PRESENT DAY MANAGEMENT OF RECRURRENT MISCARRIAGES
Spontaneous miscarriage occurs in 12%-15% of all pregnancies. Thirty percent are lost between implantation & 6th week. The management of recurrent miscarriages needs proper evaluation & guidance since 50% of cases of these cases will not have a clearly defined cause. The investigations and management of recurrent miscarriages is one of the most debated topics. This article will help in providing evidence based approach to manage such cases.
Recurrent miscarriages is defined as 3 Consecutive miscarriages or Early failed pregnancies.
Risk of miscarriage after 2 loses in 17%-25% and after 3 or more miscarriages 25%-46%. Risk gets worse with increasing maternal age and in patients with a history of infertility.
Investigations: Chromosomal analysis of the products of conception should be done since common abnormality is Aneuploidy with trisomy in more than 50% of chromosomally abnormal fetuses. Anatomical defects of uterus are found in 3.2%-16.9% of women with recurrent miscarriage. Combined hysteroscopy and laparoscopy should be the gold standard in evaluating such cases. 3D ultrasound and MRI may also help in assessment.
Infections: Bacterial vaginosis screening during pregnancy is recommended in such cases. Haemotological disorders- antiphospholipid antibodies is associated with adverse pregnancy outcome. 5%-15% of women with recurrent pregnancy loses have such antibodies. Inherited thrombophilias such as factor V leidin mutation, prothrombin gene mutation and deficiencies of natural anticoagulants protein C, protein S and anti thrombin are associated with recurrent miscarriages and sometime hyperhomocysteinima.
Endocrine abnormalities like Polycystic ovaries, LH and insulin resistances is found in 40% of women with recurrent miscarriages. Luteal phase defects, diabetes mellitus. Thyroid abnormalities are commonly found in such cases.
Immunological causes- A significant proportion of recurrent pregnancy loss is associated with immune antibodies. Example peripheral natural killer cells and uterine natural killer cells have been associated with reproductive failure.
Role of male factor- sperm samples from recurrent pregnancy losses have an increase in their sperm DNA fragmentation.
Management- Referred to our recurrent miscarriage clinic and expert advice help to improve the reproductive outcome.
Tender loving care and lifestyle advice for stress reduction should be emphasized. Healthy life style, free from tobacco, alcohol, illicit drugs helps in having a favorable outcome. Prenatal genetic testing is a suggested in the management of couples with chromosomal abnormalities and recurrent miscarriages. It is specifically helpful in Patients who have translocation abnormalities. Management of anatomical defects of the uterus, treatment of abnormal vaginal discharge and bacterial vaginosis with oral clindamycin in early in the second trimester reduces the chances of late miscarriage. Management of antiphospholipid syndrome and inherited thrombophilia is recommended in recurrent miscarriages.