Tarangini has just been told by her obstetrician that her pregnancy is not growing. She is two months pregnant, and the baby has no heartbeat on ultrasound. She and her husband are devastated. This is their third pregnancy that has ended in a miscarriage.
What is recurrent or repeated miscarriage?
The term recurrent or repeated pregnancy loss is used when miscarriage occurs consecutively in three or more pregnancies. When this occurs before 12 weeks (3 months) of pregnancy, it is classified as recurrent ‘early' pregnancy loss.
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It is important that the miscarriages are properly documented. Some women may have a delayed period followed by a positive pregnancy test but the ultrasound may not show any pregnancy in the uterus. This is called a ‘biochemical pregnancy'. These ‘pregnancies' should not be considered a miscarriage.
What causes recurrent miscarriage?
Many factors can lead to recurrent miscarriage though the cause cannot be found in almost 50 per cent of repeated miscarriages. The common causes of repeated miscarriage are
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Medical problems related to obesity, such as diabetes and polycystic ovaries, can also lead to repeated miscarriages.
Chromosomal problems
More than half of miscarriages in the first three months of pregnancy are caused by problems with the chromosomes of the foetus. Chromosomes are threadlike structures found in the nucleus of most living cells, carrying genetic information in the form of genes. A miscarriage can occur if there are too many or too few chromosomes. There can also be problems with the genes they carry. Extra or missing chromosomal material can result in an abnormal foetus. Miscarriage is nature's way of ending a pregnancy in which the foetus is abnormal.
Antiphospholipid syndrome
Antiphospholipid syndrome is a disorder of the immune system. A blood test can show the presence of these antibodies, called anticardiolipin antibodies and lupus anticoagulant.
Uterine abnormalities
Some abnormalities of the uterus are associated with repeated miscarriage. Though not common, they include a uterus that is divided into two sections by a wall of tissue (septate uterus) and a condition where the cervix opens up painlessly after the fourth month of pregnancy (cervical incompetence) .
What tests are required for repeated miscarriage?
Most obstetricians will ask for tests after the second miscarriage and not wait for a third miscarriage.
The two common tests done are a blood test for the presence of antiphospholipid antibodies and evaluation to rule out an abnormality of the uterus. A good quality ultrasound scan (including a 3D scan) or a hysteroscopy (where a thin, lighted telescope-like instrument is introduced into the uterus) will reveal abnormalities of the uterus that could have lead to repeated pregnancy loss.
Usually a chromosomal test for the couple is done if there have been three or more miscarriages. Sometimes one of the partners has a chromosomal abnormality which can get passed down to the foetus and cause a miscarriage. Even in this case, the couple has a 75 per cent chance of having a normal pregnancy.
A test called TORCH panel is absolutely unnecessary and should not be done in cases of repeated miscarriage. The infections that are tested for in the TORCH panel do not cause repeated miscarriage and do not require treatment.
What is the treatment for repeated miscarriage?
The treatment depends on whether there is an identified cause for the miscarriage. The treatments that have absolutely no basis in science are:
· Bed rest
· Hormone tablets and injections
Unfortunately relatives, friends and sometimes even doctors, ask the woman to be at complete bed rest once she gets pregnant. Remember that if the pregnancy is normal, it will grow even with normal activity whereas an abnormal pregnancy will get expelled from the body even if you stay completely motionless in bed!
The body produces a huge amount of the hormones required to protect the pregnancy; there is no need for hormones to be given to a pregnant woman.
When the woman has antiphospholipid antibodies, she is usually given a low dose aspirin tablet and injections of heparin, which is a blood thinner.
If a woman has an incompetent cervix, where the mouth of the uterus opens up painlessly, she will benefit from the placement of a stitch in the third month of the pregnancy. This stitch will hold the mouth of the uterus closed till full term.
It is important to remember that even if you have had repeated miscarriages, you still have a good chance of having a baby. Do not get desperate and perform unnecessary tests and take unproven or controversial treatment.
(The author is an obstetrician and gynaecologist practising in Chennai and has written the book ‘Passport to a Healthy Pregnancy').