What is Recurrent Pregnancy Loss?
Recurrent pregnancy loss (RPL) is when a woman experiences two or more consecutive miscarriages, verified by an ultrasound or a lab test of tissue samples. This is the definition used in the United States. However, in the United Kingdom, the criterion is three or more consecutive early pregnancy losses.
About 2 percent of pregnant women go through two consecutive miscarriages. Interestingly, in as many as 50 percent of RPL cases, doctors find no definite cause. RPL is one of the hardest situations to tackle in reproductive medicine, leaving patients, their families, and doctors feeling frustrated. The uncertainty can also cause anxiety and worry among the affected women.
RPL can occur in two forms: primary and secondary. Primary RPL is when a woman has never had a successful pregnancy that resulted in a live birth. On the other hand, secondary RPL is when a woman has a miscarriage after already having one or more successful pregnancies.
What Causes Recurrent Pregnancy Loss?
Recurrent Pregnancy Loss (RPL), or repeated miscarriages, can be caused by many different things:
1. Genetics: Genetic issues, like Aneuploidy (an abnormal number of chromosomes), can often cause RPL. Also, issues with fetal chromosomes can lead to miscarriages.
2. Anatomy: Sometimes, the shape or structure of the uterus can cause RPL. This can mean women who have a divided (septate), one-sided (unicornuate), two-sided (bicornuate), or two different uterus (didelphic and arcuate). Other issues like fibroids, polyps, or Asherman syndrome (scar tissue inside the uterus) can also make RPL more likely.
3. Endocrine: Issues with the mother’s hormones, like diabetes or thyroid problems, can contribute to RPL. Even high levels of prolactin in the blood can potentially cause RPL.
4. Antiphospholipid antibody syndrome: This is also a common cause of RPL. It makes blood clots more likely and can affect blood flow to the placenta.
5. Environment: Lifestyle choices can sometimes cause RPL. These can include smoking, being overweight, consuming alcohol or high amounts of caffeine, or using drugs like cocaine.
6. Immunology: There is some evidence that inherited blood clotting disorders may be linked to RPL. However, it is not currently standard to test for these unless the woman herself has a history of blood clots, or a family history of these types of disorders.
These are all potential causes of RPL, so it’s important to talk to a doctor about what might be causing it in each case. This way, appropriate steps can be taken to manage and treat whichever issue may be contributing to RPL.
Risk Factors and Frequency for Recurrent Pregnancy Loss
About 2 percent of pregnant women experience two or more continuous pregnancy losses. Also, up to 50 percent of patients who experience repeated pregnancy loss do not have a clearly defined cause.
Signs and Symptoms of Recurrent Pregnancy Loss
When consulting with a patient about recurrent pregnancy loss (RPL), it’s necessary to take a comprehensive medical history that includes all the information about any previous pregnancy losses. It’s important to know the stage of pregnancy when prior losses occurred, as RPL often happens at the same stage in each subsequent pregnancy. The type of treatment received for prior pregnancy losses should also be noted, since some procedures like dilation and curettage could potentially increase the risk of conditions like Asherman syndrome and cervical incompetence, which may lead to further instances of RPL.
Besides personal pregnancy history, it’s also important to document the patient’s general medical, surgical, and menstrual history. Any family history or personal incidence of blood clots, lifestyle habits such as smoking, alcohol and drug use, and exposure to any environmental toxins should be recorded. A thorough physical examination, including a general and pelvic exam, should complete the examination process.
Testing for Recurrent Pregnancy Loss
If you and your partner have experienced recurrent pregnancy loss (RPL), a thorough evaluation involving various tests is vital. These tests aim to identify any possible causes for the repeated miscarriages and help with future treatment plans.
Firstly, your doctor will order tests to check for any medical conditions that could be affecting pregnancy, such as diabetes, thyroid problems, and hyperprolactinemia, which is a condition where the body produces too much of the hormone prolactin.
Your doctor may also recommend a genetic evaluation to identify any chromosomal abnormalities which could be contributing to the recurrent miscarriages. This could involve taking a small sample of your and your partner’s blood for a karyotype assessment, a test that examines the structure of your chromosomes.
Identifying any abnormalities in the uterus, whether congenital (present at birth) or acquired, can also be useful. These can be detected using various techniques such as pelvic ultrasound, saline infusion sonohysterography (an ultrasound of the uterus after it has been filled with saline), hysterosalpingogram (an X-ray of the womb and fallopian tubes), hysteroscopy (inspection of the uterus with a small camera), or an MRI.
An immunologic workup, which focuses on checking the health of your immune system, is also important. Your doctor may test you for the antiphospholipid antibody syndrome, a condition that can impair successful pregnancy. This involves measuring the levels of certain antibodies in your blood which have been linked to pregnancy loss.
While checking progesterone levels is common in some fertility investigations, this isn’t typically necessary for investigating RPL, as the progesterone level is not a reliable predictor of future pregnancies. Similarly, an endometrial biopsy, a test where a small sample of the lining of the uterus is removed for examination, is also not a recommended test for investigating RPL.
