Recurrent Pregnancy Loss
Of all pregnancies, the risk of miscarriage is 10% or higher as woman ages. Approximately, 80% of pregnancy losses occur in the first 12 weeks of pregnancy called the first trimester.
About Recurrent Pregnancy Loss
Content reviewed by RESOLVE's Professional Member, Mark P. Trolice, MD, Fertility CARE – The IVF Center.
A pregnancy loss for the woman or couple can be absolutely soul crushing. While one pregnancy loss is not uncommon but heartbreaking, recurrent losses can be overwhelming resulting in feelings of despair.
Recurrent pregnancy loss (RPL) is defined as the loss of two or more clinical pregnancies, i.e., a pregnancy documented by ultrasound to be located inside the uterus or one where there is a confirmation of a pregnancy by pathologic tissue diagnosis.
RPL happens in 10% of pregnancies in women less than 30 years and increases in frequency as a woman ages. For women in their mid-40s, the risk of miscarriage is approximately 50%. In women who have a history of two or more previous losses, the risk of yet another pregnancy loss increases to about 30%. In total, that’s about 5% of women who will have at least two consecutive losses while only 1% experience three or more. This is why it is so important that if you or your partner have had two more pregnancy losses, you should talk to an infertility specialist ASAP who can begin looking into the possible causes.
An isolated miscarriage is typically due to a random chromosomal abnormality of the embryo, found in up to two-thirds of cases. Here are some of the most common causes that can lead to RPL:
- Genetics: Chromosomal abnormalities can contribute to 5% of causes for RPL. The problem is called a balanced translocation where one of the couple have a rearrangement of two chromosomes but still have all the proper amount of DNA. When conception occurs, the translocation can result in the embryo being “unbalanced” with an abnormal amount of DNA that can result in an early loss, although rarely will the pregnancy continue to term.
- Abnormal Hormone Levels: Miscarriages can also occur due to thyroid disease, elevated prolactin levels (a hormone that prepares the breast during pregnancy to provide milk to the baby) and uncontrolled blood sugar i.e. diabetes
- Anatomy: Structural problems or the shape of the uterus may cause miscarriage, usually by interfering with the implantation and/or development of the fertilized egg (embryo). Some women are born with a abnormal shaped uterus, called a septate uterus, resulting in a divided uterine cavity which increases the risk of miscarriage. Surgery has traditionally been recommended to treat this condition, although there has been recent debate over its true usefulness.
Benign growth of the uterus, e.g. fibroids or polyps, can cause miscarriage and infertility. affecting the normal functioning of the uterine lining.
Other less common anatomical causes of miscarriage are uterine scarring, called Asherman syndrome, and a “T-shaped” uterus due to fetal exposure of a hormone called DES.
- Cervical Issues: Another cause of miscarriage that can occur in the second trimester is an “incompetent cervix,” meaning the cervical muscle is weakened and cannot remain closed as the developing fetus grows and reaches a certain weight, thereby putting pressure on the cervical opening resulting in the fetus prematurely delivering.
- Environmental Factors: The environmental toxins you may be exposed to in the air around you can also result in fetal damage or pregnancy loss, especially if you experience regular exposure after 20 weeks of pregnancy. Studies also indicate that the use of marijuana, tobacco, caffeine, and alcohol can all affect fetal development and result in pregnancy loss. Most doctors suggest that women limit or avoid their use during pregnancy.
- Blood Causes: The presence of acquired thrombophilias in RPL is called the antiphopholipid antibody syndrome that is associated with clotting Blood tests are used to detect the presence of these antibodies. If present, medicationthat helps thin the blood may be used. Along withbaby aspirin (81 mg) daily, Heparin an injectable medication called lovenox is given daily during the pregnancy.
Some women experience signs and symptoms before a pregnancy loss actually occurs, otherwise they tragically learn, during an ultrasound exam, that the embryo or fetus does not have a heart rate.. Some of the signs that a pregnancy loss may be about to start are: vaginal spotting or bleeding, which can be dark brown and changing to pink or red; a decrease in breast tenderness or fullness; and an absence of fetal movement. Cramping and vaginal bleeding are signs that the a pregnancy loss may be occurring so it’s best to be proactive and call your doctor immediately for confirmation.
If you do find that you are bleeding, please have your blood type checked. If your blood is Rh negative, e.g. A-, your doctor will discuss with you an injection called Rhogam which works to block you from making antibodies that can harm the fetus and result in multiple birth defects. ,If, unfortunately, you miscarry at home you may be able to save the tissue so your doctor analyze genetically for a possible cause.
If you have experienced more than two pregnancy losses run, a fertility specialist can help narrow down possible causes and determine what can be done to, hopefully, prevent future losses.
Here are some of the tests your doctor may recommend:
- Hormonal Tests: Thyroid, prolactin, blood sugar (HgA1c), and, if abnormal, may be improved by medication.
- Anatomy Tests: A hysterosalpingogram (HSG), saline infusion ultrasound, or hysteroscopy to evaluate the shape of your uterus and to rule out possible scarring in the uterus, polyps, fibroids, or a septum. These abnormalities may be treated by surgery, which could affect implantation.
- Genetic Testing: Chromosomal testing on your and your partner to determine the presence of a balanced translocation (as discussed above) and, if applicable, consideration of in vitro fertilization (IVF) with preimplantation genetic testing of the embryo. You may have the same pregnancy success without IVF although more an increasing risk of miscarriage. Genetic testing of the products of conception can provide confirmation of an abnormal embryo/fetus as the cause of the pregnancy loss.
- Antiphospholipid antibody test: These factors involve testing for the lupus anticoagulant, anticardiolipin antibodies and beta2 glycoprotein. The antiphospholipid syndrome is diagnosed if one of these factors remains elevated more than 3 months apart. .
Pregnancy loss can leave you and your partner with many intense feelings of sadness, confusion, and, unnecessarily, guilt. These feelings should not be dismissed or devalued. All too often, they can be suppressed and misunderstood by friends and family.
Allow yourself time to process and grieve the loss. It is okay to feel angry and depressed. Talk to your spouse and remember, that men and women sometimes experience grieve in different ways so its best to support each other during this challenging time.
A support group or a grief counselor may be valuable for your coping and recovery. If you experience friends and family who have trouble understanding your loss, you may find comfort in knowing they are often just as inexperienced in managing a loss. If you remain challenged in dealing with the loss, please seek professional support.