Recurrent Pregnancy Loss (Miscarriage)

What is recurrent miscarriage?

Recurrent miscarriage, also known as recurrent pregnancy loss (RPL), is transitionally considered the loss of three or more consecutive pregnancies. More recent definitions refer to the loss of two or more consecutive pregnancies. The prevalence of recurrent pregnancy loss is estimated to be between 1 and 5% of all pregnancies. It can be a physically and emotionally difficult experience for those affected by it.

Types of Recurrent Pregnancy Loss

Recurrent early miscarriages and recurrent late miscarriages are both forms of recurrent pregnancy loss (RPL), but they occur at different stages of pregnancy.

Recurrent First Trimester Pregnancy Loss

Recurrent early miscarriages, also known as first-trimester pregnancy loss, occur during the first trimester of pregnancy, typically before 13 weeks.

The majority are unexplained, where no cause can be identified. It is though that many cases are due to chromosomal abnormalities in embryo formation. This can happen without family history and can happen to any couple. Increased maternal age will increase the risk.

Recurrent miscarriages in the first trimester, however, can be associated with various other problems, including:

blood disorders,
immunological disorders,
metabolic/endocrine disorders,
pelvic pathology like endometriosis and
uterine cavity abnormalities like adhesions, uterine septum and intrauterine fibroids

If you have experienced recurrent pregnancy loss I will help to arrange appropriate investigations to help determine the best treatment course ahead.

Recurrent Second Trimester Pregnancy Loss

Recurrent late miscarriages, also known as second-trimester pregnancy loss, occur during the second trimester of pregnancy, typically between 13 and 24 weeks. It is considered a rare but distressing condition, affecting about 1% of couples trying to conceive.

The causes of recurrent second-trimester loss can be complex and multifactorial and can include the:

Structural issues in the reproductive organs include: congenital anomalies of the uterus or cervical incompetence.
Placental problems: such as placenta previa, placental abruption, or placental insufficiency
Immune system disorders: such as antiphospholipid syndrome (APS)
Genetic or chromosomal issues: although chromosomal abnormalities are more commonly associated with early miscarriages, they can also occur in the second trimester.
Maternal medical conditions: such as hypertension, diabetes, or thyroid disorders
Lifestyle factors: such as smoking, alcohol consumption, and substance abuse.

Pregnancy Loss Due To Cervical Incompetence

This is the inability of the cervix to hold the pregnancy until full term.

This can be treated with observation and Progesterone pessaries or Cervical cerclage (cervical suture).

If the suture is the recommended approach, it is usually inserted around 12 -14 weeks under general or spinal anesthetic in the operating theatre, usually as a day-only procedure.

Pregnancy Loss Due To Placental Problems

Placental problems can cause pregnancy loss in the early and late stages of pregnancy. Some of the most common placental problems that can lead to pregnancy loss include:

Placenta Previa: This is a condition in which the placenta implants in the lower part of the uterus, covering all or part of the cervical opening. Placenta previa can lead to severe bleeding and pose a risk of premature delivery or miscarriage.
Placental Abruption: This is a serious condition in which the placenta separates from the uterus, causing bleeding and a lack of oxygen to the fetus. Placental abruption can lead to preterm labour, stillbirth, or miscarriage.
Placental Insufficiency occurs when the placenta cannot provide the fetus with enough oxygen and nutrients. Placental insufficiency can cause growth restriction, preterm birth, or fetal death.

These placental problems can occur on their own or in conjunction with other conditions, like hypertension or pre-eclampsia, which can also impact the pregnancy outcome.

Pregnancy Loss Due To Antiphospholipid syndrome (APS)

Antiphospholipid syndrome (APS) is an autoimmune disorder characterised by certain antibodies (called antiphospholipid antibodies) in the blood. These antibodies can cause blood clots to form in small blood vessels, increasing the risk of pregnancy loss, both in the early and late stages of pregnancy.

Diagnosis of APS usually involves blood tests to detect the presence of antiphospholipid antibodies. Treatment for APS usually involves anticoagulant medications to prevent blood clots from forming. High-risk pregnancies may require extra monitoring, such as ultrasound and Doppler, to monitor the growth of the fetus and blood flow to the placenta.

