Recurrent Miscarriage

Recurrent Miscarriage 

Definition

Recurrent miscarriage is defined as three or more miscarriages of a fetus before 20 weeks of gestation (i.e., before the fetus can live outside the womb).

Description

Also referred to as spontaneous abortion, miscarriage occurs in 15-20% of all conceptions. The majority of miscarriages occur during the first trimester. The number of previous miscarriages does not affect subsequent full-term pregnancies.

Causes and symptoms

Recurrent miscarriage can be caused by several factors, including fetal, placental, or maternal abnormalities.

• In over half of all miscarriages, the fetus is abnormal. The abnormality can either be genetic or developmental. The fetus is very sensitive to ionizing radiation. Tobacco and even moderate alcohol consumption are known to cause fetal damage that may lead to miscarriage. There is some evidence that over four cups of coffee a day, because of the caffeine, adversely affect pregnancy, as well.
• Placental abnormalities, including abnormal implantation in the placental wall and premature separation of the placenta, can cause miscarriage.
• Maternal abnormalities include insufficient hormones (usually progesterone) to support the pregnancy, an incompetent cervix (mouth of the womb does not stay closed), or a deformed uterus (womb). A deformed uterus can be caused by diethylstilbestrol (DES) given to the mother's mother during her pregnancy. Some immunologic abnormalities may cause the mother to reject the fetus as if it were an infection or a transplant. Maternal blood clotting abnormalities may cut-off blood supply to the fetus, causing miscarriage.
• Maternal diabetes mellitus causes miscarriage if the diabetes is poorly controlled. Maternal infections may occasionally lead to miscarriage. There is some evidence that conceptions that take place between old eggs (several days after ovulation) or old sperm (that start out several days before ovulation) may be more likely to miscarry.

Symptoms of miscarriage include pink or brown colored discharge for several weeks, which develops into painful cramping and increased vaginal bleeding; dilation of the cervix; and expulsion of the fetus.

Diagnosis

A pelvic examination can detect a deformed uterus, and frequent examinations during pregnancy can detect an incompetent cervix. Blood tests can detect the presence of immunologic or blood-clotting problems in the mother. Genetic testing can also determine if chromosomal abnormalities may be causing the miscarriages.

Treatment

If a uterus is deformed, it may be surgically repaired. If a cervix is incompetent, it can be surgically fortified, until the fetus matures, by a procedure known as circlage (tying the cervix closed). Supplemental progesterone may also help sustain a pregnancy. Experimental treatment of maternal immunologic abnormalities with white cell immunization (injecting the mother with white cells from the father) has been successful in some cases of recurrent miscarriage. Clotting abnormalities can be treated with anticoagulant drugs, such as heparin and aspirin, to keep blood flowing to the fetus.

Prognosis

If there is no underlying disease or abnormality present, the rate of successful pregnancy after several miscarriages approaches normal. Seventy to eighty-five percent of women with three or more miscarriages will go on to complete a healthy pregnancy.

Resources

Books

Cunningham, F. Gary, et al., editor. Williams Obstetrics. Stamford: Appleton & Lange, 1997.

Key terms

Fetus — A developing embryo in the womb after the first eight weeks of gestation.

Ionizing radiation — Radiation produced by x rays and radioactivity.

Ovulation — Release of an egg for fertilization from the ovary that happens about fourteen days before each menstrual period.