Pregnant pause

Dr Seema Sharma and Dr Ritambhara Bhalla

Recurrent miscarriage or recurrent pregnancy loss (RPL) is a foetal loss syndrome (also known as foetal wastage syndrome). Characterised by recurrent spontaneous abortion, this is an important reproductive health issue that affects 2 per cent to 5 per cent of couples. Two or more consecutive pregnancy losses before 20 weeks from the last menstrual period can be defined as a miscarriage. 

It is a relatively common problem that affects many young women, especially with first-time pregnancies. However, it does not indicate that pregnancy cannot happen again. For couples who experience recurrent pregnancy loss, it can be emotionally traumatic, similar to trauma associated with stillbirth or neonatal death. Many times evaluation of this loss can be frustrating and difficult because the manner of causation condition cannot be determined in about 50 per cent cases. But it is important to remember that most women with RPL have a good chance for a successful pregnancy in future, even when there is no definitive diagnosis and treatment. However, women with a history of RPL, who become pregnant later, may be at higher risk for developing foetal growth restriction and have premature delivery. 

What causes a recurrent miscarriage? 

Some established causes of a miscarriage include uterine anomalies, antiphospholipid syndrome (an autoimmune disease), hormonal and metabolic disorders and cytogenetic abnormalities. Most miscarriages occur because the foetus is not developing normally and gets terminated by the 12th week of pregnancy. 

However, most women who experience some kind of vaginal spotting or bleeding in the first trimester can go on to complete successful pregnancies as well. But precaution is paramount and any woman who experiences vaginal spotting should immediately consult her gynaecologist. Other factors include immunological disorders, bacterial infections in the reproductive tracts, exposure to X-ray radiations, severe kidney or heart disease, hormonal problems, malnutrition and being underweight or overweight.

These days due to lifestyle changes, stress is a major contributor and maternal diseases like uncontrolled diabetes, frequent infections, hormonal problems, uterus or cervix problems and thyroid disease can also impact the pregnancy. Overall risk of miscarriage in the next pregnancy remains about 15 per cent after one miscarriage, but rises to 17 to 31 per cent after two miscarriages and to 25 to 46 per cent after three or more miscarriages. 

Many a time an abnormally shaped uterus or incompetent cervix could also lead to a miscarriage. Mothers should avoid consuming high-mercury fish because it can cause several infections. Any kind of processed food, meats, organ meat, raw eggs, raw sprouts and caffeine should be avoided. 

Prevention

Over the years, evidence-based treatments such as surgical correction of uterine anomalies or aspirin and heparin for antiphospholipid syndrome have improved outcomes for recurrent pregnancy loss. However, almost half of the cases remain unexplained and are empirically treated using supplementation and immunomodulatory treatments. 

However, women should avoid extensive evaluation after just one spontaneous miscarriage after first trimester or early second trimester (up to 20 weeks), given these are relatively common, sporadic events. 

A miscarriage is preventable if a woman simply focuses on taking good care of herself and the foetus. Doing some regular, moderate exercise during pregnancy and avoiding junk food ensures healthy weight for the mother and helps in baby’s proper growth. A pregnant woman must have regular prenatal care; avoid any stress and known risk factors like smoking and drinking alcohol. A mother’s lifestyle, habits and surroundings have a bearing on the foetus growing inside her. A healthy lifestyle can contribute significantly to a healthy pregnancy. 

Overcoming the syndrome

Miscarriage can traumatic for an expectant couple. A couple should support each other or even opt for professional help if it has problems in facing the loss. Psychological and medical support, regular ultrasonography examinations, avoiding heavy work, travel and sexual activity for some time are some other preventive measures.

Watch out for these symptoms

• Vaginal spotting or bleeding
• Sudden pain or cramping in your abdomen or lower back
• Some kind of fluid or tissue passing from your vagina

Risk factors

There are several risk factors that can increase the chances of a miscarriage.

Maternal age: The age of conception is a major factor. The risk of abortion at 25-30 years is around 12 per cent which rises to 25 per cent as a woman crosses 35 and 51 per cent at 40 years or after.

Genetic: If there is frequent or recurrent loss, genetic testing of the couple is generally recommended along with the genetic evaluation of the aborts.

Hormonal imbalance: Overt-thyroid disorder or suspected or subclinical hypothyroidism needs testing and treatment. Patients with diabetes need to control blood sugar prior to conception.

Coagulation defects: Antiphospholipid antibody syndrome is a treatable risk factor for recurrent pregnancy loss which can be evaluated and treated. 

Uterine abnormalities are managed surgically if detected in time. 

Lifestyle correction: Avoid or quit smoking and alcohol consumption. Decrease intake of caffeine, tea, coffee, etc. Being overweight or obese is a major cause for pregnancy loss.

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Risk rate

Week 0 to 6: These early weeks mark the highest risk of miscarriage.

Weeks 6 to 12: Once a pregnancy makes it to 6 weeks and has confirmed viability with a heartbeat, the risk of having a miscarriage drops to 10 per cent.

Weeks 13 to 20: By week 12, the risk may fall to 5 per cent.

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Be careful 

• Avoid late marriage  
• Do not delay first child birth
• Control hypothyroidism and diabetes, if afflicted
• Keep a normal weight and healthy lifestyle to ensure appropriate BMI

— The writers are gynaecologists, Cloudnine Group of Hospitals, Chandigarh