By Dr. Christian Pope December 02, 2010 12:00 AM

A 30-year-old woman presents after having three consecutive miscarriages. Before these miscarriages, she had one successful pregnancy. she is a healthy woman with no medical problems.

What’s next?

As with many women’s health issues, there is no one answer or treatment that can prevent or cure miscarriages. It is always difficult and should be fully evaluated by your health care provider.

There are a number of factors and reasons that miscarriages occur, from health complications such as diabetes or uterine malformations to caffeine intake or chromosomal issues. It is important to undergo a full evaluation and provide as much information as you can to your obstetrician. the following is a quick overview of types of miscarriage and the evaluation process.

A miscarriage is the spontaneous loss of a pregnancy before 20 weeks. Miscarriage occurs in 15 percent to 20 percent of pregnancies. A majority of miscarriages that occur before 10 weeks of pregnancy are due to chromosomal problems. the rate of miscarriage increases when maternal age is less than 18 years or greater than 35 years old.

Recurrent miscarriage, defined as the loss of three or more consecutive pregnancies, occurs in approximately 1 percent of couples attempting pregnancy.

Many experts consider two consecutive losses as sufficient for the diagnosis of recurrent miscarriage, because the recurrence rate is similar to that after three losses. this can occur in up to 5 percent of reproductively active couples and occurs in an even higher proportion of women 35 or older. For many couples, the evaluation does not reveal a cause and yet, in some cases, may lead to an unrelated finding and therefore unnecessary treatments with vitamin supplements or blood thinners.

Most women with recurrent miscarriage have recurrent early miscarriage — that is, miscarriage before 10 completed weeks of pregnancy. Signs may be no fetal heart rate seen by ultrasound, the size of the embryo or pregnancy sac measuring considerably less than expected, and/or symptoms of uterine bleeding and/or cramping. A substantial proportion of recurrent early miscarriages are due to the embryo having a chromosomal problem, although it is less common than with sporadic miscarriages.

A smaller proportion of women with recurrent miscarriage have a late miscarriage — after 10 weeks of pregnancy but usually before 16 completed weeks. Recurrent miscarriage at any time is distressing and gives rise to frustration for the couple and their physician.

The nature of previous losses in a women’s obstetrical history is crucial. this history should be carefully obtained. Also, any general medical problems must be presented and evaluated, since many medical concerns may contribute to pregnancy loss, such as uncontrolled diabetes and thyroid disease, autoimmune diseases and clotting problems known as thrombophilias.

Obesity, smoking, excessive alcohol use and moderate-to-heavy caffeine intake may all be associated with sporadic miscarriage, but have not been proven to be a causative risk of recurrent miscarriage.

Uterine malformations, most commonly “arcuate” and “septate uteruses,” which refers to a congenitally misshaped uterine, are detected in 10 percent to 25 percent of women with recurrent miscarriage. Therefore, evaluation of the uterus with different modalities should always be performed.

In 3 percent to 6 percent of the cases of recurrent miscarriage, one partner, usually the woman, has a chromosomal problem. the most common type is called translocation, which may be detected with blood work.

Years ago, intrauterine infection was thought to cause recurrent miscarriage, and physicians commonly performed expensive laboratory testing on many patients to try to discover the causative organisms.

However, after many studies, there is no proven infectious cause of recurrent miscarriage and the testing is no longer recommended.

Similarly, although a deficiency of progesterone has been proposed as a cause as well, it has not proven true and, again, such testing and progesterone supplementation is no longer recommended.

Medical history requires:

• an accurate obstetrical history as to timing and pattern of previous miscarriages, if such information is available.
• Previous pathology of placenta information from previous miscarriage, if available.
• Prior imaging/ultrasounds if available for comparison with current studies to be performed.
• Assessment for other medical conditions such as thyroid disease or diabetes.

Physical examination includes:

• Gynecologic pelvic examination.
• General medical examination.

Recommended tests include:

• Pelvic ultrasound, hysteroscopy and possible hysterosalpingography (HSG) to evaluate uterine cavity; rarely, uterine MRI is performed.
• Labs: lupus anticoagulant, anticardiolipin antibodies, TSH, HgbA1c.
• Chromosomal testing of the mother and father who are trying to conceive.

The prognosis for women with a history of recurrent miscarriage is often favorable, even without any treatment.

Among women with recurrent miscarriage and positive lab testing for a blood-clotting disorder, such as antiphosholipid antibody syndrome, improved pregnancy and live birth rates have been shown with the use of a blood thinner called heparin together with low-dose aspirin.

For women with unexplained recurrent miscarriage, there is no evidence to support the use of aspirin or heparin.

In women with a uterine anatomical anomaly such as a uterine septum, surgical correction is recommended. this is often performed by a technique called hysteroscopy, that uses a small camera inserted through the vagina into the uterus, without any abdominal incisions. this typically is an outpatient procedure.

In couples who have a genetic contribution to their recurrent pregnancy loss, the prognosis varies depending on the underlying cause; however, overall there is up to a 70 percent chance of a live birth without any interventions.

In-vitro fertilization and pre-implantation genetic diagnosis has been used in some patients, as well with successful outcomes.

My recommendations listed above for evaluation and treatment are based on the most recent guidelines issued by the American College of Obstetricians and Gynecologists, and the American Society for Reproductive Medicine. Couples who have suffered multiple miscarriages should undergo the proper evaluation to help uncover any possible contributing causes.

However, they should also be informed that good evidence is lacking to support several commonly used interventions for recurrent miscarriage and that observation balanced with cautious optimism is a reasonable strategy, since without intervention, a subsequent pregnancy will result in a live birth for more than two-thirds of couples.

Have a women’s health topic you would like covered? Dr. Pope is happy to answer your questions or write a column on a topic you choose. Send your women’s health topic requests to Joyce Brennan at .

Dr. Christian S. Pope specializes in obstetrics and gynecology. He has offices in new Bedford and Mattapoisett and practices at St. Luke’s Hospital, the new Bedford site of Southcoast Hospitals Group. He can be reached at 508-999-6245.

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