage is associated with potential hazards related to the surgery and the risk of hazards related to the surgery and the risk of stimulating uterine contractions and hence stimulating uterine contractions and hence should only be considered in women who are should only be considered in women who are likely to benefit.likely to benefit.

Cervical weakness is often Cervical weakness is often over-diagnosedover-diagnosed as a as a cause of mid-trimester miscarriage. cause of mid-trimester miscarriage.

The diagnosis is usually based on The diagnosis is usually based on a historya history of late of late miscarriage, preceded by spontaneous rupture of miscarriage, preceded by spontaneous rupture of membranes or painless cervical dilatation.membranes or painless cervical dilatation.

Transvaginal ultrasound assessment of the cervix Transvaginal ultrasound assessment of the cervix during pregnancy during pregnancy maymay be useful in predicting be useful in predicting preterm birth in some cases of suspected cervical preterm birth in some cases of suspected cervical weakness weakness

Transabdominal cerclage has been advocated as a Transabdominal cerclage has been advocated as a treatment for second-trimester miscarriage and the treatment for second-trimester miscarriage and the prevention of early preterm labour in selected prevention of early preterm labour in selected women with previous failed transvaginal cerclage women with previous failed transvaginal cerclage and/or a very short and scarred cervix and/or a very short and scarred cervix

Endocrine factorsEndocrine factors

Routine screening for occult Routine screening for occult diabetes and thyroid disease diabetes and thyroid disease

with oral glucose tolerance and with oral glucose tolerance and thyroid function tests in thyroid function tests in asymptomatic women asymptomatic women

presenting with recurrent presenting with recurrent miscarriage is uninformativemiscarriage is uninformative

well-controlled diabetes mellitus is not a well-controlled diabetes mellitus is not a risk factor for recurrent miscarriage, nor risk factor for recurrent miscarriage, nor is treated thyroid dysfunction is treated thyroid dysfunction

There is insufficient evidence to There is insufficient evidence to evaluate the effect of evaluate the effect of

progesterone supplementation progesterone supplementation in pregnancy to prevent a in pregnancy to prevent a

miscarriagemiscarriage hormonal treatments for luteal phase deficiency concluded hormonal treatments for luteal phase deficiency concluded that the benefits are uncertain the low progesterone levels that the benefits are uncertain the low progesterone levels that have been reported in early pregnancy loss may that have been reported in early pregnancy loss may reflect a pregnancy that has already failed. Exogenous reflect a pregnancy that has already failed. Exogenous progesterone supplementation should only be used in the progesterone supplementation should only be used in the context of randomised controlled trials. context of randomised controlled trials.

Progesterone doesn't prevent miscarriages. Miscarriages happen for many reasons,

but lack of progesterone as a cause for miscarriage is not proven. The low progesterone levels found in pregnancies which go on to become miscarriages is a sign that the pregnancy is already failing

There is insufficient evidence to There is insufficient evidence to evaluate the effect of human evaluate the effect of human

chorionic gonadotrophin (hCG) chorionic gonadotrophin (hCG) in pregnancy to prevent in pregnancy to prevent

miscarriagemiscarriage..early pregnancy hCG supplementation early pregnancy hCG supplementation

failed to show any benefit in pregnancy failed to show any benefit in pregnancy outcome outcome

Prepregnancy suppression of Prepregnancy suppression of high luteinising hormone (LH) high luteinising hormone (LH)

concentration among ovulatory concentration among ovulatory women with recurrent women with recurrent

miscarriage and polycystic miscarriage and polycystic ovaries who hypersecrete LH ovaries who hypersecrete LH

does not improve the live birth does not improve the live birth raterate the outcome of pregnancy without the outcome of pregnancy without

pituitary suppression is similar to that pituitary suppression is similar to that of patients without raised LH. of patients without raised LH.

