Miscarriage – Recurrent Pregnancy Loss

Miscarriage, also known as spontaneous abortion and pregnancy loss, is more common than most realize and can occur in 25% of pregnancies.  The majority of miscarriages occur at less than 10 weeks gestation and result from chromosome abnormalities in the embryo.  A common sign of a miscarriage is vaginal bleeding, which can range from spotting to heavier bleeding like a period. It is important to keep in mind that many normal pregnancies can also experience vaginal bleeding.  Vaginal bleeding can be associated with menstrual-like cramps. Mild cramping during an early pregnancy is common and is not necessarily a sign of a miscarriage.

Recurrent pregnancy loss, or RPL, is characterized by recurrent or repetitive miscarriages. While the definition of RPL can vary, the American Society for Reproductive Medicine (ASRM) defines it as two or more failed clinical pregnancies <20 weeks gestation.  A failed clinical pregnancy is defined as a pregnancy loss after an ultrasound shows at least a pregnancy sac.  Women who experience RPL may also have associated infertility.

Women evaluated for RPL, undergo a complete history and physical examination, as well as a baseline ultrasound to assess both the uterine anatomy as well as a follicle count of the ovaries, which is a marker of one’s ovarian reserve (egg quality and quantity).

Additional assessment includes focusing on screening for:

Uterine anatomy– assessment of the uterine cavity by sonohysterogram or hysterosalpingogram (HSG) allows for the assessment of acquired or congenital uterine anomalies.

Sonohysterogram- also referred to as a saline sonogram, a transvaginal ultrasound procedure involving the placement of a tiny catheter into the uterine cavity. Sterile saline solution is then injected into the uterine cavity causing distension and allowing assessment for any abnormalities.

HSG- commonly referred to as the “dye test,” is an x-ray test and is usually performed by a radiologist.  A thin catheter is placed through the cervix and a small amount of contrast dye is injected while x-ray pictures are captured as the dye passes through the uterus and then into the fallopian tubes. These images are analyzed to detect abnormalities of the uterus as well as to detect blocked or damaged fallopian tubes.

Occasionally a pelvic MRI or a 3-D sonogram may also be performed. Depending on the finding, a hysteroscopy may be recommended. Hysteroscopy is a minimally invasive same-day surgical procedure, involving the placement of a narrow telescope into the uterus, which can be used to remove endometrial polyps, fibroids, scar tissue or a septum.

Genetic factors– assessment of maternal and paternal chromosomes via a blood test, known as a karyotype, indicating whether that person is a carrier for a genetic abnormality.

If a genetic factor is identified, genetic counseling is recommended.  In order to decrease the likelihood of a subsequent miscarriage or live born with a chromosome abnormality, in vitro fertilization (IVF) with Preimplantation Genetic Diagnosis (PGD) can be performed with transfer of an unaffected embryo.  Another treatment option is the use of donor gametes (eggs or sperm).

Antiphospholipid syndrome (APS)- maternal blood testing for anticardiolipin antibodies, Lupus anticoagulant, and β2 glycoprotein. Treatment for APS consists of blood thinners (both baby aspirin and heparin).

Hormonal and metabolic factors– screening for thyroid (TSH), prolactin, and uncontrolled diabetes (HbA1c). If a hormonal or metabolic abnormality is detected, medical treatment of the underlying condition can be performed.

Lifestyle variables– cigarette smoking, obesity, illicit drug use, alcohol consumption (3-5 drink per week), and caffeine consumption (> 200mg per day) have been associated with increased risk of miscarriage.

Routine screening for an inherited thrombophilias, infections, and immunologic factors are not currently recommended in the evaluation for RPL.

No apparent causative factor is identified in 50-75% of cases with RPL. The majority of miscarriages are sporadic, resulting from chromosomal abnormalities in the embryo, and are influenced tremendously by maternal age. In women over the age of 35, the incidence of miscarriage increases as a result of the associated increased risk of a chromosomally abnormal pregnancy.  For women over the age of 40, the miscarriage rate can be over 50%.  It is important to keep in mind, that with appropriate treatment and management, most women who suffer from RPL have a good prognosis and will still achieve a livebirth.

Couples facing factors such as advanced maternal age (over 35), a history of failed IVF cycles or RPL may have an increased risk of developing a chromosomally abnormal embryo. Recent research studies have found that women undergoing IVF with Preimplantation Genetic Screening (PGS), also referred to as Comprehensive Chromosomal Screening (CCS), may significantly improve the chances of having a healthy and successful pregnancy by selecting and transferring only a chromosomally normal embryo.  PGS refers to testing and screening for potential chromosomal deficiencies (aneuploidy). It is estimated that approximately half of miscarriages that take place during the first trimester of a pregnancy result from a chromosomal abnormality. These abnormalities may result from advanced maternal age, as chromosomal aneuploidy rates increase with increasing maternal age, and is why older women have higher miscarriage rates. PGS can identify embryos that are most likely to possess the normal chromosomal complement and select them for embryo transfer, thus greatly reducing the risk of miscarriage. The ability to prevent an abnormal pregnancy allows patients to avoid the physical and emotional suffering of a miscarriage.

The grief and anxiety associated even with just a single pregnancy loss can be devastating to couples, and many bottle up these emotions as they may feel uncomfortable discussing it with friends and family. At RMA of New York we employ a comprehensive team approach to care for patients who suffer from a single pregnancy loss or RPL, recognizing the associated emotional and psychological needs.  As a result, these patients may benefit from speaking with our licensed psychologist on staff.

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