Recurrent miscarriages

Recurrent or recurrent spontaneous abortions are called repeated consecutive abortions of three or more clinically recognized pregnancies.

Recurrent miscarriages are classified into primary and secondary.

•  The term primary miscarriage refers to women who have had three or more consecutive spontaneous miscarriages, with the same partner, and no pregnancy after week 20. This condition occurs in one in 144 pregnancies and is responsible for 61% of fetal losses.
• The term secondary miscarriages refers to women who have had three spontaneous miscarriages, with the same partner, after the birth of a child or after an intrauterine death. This condition occurs in one in 500 pregnancies and is responsible for 1.51% of fetal losses.

Possible causes of recurrent miscarriages include anatomical, genetic causes, hormonal disorders, immunological causes, hematological disorders and infections. 

If we make a more detailed classification, we would say that:

Genetic causes are perhaps the most common cause of miscarriage. It appears that over 50% of early miscarriages are due to chromosomal abnormalities. In the vast majority, these are de novo, sporadic mutations that occurred spontaneously, without any inherited problem from the parents. Heredity is only implicated in 2-4% of miscarriages. 

Continuing, we would say that the anatomical reasons that predispose and lead to a miscarriage are: 

1. Diaphragms in the uterus.
2. Abnormalities in the shape of the uterus (unicorn, dicorn, didelphys, etc.) 
3. The most common cause is fibroids, those of the endometrial cavity, that is, the submucosal ones. 

The majority of these causes can be treated surgically (usually with a combination of hysteroscopy and laparoscopy). 

Another reason for expulsion in 1The trimester of pregnancy are serious endocrine problems.

Hyperthyroidism, hypothyroidism, and diabetes mellitus should be controlled before the start of a pregnancy or at least regulated as soon as possible after its onset so that the woman is euthyroid and has a normal blood sugar curve. 

Hyperprolactinemia is also a common diagnosis. Mild hyperprolactinemia is often seen in women with polycystic ovary syndrome. 

Mild conditions are treated with medication, but in the case of macroadenomas, they are quite large and surgical removal is recommended. 

Another topic that has been the subject of much debate. During embryo implantation and during pregnancy, there must be a delicate balance between, on the one hand, good blood flow and formation of new vessels in the embryo and placenta and, on the other hand, the need for good blood clotting to prevent hemorrhages and hematomas that will lead to death and miscarriage of the embryo. If this balance is disturbed, there will be either thrombosis of the vessels with subsequent death of the embryo or hemorrhage. There are certain disorders associated with coagulation disorders. Most commonly, we see mutations of factor V Leiden, and prothrombin. More rarely, we see a lack of proteins C, S and antithrombin III. We also quite often see the so-called antiphospholipid syndrome (related to the tests that doctors request: lupus anticoagulants, anticardiolipid antibodies, etc.). 

A woman with recurrent miscarriages should have tests for protein C, prothrombin time, hyperhomocysteinemia, and antiphospholipid antibodies. 

Especially for women with antiphospholipid antibodies, various treatments have been tried. It has been shown that aspirin alone does not improve the prognosis in recurrent miscarriages. In women who do not suffer from thrombosis, we use prophylactically low molecular weight heparin in combination with a low dose of aspirin.

Both excessive maternal weight and very low maternal weight have been associated with an increased incidence of miscarriage. A woman with recurrent miscarriages and extreme maternal weight should not attempt another pregnancy unless she is of normal body weight for her height.

Other factors associated with recurrent miscarriages are smoking, excessive coffee and alcohol consumption.

Finally, in 501% of cases, no clear cause is found for the miscarriages, and the tests are normal. 

The certain and optimistic thing is that in the modern era we live in and the experience of gynecologists, with the appropriate therapeutic approach and proper medical monitoring, the woman will be led to what she always wanted, namely a healthy child in her arms. 

Sincerely, Ioannis Kalogirou DFFP,DRCOG 

Obstetrician gynecologist