Polycystic ovary morphology itself Polycystic ovary morphology itself does not predict an increased risk of does not predict an increased risk of

future pregnancy loss among future pregnancy loss among ovulatory women with a history of ovulatory women with a history of

recurrent miscarriage who conceive recurrent miscarriage who conceive spontaneouslyspontaneously..

pelvic ultrasound criteria, is significantly higher pelvic ultrasound criteria, is significantly higher among women with recurrent miscarriage (41%) among women with recurrent miscarriage (41%) when compared with the general population (22%).when compared with the general population (22%).

However, despite this high prevalence, polycystic However, despite this high prevalence, polycystic ovary morphology itself does not predict an ovary morphology itself does not predict an increased risk of future pregnancy loss among increased risk of future pregnancy loss among ovulatory women with a history of recurrent ovulatory women with a history of recurrent miscarriage who conceive spontaneously.miscarriage who conceive spontaneously.

There is insufficient evidence There is insufficient evidence to assess the effect of to assess the effect of

hyperprolactinaemia as a risk hyperprolactinaemia as a risk factor for recurrent factor for recurrent

miscarriagemiscarriage..

Immune factorsImmune factors

One in ten women with recurrent miscarriages show One in ten women with recurrent miscarriages show evidence of auto immune factors on investigationevidence of auto immune factors on investigation

As much as As much as 40 percent40 percent of unexplained infertility may of unexplained infertility may be the result of immune problems, as are as many as be the result of immune problems, as are as many as

80 percent80 percent of "unexplained" pregnancy losses. of "unexplained" pregnancy losses. Unfortunately for couples with immunological Unfortunately for couples with immunological

problems, their chances of recurrent loss increase with problems, their chances of recurrent loss increase with each successive pregnancyeach successive pregnancy..

Antithyroid antibodiesAntithyroid antibodies

Routine screening for thyroid Routine screening for thyroid antibodies in women with antibodies in women with recurrent miscarriage is not recurrent miscarriage is not recommended.recommended.

Antiphospholipid syndromeAntiphospholipid syndrome To diagnose APS it is mandatory that the To diagnose APS it is mandatory that the

patient should have two positive tests at patient should have two positive tests at least six weeks apart for either lupus least six weeks apart for either lupus anticoagulant or anticardiolipin (aCL) anticoagulant or anticardiolipin (aCL) antibodies of IgG and/or IgM class present antibodies of IgG and/or IgM class present in medium or high titre.in medium or high titre.

Adverse pregnancy outcomes include Adverse pregnancy outcomes include (a) three or more consecutive miscarriages (a) three or more consecutive miscarriages

before ten weeks of gestation,before ten weeks of gestation, (b) one or more morphologically normal fetal (b) one or more morphologically normal fetal

deaths after the tenth week of gestation anddeaths after the tenth week of gestation and (c) one or more preterm births before the 34th (c) one or more preterm births before the 34th

week of gestation due to severe pre-eclampsia, week of gestation due to severe pre-eclampsia, eclampsia or placental insufficiency. eclampsia or placental insufficiency.

Currently there is no reliable evidence to Currently there is no reliable evidence to show that steroids improve the live birth show that steroids improve the live birth rate of women with recurrent rate of women with recurrent miscarriage associated with aPL when miscarriage associated with aPL when compared with other treatment compared with other treatment modalities; their use may provoke modalities; their use may provoke significant maternal and fetal morbidity.significant maternal and fetal morbidity.

In women with a history of recurrent In women with a history of recurrent miscarriage and aPL, future live birth miscarriage and aPL, future live birth rate is significantly improved when a rate is significantly improved when a combination therapy of aspirin plus combination therapy of aspirin plus heparin is prescribed.heparin is prescribed.

Pregnancies associated with aPL treated Pregnancies associated with aPL treated with aspirin and heparin remain at high with aspirin and heparin remain at high risk of complications during all three risk of complications during all three trimesterstrimesters..

