Pregnancies are usually hugely anticipated and awaited events post marriage in most families.and in a society like India, the whole family rejoices in hearing the ‘good news’.hence, when a miscarriage occurs unexpectedly, it causes a lot of stress for the couple.they have to deal with their disappointment as well as deal with all the advice and reasoning which will invariably follow from those around them.
So what is a miscarriage?
It is the loss of a pregnancy before 20 weeks or five months and the general incidence is about 15%.
Thankfully, most often they happen sporadically due to bad luck and there is no problem in the next pregnancies.hence, extensive testing is not required after one.
- Advanced maternal age-increasing age of the mother affects the oocyte and can lead to the formation of a chromosomally abnormal embryo which will miscarry.
- Uncontrolled diabetes-if sugars are not controlled before trying to get pregnant, it can lead to increased incidence of miscarriages.
- History of previous miscarriages depending on the causative factor.
First trimester-before 12 weeks
Second trimester-13 to 20 weeks
Causes of Miscarriages
- 50 to 90% of early miscarriages are caused by chromosomal defects in that particular embryo and hence it does not continue growing. The earlier the loss, the more chance of this being the cause.
- Maternal infections like rubella, herpes simplex, listeriosis, toxoplasmosis
- Maternal medical disorders like uncontrolled diabetes, PCOS, uncontrolled thyroid dysfunction etc.
- Immunological causes like APLA(antiphospholipid antibody syndrome) or SLE May be causative factors both in the first or second trimester.
- Uterine anamolies-like septum(a thick tissue growing inside the cavity where the baby forms), submucosal fibroids(fibroids which grow inside the cavity) can cause early or late miscarriages.
- Cervical insufficiency or incompetence-condition where the cervix or mouth of the uterus is not strong and hence once the baby grows beyond four months, it opens and the baby is expelled without any pains.it usually is the cause for second-trimester losses only.
Recurrent Pregnancy Loss
This is when a couple suffers three consecutive pregnancy losses.itnoccurs in about 1% of couples.
But in today’s scenario, where couples are increasingly anxious, we evaluate for causes after two miscarriages also.
Common causes implicated are
- Parental genetic abnormalities.
- Antiphospholipid antibody syndrome in about 15% cases where there are antibodies which can interrupt the blood supply going to the developing fetus.
- Uterine factors like septum or fibroid as detailed above.
- Cervical incompetence.
Investigation in RPL
- Detailed history as to the number of miscarriages, ultrasound findings, the period at which it occurred etc
- GTT or assessment of control of sugars in known diabetics.
- Thyroid function tests.
- Karyotyping of both parents to know their genetic makeup
- 3-D ultrasound pelvis or MRI pelvis to assess the uterine cavity.
- Testing for antiphospholipid antibodies like anticardiolipin IgG and IgM, lupus anticoagulant and anti-beta 2 glycoprotein 1.
- Treatment will then focus on any cause which has been identified.
- Uterine factors-removal of the septum or submucosal fibroid by hysteroscopic surgery.
- Positive APLA-low dose aspirin, low molecular weight heparin(LMWH) injections throughout pregnancy
- Genetic abnormalities in either parent-genetic counseling followed by where required use of third party donors or preimplantation genetic testing of embryos.
- Cervical incompetence-placing a stitch at the completion of three months to keep the cervix closed.
What we have to remember and take positively is that in patients where no cause has been identified after extensive testing, emotional support and loving care may be sufficient to give the couple a normal pregnancy in their next attempt.