Pregnancy is a very crucial and critical period in every woman’s life. It requires a lot of care, aequate rest, a healthy diet, an appropriate fitness routine, and a stress-free environment. But sometimes, even after taking the utmost care and precautions, you may suffer an extremely unfortunate pregnancy loss. Pregnancy loss can be devastating and might require fertility counselling for the couple.
A recurring pregnancy loss is typically defined as the occurrence of three or more miscarriages. However, in recent times, the American Society of Reproductive medicine (ASRM) has redefined recurrent pregnancy loss as two or more miscarriages or pregnancy losses prior to 20 weeks gestation. This condition affects 1 – 2% of fertile women.
Pregnancy loss is classified in to various types based on when it has occured. It is defined as a clinically recognized pregnancy loss when it occurs after the pregnancy has been confirmed by ultrasound. A biochemical pregnancy loss is usually an extremely early pregnancy loss that is detected through blood or urine samples only, and thus is not “clinically recognized”. Biochemical pregnancy losses are not recorded in a recurring pregnancy loss report.
While a common myth is that pregnancies most likely end because of stress, insufficient or inadequate diet or environmental factors, these factors are not the sole causes of a pregnancy loss. Most pregnancy losses are due to chromosomal (genetic), endocrine or hormonal abnormalities, anatomic abnormalities, infections, autoimmune disorders, and / or lifestyle factors.
Here are some of the most common factors that cause recurring pregnancy loss.
Chromosomes are a component of cells that contain a person’s genes. The chromosomes and genes determine how a person will develop [ anatomy ] and how he will behave [ phenotype ]. There are a total of 46 chromosomes in a normal fetus or embryo. An increase or decrease in this number of chromosomes may cause an abnormality or loss of pregnancy. There could be an extra chrmosome (trisomy) or absence of one [ monosomy ] or the complete set could be extra [ tri polidy ]. For instance, a fetus with Down’s syndrome has 47 chromosomes [ trisomy 21 – one extra chromosome no 21 ] or Turner’s syndrome [ 45 X – one less sex chromosome ]. Chromosomal and / or genetic abnormalities can stall the development of a pregnancy leading to an abortion or could result in development of a fetus with abnormalities or deformities. Miscarriages due to a chromosomal problem genefally occur very early in the pregnancy. Advanced maternal or paternal age also contribute to the poor ovary and sperm quality and may play a role in pregnancy losses.
The endocrine system includes all the different glands of the body. Each of these glands produces different hormones needed for the normal functioning of our system. This includes reproduction, general growth, metabolism, and mental well-being. Some of the most important glands are the Pituitary gland, Hypothalamus, Thyroid gland, Pancreas, Ovaries, and Testes.
Since most of the tissues of the human body respond to endocrine hormones, an imbalance in these hormones causes major ailments that further contribute to pregnancy losses. Endocrine disorders contribute to 8 – 12% of RPL. Diabetes and thyroid diseases are relatively common during pregnancy. Hyperthyroidism, Hypothyroidism, Type 1 and 2 Diabetes, and gestational diabetes are some of the more common disorders which may cause impaired fertility and pregnancy loss. Additional to these, luteal phase defects, polycystic ovary syndrome, hyperprolactinemia, and elevated androgen levels have also been evaluated in any case of RPL.
In some cases, a mother may have a uterus which has an abnormality or an irregularly shape. These abnormalities may be since birth [ congenital ] or acquired later on in life. The risk of a miscarriage or premature delivery is higher in the presence of some of these abnormalities. Some important abnormalities are unicornuate uterus [ only one half of the uterus is developed ], septate uterus [ presence of a band or a curtain in the uterus ]. The pregnancy occurs due either less space or insufficient blood supply to the embryo or increased contractions in the uterus.
Other anatomic disorders include abnormalities or weakening of the cervix [ mouth of the uterus ], presence of fibroids – benign muscle tumors of the uterus.
Certain Infections have been recognized to possibly cause Recurrent Pregnancy losses. Infections like PID (Pelvic inflammatory disease), Chlamydia, and Mycoplasma hominis are known to damage the inner lining of the uterus and may contribute to RPL, although this is not always the case.
Antiphospholipid Antibody Syndrome is a rare autoimmune disorder that causes the person’s immune system to mistakenly attack its own normal proteins in the blood. In simpler words, Antiphospholipid Antibodies may cause blood clots in the body and this almost always results in RPL. Women who have this disorder may experience RPL and stillborn children.
A bad or unhealthy lifestyle may affect normal pregnancies. Smoking, alcohol consumption, drugs, and other such factors may cause RPL. These unhealthy lifestyle choices are also some of the biggest infertility risk factors.
Investigating for recurrent pregnancy loss requires a systematic approach depending on the suspected problem – when do the miscarriages happen, is there a healthy child etc. Chromosomal problems can be detected by carrying out a karyotype of the aborted pregnancy and / or both parents. The purpose of this is to discover whether there was an abnormality in the pregnancy and if so, is this present and passed on to the pregnancy or is it de novo [ arising on its own ].
Abnormalities in the woman’s uterus may be evaluated by ultrasound or an X-ray or a saline ultrasound or an MRI. These tests often examine the uterine cavity, the tubes and shape of the uterus, and help in finding benign muscles or fibroids if any.
Hormonal, autoimmune disorders can be diagnosed by blood tests.
As there are multiple causes of RPL, and each cause needs separate tests, it is important that detailed information of all pregnancy losses is maintained – at what month of pregnancy did they occur, was the fetus and its heart beat visible etc. This will help the doctor in ordering the appropriate investigations and arrive at the correct diagnosis.
The treatment of Recurrent Pregnancy Loss essentially depends on the cause of the pregnancy losses. The treatment could be medical and / or surgical. However, in a significant number of patients, no specific cause can be found and hence no specific treatment may be offered. However, it is important to remember that even after three or more consecutive miscarriages, there is a more than 50 % chance of that the subsequent pregnancy has a good outcome.
Recurring pregnancy loss can be a very challenging condition, both physically and emotionally. Ensuring that you receive the best prenatal care can go a long way in helping you experience a healthy pregnancy.
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