Alloimmune factorsAlloimmune factors

Immunotherapy, including Immunotherapy, including paternal cell immunisation, paternal cell immunisation, third-party donor leucocytes, third-party donor leucocytes, trophoblast membranes and trophoblast membranes and intravenous immunoglobulin intravenous immunoglobulin (IVIG), in women with previous (IVIG), in women with previous unexplained recurrent unexplained recurrent miscarriage does not improve miscarriage does not improve the live birth ratethe live birth rate

Infective agentsInfective agents

TORCH (toxoplasmosis rubella, TORCH (toxoplasmosis rubella, cytomegalovirus and herpes simplex cytomegalovirus and herpes simplex virus), other [congenital syphilis and virus), other [congenital syphilis and viruses], screening is unhelpful in the viruses], screening is unhelpful in the investigation of recurrent miscarriage.investigation of recurrent miscarriage.

For an infective agent to be implicated in the For an infective agent to be implicated in the aetiology of repeated pregnancy loss, it must aetiology of repeated pregnancy loss, it must be capable of persisting in the genital tract be capable of persisting in the genital tract and avoiding detection or must cause and avoiding detection or must cause insufficient symptoms to disturb the women. insufficient symptoms to disturb the women. Toxoplasmosis, rubella, cytomegalovirus, Toxoplasmosis, rubella, cytomegalovirus, herpes and listeria infections do not fulfil herpes and listeria infections do not fulfil these criteria and routine TORCH screening these criteria and routine TORCH screening should be abandone should be abandone

Screening for and treatment of Screening for and treatment of bacterial vaginosis in early bacterial vaginosis in early pregnancy among high risk pregnancy among high risk women with a previous history women with a previous history of second-trimester miscarriage of second-trimester miscarriage or spontaneous preterm labour or spontaneous preterm labour may reduce the risk of recurrent may reduce the risk of recurrent late loss and preterm birth.late loss and preterm birth.

Group B StreptococcusGroup B Streptococcus Pre and Post-conceptional, broad-Pre and Post-conceptional, broad-

spectrum intravenous antibiotic spectrum intravenous antibiotic therapy was used in patients with therapy was used in patients with multiple miscarriagesmultiple miscarriages

Although this is a relatively small series Although this is a relatively small series and does not establish a cause and effect and does not establish a cause and effect relationship between Group B relationship between Group B Streptococcus and habitual abortions, the Streptococcus and habitual abortions, the beneficial effects of antibiotic therapy is beneficial effects of antibiotic therapy is unquestionable unquestionable

Inherited thrombophilic Inherited thrombophilic defectsdefects

Inherited thrombophilic defects,Inherited thrombophilic defects, including activated protein C resistance including activated protein C resistance

(most commonly due to factor V Leiden (most commonly due to factor V Leiden gene mutation), deficiencies of protein gene mutation), deficiencies of protein C/S and antithrombin III, C/S and antithrombin III, hyperhomocysteinaemia and hyperhomocysteinaemia and prothrombin gene mutation,prothrombin gene mutation,

are established causes of systemic are established causes of systemic thrombosis thrombosis

Environmental factorsEnvironmental factors

Exposture to noxious or toxic substances Exposture to noxious or toxic substances are known to be associated withare known to be associated with  recurrent recurrent miscarriage ( social drugs, miscarriage ( social drugs, cigarretes,alcohol and caffeine ,anaestetic cigarretes,alcohol and caffeine ,anaestetic gases,petrolium products )gases,petrolium products )

Unexplained recurrent Unexplained recurrent miscarriagemiscarriage

In about half the women in the research In about half the women in the research studies, studies, no cause no cause could be found, so no

specific treatment could be given. However, this group responded very However, this group responded very

well to a programme which removed as well to a programme which removed as many many stress factorsstress factors as possible from as possible from

their lives, resulting in an 80% success their lives, resulting in an 80% success rate with the subsequent pregnancy rate with the subsequent pregnancy

Women with unexplained recurrent Women with unexplained recurrent miscarriage have an excellent miscarriage have an excellent prognosis for future pregnancy prognosis for future pregnancy outcome without pharmacological outcome without pharmacological intervention if offered supportive intervention if offered supportive care alone in the setting of a care alone in the setting of a dedicated early pregnancy dedicated early pregnancy assessment unitassessment unit.. After all these investigations 50% of After all these investigations 50% of recurrent aborters will be found to have recurrent aborters will be found to have no abnormalities and these should be no abnormalities and these should be attributed to chromosomal defect in the attributed to chromosomal defect in the conceptusconceptus..

According to the American According to the American College of Obstetricians and College of Obstetricians and

GynecologistsGynecologists cultures for bacteria and virusescultures for bacteria and viruses glucose tolerance testingglucose tolerance testing thyroid tests thyroid tests antibodies to infectious agentsantibodies to infectious agents antithyroid antibodies antithyroid antibodies paternal human leukocyte antigen status, or paternal human leukocyte antigen status, or

maternal antiparental antibodiesmaternal antiparental antibodies are not beneficialare not beneficial and, therefore, and, therefore, are are not recommendednot recommended in the evaluation of in the evaluation of

otherwise normal women with recurrent otherwise normal women with recurrent pregnancy losspregnancy loss. .

Things unlikely to cause Things unlikely to cause recurrent miscarriagerecurrent miscarriage

RetroversionRetroversion - or backward tilting of the uterus. - or backward tilting of the uterus. Infection Infection - such as toxoplasmosis, listeria, brucella, - such as toxoplasmosis, listeria, brucella,

chlamydia, herpes simplex and cytomegalovirus. chlamydia, herpes simplex and cytomegalovirus. Endocrine or metabolic diseaseEndocrine or metabolic disease - hypothyroidism - hypothyroidism

(underactive thyroid), diabetes mellitus, Crohn's (underactive thyroid), diabetes mellitus, Crohn's disease, sickle cell or endometriosis. disease, sickle cell or endometriosis.

Occupational exposuresOccupational exposures - very little reliable evidence - very little reliable evidence exists for things such as herbicide spraying, exists for things such as herbicide spraying, electromagnetic fields, chemical inhalation, anaesthetic electromagnetic fields, chemical inhalation, anaesthetic gases or VDU usage. gases or VDU usage.

Not resting enoughNot resting enough - bedrest doesn't alter whether - bedrest doesn't alter whether you miscarry or not. Nor does working when you're you miscarry or not. Nor does working when you're pregnant, exercise, making love or flying. pregnant, exercise, making love or flying.

ManagementManagement

Miscarriages, like infertility, is a problem of a Miscarriages, like infertility, is a problem of a couple and they should be seen together. The couple and they should be seen together. The majority can be reassuared. majority can be reassuared.

most cases, neither a woman nor her most cases, neither a woman nor her doctor can do anything to prevent a doctor can do anything to prevent a miscarriage miscarriage

Controversies surrounding Controversies surrounding treatment for pregnancy losstreatment for pregnancy loss Evidence-based medicine (EBM) has Evidence-based medicine (EBM) has

not succeeded in giving patients and not succeeded in giving patients and physicians the data they need to physicians the data they need to choose (or not choose) a therapy in choose (or not choose) a therapy in the field of pregnancy loss the field of pregnancy loss

If any of the above tests should If any of the above tests should come back indicating an come back indicating an underlying reason for the underlying reason for the

problemproblem

treatment is direced at the cause treatment is direced at the cause eg : genetic counselling,eg : genetic counselling, removal of fibroids,removal of fibroids, cervical stitch cervical stitch

If all of the above have been If all of the above have been excludedexcluded

(as they will do in most cases), the diagnosis is recurrent (as they will do in most cases), the diagnosis is recurrent miscarriage of unknown causemiscarriage of unknown cause

the use of empirical treatment in women with unexplained the use of empirical treatment in women with unexplained recurrent miscarriage is unnecessary and recurrent miscarriage is unnecessary and should be resisted should be resisted

for both partners to be as healthy as possible for both partners to be as healthy as possible before she conceive (avoid drugs, alcohol, before she conceive (avoid drugs, alcohol, chemicals, etc) and to get any other medical chemicals, etc) and to get any other medical conditions under control. conditions under control.

The only intervention to have demonstrated benefit is serial The only intervention to have demonstrated benefit is serial ultrasound scans in the early months of pregnancy.ultrasound scans in the early months of pregnancy.

It is certainly not unreasonable to expect this psychological It is certainly not unreasonable to expect this psychological support to improve outcome given the close interaction between support to improve outcome given the close interaction between the higher areas of the mind and the delicately balanced hormonal the higher areas of the mind and the delicately balanced hormonal system.system.

Education and reassuarance with these good statistical oddsEducation and reassuarance with these good statistical odds Education about smoking, alcohol and drug abuse is also importantEducation about smoking, alcohol and drug abuse is also important

Psychological supportPsychological support The value of psychological support in improving The value of psychological support in improving

pregnancy outcome has not been tested in the pregnancy outcome has not been tested in the form of a randomised controlled trial. However, form of a randomised controlled trial. However, data from several non-randomised studiesdata from several non-randomised studies86–88 86–88 have suggested that attendance at a dedicated have suggested that attendance at a dedicated early pregnancy clinic has a beneficial effect, early pregnancy clinic has a beneficial effect, although the mechanism is unclearalthough the mechanism is unclear

All professionals should be aware of the All professionals should be aware of the psychological sequelae associated with psychological sequelae associated with miscarriage and should provide support and miscarriage and should provide support and follow-up, as well as access to formal follow-up, as well as access to formal counselling when necessary.counselling when necessary.

Emprical treatmentEmprical treatment the use of empirical treatment in women with unexplained the use of empirical treatment in women with unexplained

recurrent miscarriage is unnecessary and recurrent miscarriage is unnecessary and should be should be resisted resisted

BUTBUTSome doctors give treatment like Some doctors give treatment like

Low dose asprinLow dose asprin Subcutaneous hepaeinSubcutaneous hepaein Folic acid Folic acid ProgesteroneProgesterone Solcoseryl(increase oxygen supply)Solcoseryl(increase oxygen supply) Nitroglycerin (increase implantation by increase uterine Nitroglycerin (increase implantation by increase uterine

blood flow)blood flow) tocolytictocolytic

TreatmentTreatment of miscarriageof miscarriage Surgical uterine evacuation for miscarriage Surgical uterine evacuation for miscarriage

should be performed using suction curettage.should be performed using suction curettage. All at risk women undergoing surgical uterine All at risk women undergoing surgical uterine

evacuation for miscarriage should be screened evacuation for miscarriage should be screened for Chlamydia trachomatis.for Chlamydia trachomatis.

Medical and expectant methods are also effective Medical and expectant methods are also effective in the management of confirmed miscarriage.in the management of confirmed miscarriage.

Medical and expectant management should be Medical and expectant management should be offered only in units where patients have access offered only in units where patients have access to 24-hour telephone advice and immediate to 24-hour telephone advice and immediate admission can be arranged.admission can be arranged.

Tissue obtained at the time of miscarriage should Tissue obtained at the time of miscarriage should be examined histologically to confirm pregnancy be examined histologically to confirm pregnancy and to exclude ectopic pregnancy or gestational and to exclude ectopic pregnancy or gestational trophoblastic disease.trophoblastic disease.

FateFateA woman who has suffered a single A woman who has suffered a single

sporadic miscarriage has an 80% sporadic miscarriage has an 80% chance and a woman with three chance and a woman with three consecutive miscarriages a 60% consecutive miscarriages a 60% chance of her next pregnancy being chance of her next pregnancy being successful successful