Recurrent Pregnancy Loss

About 2% of couples have this problem. Diagnosis and treatment of this condition is one of the most difficult issues of reproductive medicine.

Miscarriage (abortion) is the most common complication of pregnancy. In fact, in some months, women may have a "silent miscarriage" with menstrual bleeding, without even realizing that they are pregnant. In other words, not every fertilization results in a healthy pregnancy. Sometimes fertilization occurs, but the fertilization product does not settle in the uterus and falls silently, with menstrual bleeding. This can only be detected with pregnancy tests. We call this a "chemical pregnancy".

Recurrent Pregnancy Loss: Causes can be listed as;

1. Uterus (uterus) structural disorders and cervix (cervix) insufficiency
2. Endocrine (hormonal) disorders
3. Infections
4. Chromosomal disorders
5. Autoimmune diseases (Immune system diseases)
6. Environmental and other factors

To consider each one separately;

1) Uterus (uterus) anatomical disorders and cervix (cervix) insufficiency

Cervical insufficiency is a condition that occurs when the cervix is opened without pain, especially between the 4th and 6th months of pregnancy, and the fetus (baby) is expelled by rupture of the gestational membranes.

Treatment is usually surgery. At the end of the third month, the cervix can be sutured properly (McDonald and Shirodkar surgeries).

Structural disorders of the uterus are fibroids, intrauterine adhesions (adhesions), presence of a partition in the uterus (uterine septum), double uterus (uterus didelphis) and other deformities.

The frequency of these disorders is 10-15% in patients with recurrent pregnancy loss. These disorders; either by adversely affecting vascularization or by reducing and changing the dimensions of the uterine cavity, making the area where the fetus will be placed unsuitable.

Surgical correction of these abnormalities reduces miscarriage rates.

2) Endocrine (hormonal) disorders

Three types of disorders are most commonly thought to cause recurrent pregnancy loss. These;

• Diabetes
• Thyroid gland diseases
• It is “corpus luteum insufficiency” which is a menstrual pattern problem.

It is well known that controlled diabetes does not increase the risk of miscarriage. In other words, if the blood sugar of a pregnant diabetes patient is well controlled, the possibility of miscarriage does not increase.

Scientific evidence that thyroid disease causes pregnancy loss is inconclusive. For this reason, it is said that it is not necessary to look at thyroid hormones in patients with recurrent miscarriage.

Problems with the menstrual cycle are mostly seen in "ovulation", that is, ovulation-related problems. It is thought that disorders that cause insufficiency of the hormone "progesterone", which is necessary for the continuation of pregnancy, may cause recurrent miscarriages.

It is useful to explain the normal physiology in order to better understand how problems with the menstrual cycle can cause miscarriage.

The residual structure remaining in the ovaries after ovulation occurs and the egg is thrown is called “Corpus luteum” or “yellow body” due to its color. The task of the corpus luteum is to produce the hormone progesterone in order to ensure the continuation of pregnancy after fertilization. The task of the hormone progesterone is to prevent a newly formed pregnancy from being rejected by the body.

Although the secretion period of the progesterone hormone is as long as the life of the corpus luteum in cases where pregnancy does not occur, that is, 14 days, in cases where pregnancy does occur, it continues for up to 3 months and then transfers its place to the placenta.

If the corpus luteum gets old in a shorter time and disappears without transferring its duty to the placenta, although pregnancy occurs, in this case, "Corpus luteum failure" is mentioned and the pregnancy results in miscarriage.

The diagnosis of corpus luteum insufficiency is made by biopsy (Endometrial biopsy) taken from the inner lining of the uterus.

The treatment of corpus luteum insufficiency is to replace the progesterone hormone with drugs when the deficiency begins to appear. This treatment is usually continued in the first trimester of pregnancy.

3) Infections

It is thought that infections caused by viruses and bacteria can cause pregnancy loss.

Listeria monocytogenes, Toxoplasma species, Mycoplasma hominis, Ureaplasma urealiticum are the most common of these microorganisms. However, although these are known to cause a single miscarriage, they have not been fully proven to be the cause of recurrent miscarriage.

4) Chromosomal disorders

In cases of recurrent pregnancy loss, chromosomal abnormalities of the parents were found in 5% of the couples.

This frequency is significantly higher than in the general population. Genetic problems, in which both parents are carriers and do not cause disease, become obvious during pregnancy and result in abortions that are incompatible with life.

Genetic examination in couples can be helpful in predicting the recurrence of miscarriage. The findings are to form a basis in genetic counseling.

Chromosomal analysis of abortion material is also useful when investigating treatment failure.

5) Autoimmune diseases (Immune system diseases)

In the 1980s, researchers suggested that there may be a recurrent miscarriage cause of formations caused by a factor called anti-phospholipid antibody, which is formed as a result of deviation from normal in the body, which is effective in the regulation of the defense system, but which is not fully defined. Clear relationships were found between these substances and fetal death.

The mechanism of action of these substances; It is the formation of vascular disorders that lead to insufficient blood supply of the placenta.

In order for such patients to have a baby, steroid therapy, low-dose aspirin therapy, and treatment with a substance called heparin called "anticoagulant" may be required.

6) Environmental and other factors

Pregnancy loss increases with maternal age. Women over the age of 35 have a significantly reduced chance of normal pregnancy compared to younger women. In women over the age of 40, the risk of miscarriage approaches 50%. Women should be educated about these risks.

Studies in Scandinavian countries have shown that female employment does not increase the risk of miscarriage.

However, it is necessary to make sure that the patients do not encounter chemicals that will put the pregnancy at risk in the workplace.

Smoking and alcohol use increase the risk of miscarriage. There is no clear information about the effect of passive cigarette smoke.

It is not clear whether they are the cause of recurrent miscarriage, as psychological factors are difficult to study.

Follow-up of Patients with Recurrent Pregnancy Loss

The risk of miscarriage increases as the number of miscarriages increases. After 4 consecutive miscarriages, the risk of recurrence increases up to 50%.

Education and support is the most important approach when dealing with a patient with recurrent pregnancy loss.

Patients should be educated about the fact that the loss will increase with maternal age, even if there are no findings, and they should know that they are at an increased risk of other pregnancy complications such as preterm birth and ectopic pregnancy.

It is helpful to say that activities such as sexual intercourse and exercise that normally cause increased uterine cramps will not disrupt a healthy pregnancy.

Generally, laboratory studies should be performed after three abortions in women younger than 35 and after two miscarriages in older women. This is to reduce the laboratory load and the cost of health services to a certain extent.

However, sometimes one couple may want to wait a long time, while another may want the entire research program to be implemented after the first miscarriage.

Couples who have had a miscarriage need intensive doctor support in the first three months when they become pregnant after a complete evaluation and successful treatment.

In the case of "Thrombophilia", which has been suggested in recent years, the blood flow to the placenta falls due to the small plugs formed and the baby in the uterus is lost. After the detection of this situation, some anticoagulant drugs and a "methionine-poor diet" are recommended.

Families facing recurrent pregnancy loss should believe that it is not destiny. With this belief and patience, necessary precautions should be taken in cooperation with the doctor. It should be kept in mind that successful pregnancy rates can be very high (90%) after treatment for the cause.

Again, the low risk of detecting a heartbeat at the 8th gestational week by ultrasonography decreases to 3-5%.

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