Pregnancy Loss Due To Genetic or Chromosomal Issues

Genetic or chromosomal issues can cause pregnancy loss in the early and late stages of pregnancy. Genetic or chromosomal issues can affect the normal development of the embryo or fetus, leading to miscarriage.

One of the most common genetic or chromosomal causes of miscarriage is chromosomal abnormalities. Chromosomal abnormalities occur when there is an error in the number or structure of chromosomes in the fertilised egg or embryo. These errors can occur in the egg or sperm or as a result of errors during cell division. Chromosomal abnormalities such as Trisomy (an extra chromosome) or Monosomy (missing a chromosome) are common in miscarriage. Aneuploidy, an abnormal number of chromosomes in a cell, is one of the most common causes of first-trimester miscarriage.

Another genetic cause of miscarriage is genetic disorders, such as Turner Syndrome, Triple X syndrome, and Klinefelter Syndrome, which are caused by mutations in a single gene and can increase the risk of pregnancy loss.

In some cases, the genetic or chromosomal cause of a miscarriage may not be identified. This can happen when fetal tissue is not available for testing or genetic or chromosomal issues are extremely rare.

Pregnancy Loss Due To Environmental Factors

Some of the most common environmental factors that have been linked to an increased risk of miscarriage include:

Toxins: Exposure to certain toxins such as pesticides, lead, and other heavy metals, as well as certain chemicals such as solvents and phthalates, can increase the risk of miscarriage. Studies have also shown that exposure to air pollution can increase the risk of miscarriage.
Viral infections: Certain viral infections, such as rubella, cytomegalovirus, and parvovirus B19, can increase the risk of miscarriage.
Lifestyle factors: Poor lifestyle habits such as smoking, alcohol consumption, and drug use have been linked to an increased risk of miscarriage.
Stress: High-stress levels can also be associated with an increased risk of miscarriage, although the exact mechanism of how stress might increase the risk is not well understood.
Radiation: Exposure to high levels of radiation, such as from radiation therapy or a nuclear accident, can increase the risk of miscarriage by damaging the genetic material in the fertilised egg or early embryo.

Treatment for Recurrent Pregnancy Loss

The treatment for recurrent pregnancy loss depends on the underlying cause of the loss. However, in some cases, the underlying cause is unknown. The following are some common treatment options for recurrent pregnancy loss:

Management of underlying medical conditions: If a medical condition, such as antiphospholipid syndrome (APS) or thyroid disorder, is identified as the cause of recurrent pregnancy loss, treatment of that condition can help reduce the risk of future pregnancy loss.
Medications: If the underlying cause is an immune system disorder, such as APS, low-dose aspirin and heparin can prevent blood clots and improve blood flow to the placenta.
Surgery: In some cases, surgery may be recommended to correct structural issues in the reproductive organs, such as a septate uterus or cervical incompetence.
Genetic or chromosomal testing: Genetic or chromosomal testing of the parents and products of conception may be done to detect any underlying genetic or chromosomal causes of recurrent pregnancy loss.
Lifestyle changes: Women are encouraged to maintain a healthy lifestyle to reduce the risk of pregnancy loss, including avoiding smoking, alcohol, and drug use, managing stress and getting appropriate nutrition.
Monitoring: close monitoring during pregnancy to detect and treat potential problems early on.
Assisted Reproductive Technologies (ART) such as in vitro fertilisation (IVF) may also be considered for couples with recurrent pregnancy loss after evaluating the underlying cause. This may involve PGT to allow chromosome assessment of an embryo before it is transferred into the uterus.

Recurrent pregnancy loss can be complex, and the underlying cause may not be identified in all cases. Even if the underlying cause is not identified, treatment may still be recommended to reduce the risk of future pregnancy loss.

Coping with Recurrent Pregnancy Loss

Dealing with recurrent miscarriages can be emotionally and psychologically difficult. It's important to remember that you're not alone and that recurrent miscarriage is a common problem.

Many women go on to have successful pregnancies after experiencing recurrent miscarriages. Dr Giselle Crawford can help you explore options for increasing your chances of a successful pregnancy in the future, including assisted reproductive technology and lifestyle changes.

If you are struggling with recurrent pregnancy loss, support options include: