Miscarriage

KFP 2022.2 Case 10

Recurrent miscarriage, also known as recurrent pregnancy loss (RPL), is typically defined as the loss of two or more consecutive pregnancies before 20 weeks of gestation. It’s a distressing condition and can be challenging to manage. Understanding its causes, diagnostic approach, and management is essential for effective treatment and support.

  • Causes of Recurrent Miscarriage
    • Genetic Factors: Chromosomal abnormalities in the fetus can lead to recurrent miscarriages. This is more likely in older parents.
    • Anatomical Issues: Abnormalities in the structure of the uterus, such as septate uterus, fibroids, or cervical incompetence.
    • Hormonal Imbalances: Conditions such as thyroid disorders or polycystic ovary syndrome (PCOS) can increase the risk.
    • Blood Clotting Disorders: Conditions like antiphospholipid syndrome (APS) or inherited thrombophilias can lead to recurrent miscarriages.
    • Immunological Factors: Immune system disorders, including certain autoimmune diseases, might contribute to recurrent pregnancy loss.
    • Environmental Factors: Exposure to certain chemicals, radiation, or infectious agents.
    • Lifestyle Factors: Smoking, excessive alcohol intake, and obesity can increase the risk.
    • Unexplained: In many cases, the cause remains unexplained despite thorough evaluation.
  • Diagnosis
    • History (Hx)
      • Obstetric History: Details of previous pregnancies, outcomes, and any complications.
      • Medical History: Any underlying medical conditions, surgeries, or family history of miscarriages or genetic disorders.
      • Lifestyle Factors: Smoking, alcohol use, exposure to toxins.
    • Examination (Ex)
      • Physical Examination: General health check and a pelvic examination to assess for anatomical abnormalities.
      • Speculum and Bimanual Examination: To evaluate the cervix and uterus.
    • Investigations (Ix)
      • Blood Tests: To check for hormonal imbalances (thyroid function tests), autoimmune conditions (like antiphospholipid antibodies), and genetic karyotyping for both parents.
      • Ultrasound: To assess uterine anatomy.
      • Hysterosalpingography or Hysteroscopy: To check for uterine abnormalities.
      • Endometrial Biopsy: To assess the health of the uterine lining.
  • Management (Mx)
    • The management of recurrent miscarriage depends on the underlying cause:
      • Genetic Counseling: For chromosomal abnormalities, genetic counseling and possibly in vitro fertilization (IVF) with preimplantation genetic diagnosis (PGD).
      • Surgery: Corrective surgery for anatomical abnormalities like a septate uterus.
      • Hormonal Treatment: For conditions like thyroid disorders or PCOS.
      • Anticoagulation Therapy: In cases of antiphospholipid syndrome or inherited thrombophilias, treatment with aspirin and possibly heparin.
      • Immunotherapy: Controversial and experimental but used in some cases of immunological disorders.
      • Lifestyle Changes: Addressing lifestyle factors such as smoking cessation, reducing alcohol intake, and achieving a healthy weight.
      • Psychological Support: Counseling and support for the emotional impact of recurrent miscarriages.
      • Close Monitoring: Early and regular monitoring in subsequent pregnancies.
      • Empirical Treatments: In cases of unexplained recurrent miscarriage, treatments such as progesterone supplementation may be considered, though their effectiveness is not conclusively proven.
      • Specialist Referral: Consider referral to a specialist with expertise in recurrent miscarriages for complex cases.
  • Follow-Up
    • Regular follow-up is crucial, both for monitoring any ongoing pregnancy and for providing emotional support. The psychological impact of recurrent miscarriage can be significant, and couples may benefit from counseling and support groups.

In conclusion, the management of recurrent miscarriage is multifaceted and should be tailored to the individual needs of the patient, taking into account the underlying cause, if identified, and providing holistic care.