No routine tests are needed for infections like chlamydia, gonorrhoea, or bacterial vaginosis unless you have symptoms suggesting these. A TORCH serology test, which checks for a group of infections that can cause birth defects, is also typically not needed unless indicated.
Finally, your doctor may suggest a detailed genetic evaluation of the tissue from the miscarriage. This technique is particularly effective when combined with the above assessments, as it accurately identifies the cause of recurrent miscarriage in up to 90 percent of cases.
All these tests and evaluations are geared towards identifying the reason for the repeated miscarriages, thus aiding in planning an effective treatment strategy.
Treatment Options for Recurrent Pregnancy Loss
When it comes to treating recurrent pregnancy loss (RPL), or losing multiple pregnancies, it’s essential to tailor the treatment towards the specific cause of the problem. Doctors will guide patients and their families through the various treatment options, outlining the risks and success rates of each one. It can be an anxious time for the couples involved, so emotional support can often help improve their treatment experience. Doctors who specialize in hormonal systems (endocrinologists) and those specializing in pregnancy (obstetricians) often work together to provide the best possible care.
In some cases, RPL can be linked to existing medical conditions. Thyroid problems, diabetes, and obesity, among other things, may need to be managed alongside the patient’s attempts to conceive. Women with high levels of thyroid peroxidase antibodies, which can indicate an overactive immune response and contribute to RPL, should take steps to manage their condition.
If chromosomal abnormalities, or issues with the genes inherited from parents, have been found in the couple, they might be recommended to see genetic counselors. These professionals can provide insights into the couple’s chances of having issues with a baby’s genes in the future. Couples are also given the option to undertake genetic tests before or during pregnancy, which can help identify potential issues with a baby’s genes.
Physical abnormalities in the uterus, the organ where a baby develops during pregnancy, could also contribute to RPL. These might be birth defects or issues that have developed over time. Doctors can often correct these problems using surgery. In those cases, a referral to a reproductive endocrinologist, a doctor who specializes in fertility issues, can be beneficial.
RPL could also be linked to problems with the immune system. For example, a condition called antiphospholipid antibody syndrome can cause issues in pregnancy, but is commonly treated with medications like aspirin and heparin. Unfortunately, for women with blood clotting disorders known as thrombophilias, this regimen may not prevent RPL though it might offer maternal benefits. New treatments are also being explored for RPL, like tumor necrosis factor-alpha inhibitors and granulocyte colony-stimulating factor, though more research is needed to confirm their benefits.
Surprisingly, there are times when doctors may not be able to identify the cause of RPL—this is known as ‘unexplained’ RPL. While treatments used in the past like steroids or intravenous immunoglobulin haven’t shown to improve pregnancy outcomes in terms of live births, researchers continue to search for effective treatments for this challenging condition.
What else can Recurrent Pregnancy Loss be?
Common causes of recurrent miscarriages include:
- Fetal chromosomal abnormality
- Idiopathic recurrent miscarriage, which means the cause is unknown
Less common causes can include:
- Antiphospholipid syndrome, a disorder of the immune system
- Cervical incompetence, when the cervix cannot stay closed during pregnancy
- Parental chromosomal abnormality
- Uncontrolled diabetes
What to expect with Recurrent Pregnancy Loss
Recurrent pregnancy loss (RPL), experiencing multiple miscarriages, can have a substantial emotional and psychological impact on couples. It is linked to feelings of depression, anxiety, and low self-esteem. The chance of experiencing further pregnancy losses is significantly influenced by two main factors: the age of the mother and the number of past miscarriages. So, as a woman ages or has more miscarriages, the risk for future pregnancy losses rises.
Possible Complications When Diagnosed with Recurrent Pregnancy Loss
Recurrent pregnancy loss can be emotionally distressing for women and their partners, as it can bring about important emotional and psychological effects. This situation can generate distress, anxiety, and disappointment in a couple as they balance their hope for a successful pregnancy with their fear of experiencing another miscarriage. Not only does recurrent pregnancy loss affect the individuals directly involved, but it also poses emotional challenges for the healthcare professionals treating them. This situation can evoke emotions like anger, sadness, frustration, and confusion, and it can even place a strain on the couple’s relationship, diminishing their intimacy.
- Emotional and psychological impact on the woman and her family
- Couple’s distress due to repeated miscarriages
- Emotional toll on healthcare professionals treating the couple
- Negative emotions like anger, sadness, and frustration
- Potential strain on the couple’s relationship and decrease in intimacy
Preventing Recurrent Pregnancy Loss
In managing couples who have experienced multiple miscarriages, educating the patients is critical. Medical professionals are crucial in providing support and guidance to these couples. They should be sensitive to the couples’ feelings, needs and choices, considering their cultural backgrounds, religious beliefs, and personal wishes.
Proper management of this heartbreaking condition can’t be achieved without the participation of every member of the healthcare team. Their role is to assist patients and their families in making knowledgeable decisions about their care. They help ensure that couples going through such difficult times have the best possible outcomes.
