This is a very sensitive issue and requires counseling for both the partners.
About 3/4ths of Spontaneous Abortions occur before the 16 th Week of pregnancy.
Almost 20% of Clinically recognized pregnancies terminate in spontaneous abortions.
Causes of spontaneous abortions:
- 60% appear to be due to chromosomal defects related to maternal or paternal factors.
- 15% are due to Maternal infection, Diabetes, Hypothyroiduism, dietary deficiencies, Anatomic problems among others.
- In 25% percent the cause is not determined.
Recurrent Abortions are defined as the loss of 3 or more early pregnancies(<20 weeks or under 500g weight) in succession.
If a woman has lost 3 previous pregnancies without a cause, she still has a >60% chance of carrying a fetus to viability.
Identifying the Cause:
1. Mostly, the cause is linked to a chromosomal or a genetic reason and can happen at random.
The defect may be in the sperm, the ovum or even the embryo
2. Advancing Maternal age can be a cause
3. Uterine Abnormalities : poor blood supply or inflammation of the womb. The uterus may have an irregular shape.
4. Immune problems
5. Hormonal problems: Thyroid , Diabetes
6. Irregularities in Clotting
7. Stress is associated with RPL, but couples should be informed that there is no evidence that stress is a direct cause of pregnancy loss.
8. Based on only a few small studies, exposure to occupational and environmental factors (heavy metals, pesticide, lack of micronutrients) seems to be associated with an increased risk of pregnancy loss in women with RPL. Although exposure to possible hazardous substances should be avoided during pregnancy (for all pregnant women), there are insufficient data to recommend protection against a certain occupational or environmental factor in women with RPL.
9. Couples with RPL should be informed that smoking could have a negative impact on their chances of a live birth, and therefore cessation of smoking is recommended.
10. Couples with RPL should be informed that maternal obesity or being significantly underweight is associated with obstetric complications and could have a negative impact on their chances of a live birth and on their general health.
11. Couples with RPL should be informed that excessive alcohol consumption is a possible risk factor for pregnancy loss and proven risk factor for fetal problems (Fetal alcohol syndrome).
Tests to be done for recurrent Abortions:
Clinicians and clinics should take the psychosocial needs of couples faced with RPL into account when offering and organizing care for these couples.
1. A Clear Medical and family history needs to be taken before proceeding with any investigations. The number of previous losses is important to determine future prognosis.
2. Genetic examination of the fetus : This is not always necessary and it depends on the history and other factors. Array based Comparative genomic hybridization(CGH) is the recommended test method.
3. Chromosomal analysis of the parents i.e karyotyping: This is not always required but is done in certain situations. Even if a parental abnormality is found, the birth rates statistically are still good.
4. Screening for Antiphospholipid syndrome(APL): This is an autoimmune condition present in young women. Abnormal proteins(antibodies) are found in these cases. These antibodies can lead to clotting in arteries and alter the blood flow. This can lead to abortions in certain cases. APL can be found as a stand alone condition or in association with SLE(Systemic lupus erythromatosus). The tests done for this are antiphospholipid antibodies (Lupus
Anticoagulant [LA], and Anticardiolipin antibodies [ACA IgG and IgM]) & screening for β2 glycoprotein I antibodies (aβ2GPI)
5. Screening for ANAi.e Antinuclear antibodies: There is some evidence that presence of ANA can affect the pregnancy adversely. ANA by IF should be the method of choice.
6. Screening for hormonal defects: A T3,T4, TSH should be done along with tests for diabetes. If the TSH is abnormal, an anti-thyroid antibody test(TSHR And TPO) should be carried out.
7.All women should have an anatomical check of the uterus done by transvaginal 3D Ultrasound. A Hysterosalpingography should only be done when this is unavailable.
8. A Sperm DNA fragmentation test can be done in the male semen since there is an indirect correlation for the same.
9. In the male partner, it is suggested to assess life style factors (smoking, alcohol consumption, exercise pattern, and body weight).
10. Testing for Prolactin, AMH, PCOD is not routinely recommended but a recent study showed a link with low ovarian reserve and RPL
What Treatment is Available for Recurrent Pregnancy Loss?
1. All couples with results of an abnormal fetal or parental karyotype may be informed about the possible treatment options available including their advantages and disadvantages.
2. For women who fulfill the laboratory criteria of APS and a history of three or more pregnancy losses, studies suggest administration with low-dose aspirin (75 to 100 mg/day) starting before conception, and a prophylactic dose heparin (Unfractionated heparin [UFH] or Low molecular weight heparin [LMWH]) starting at date of a positive pregnancy test, over no treatment.
3. The GDG suggests offering anticoagulant treatment for women with two pregnancy losses and APS, only in the context of clinical research.
4.Overt hypothyroidism arising before conception or during early gestation should be treated with levothyroxine in women with RPL.
5. If women with subclinical hypothyroidism and RPL are pregnant again, thyroid stimulating hormone (TSH) level should be checked in early gestation (7-9 weeks AD), and hypothyroidism should be treated with levothyroxine.
6. Bromocriptine treatment can be considered in women with RPL and hyperprolactinemia to increase live birth rate.
7. Preconception counseling in women with RPL could include the general advice to consider prophylactic vitamin D supplementation
8. Antioxidants for men have not been shown to improve the chance of a live birth.
Lymphocyte immunization therapy should not be used as treatment for unexplained RPL as it has no significant effect and there may be serious adverse effects.
Intravenous immunoglobulin (IvIg) is not recommended as a treatment of RPL.
9. Heparin or low dose aspirin are not recommended, as there is evidence that they do not improve live birth rate in women with unexplained RPL.
Recurrent pregnancy loss has a significant emotional impact on women and their partners. For most women and their partners, pregnancy loss represents the loss of a baby and the hopes and plans invested in that child.
Feelings of loss and grief, common after a single pregnancy loss, can intensify with repeated losses, as can a sense of personal failure. Anxiety about pregnancy after RPL is both normal and understandable. Before trying to conceive, most couples want an explanation for their losses and treatment that will prevent a recurrence. The offers of tests and treatments that are not evidence- based should be avoided.