Recurrent Miscarriage

At Bedaya Hospital, we adopt a personalized approach in the management of couples who have experienced multiple miscarriages. This approach includes carrying out various investigations such as sperm DNA fragmentation testing, reproductive immunology, extensive evaluation of clotting disorders, genetics, endocrine testing and we particularly focus on the embryo-endometrium signalling pathways and offer treatment strategies to optimize pregnancy outcomes.

 

What is recurrent miscarriage?

A miscarriage is when you lose a pregnancy at some point in the first 23 weeks of your pregnancy. When this occurs three or more times it is referred to as a recurrent miscarriage.
Around one in every 100 women has recurrent miscarriages. This is about three times more than what would occur if this was due to just chance alone. This indicates that for some women there must be a specific reason that they are experiencing recurrent miscarriages. For other women, however, when no underlying problem can be identified; their repeated miscarriages may simply be due to chance alone. Fortunately, most couples who have had recurrent miscarriages in the past still have a good chance of having a successful birth in the future.

 

Why does it happen?

There are a number of reasons why some women experience recurrent miscarriages:

  • Your age: The older you are the greater your risk of having a miscarriage.
  • Genetic factors: For around 3 to 5 in every 100 women who experience recurrent miscarriages, they or their partner have an abnormality on one of their chromosomes (the genetic structures within our cells that contain our DNA and the features we inherit from our parents). Although these abnormalities cause no problems for you or your partner, they may sometimes cause problems if they are passed onto your baby.
  • Abnormalities in the embryo: An embryo is a fertilized egg. An abnormality in the embryo is the most common reason for single miscarriages. However, if you have many miscarriages this is unlikely to be the cause.
  • Autoimmune factors: Antibodies are substances produced in our blood in order to fight off infections. Around 15 in every 100 women who have had recurrent miscarriages have particular antibodies in their blood, these antibodies are called antiphospholipid antibodies (aPL). Fewer than 2 in every 100 women with normal pregnancies have aPL antibodies.
  • Some people produce antibodies that react against the body’s own tissues; this is known as an autoimmune response and this is what happens to women who have aPL antibodies. aPL antibodies essentially attack your own tissues including that of your embryo. aPL related autoimmune disorders can be treated by giving low-dose aspirin tablets and low-dose heparin injections to the mother to prevent the antibodies attacking the mother’s tissues. However, even with treatment, mothers will have an increased risk of additional problems during pregnancy such as pre-eclampsia, which can cause a restriction in the baby’s growth and a sometimes induce a premature birth. Our medical team at Bedaya Hospital is well trained to monitor such cases very carefully so that you can be given appropriate treatment immediately for any problems that arise.
  • Another type of antibody that is associated with miscarriages is the antinuclear antibody. Diseases that we typically associate with antinuclear antibodies are Systemic Lupus Erythematous (SLE). The miscarriage rate in SLE patients is much higher than that of the general population. Although most women who suffer recurrent miscarriages do not have clinical signs of SLE, many exhibit an autoimmune phenomenon which is similar to that seen in SLE patients. The placentas of these women are inflamed and weakened which is believed to attribute to the frequent miscarriages.
  • The presence of thyroid antibodies was also found to be markers for “at-risk” pregnancies. The two antibodies studied were anti-thyroid peroxidase and anti-thyroglobulin antibodies, which are collectively referred to as anti-thyroid antibodies (ATA).
  • Anatomical structure of the uterus: It is un clear how major irregularities in the structure of a women’s uterus can affect the risk of recurrent miscarriages.
  •  

However, evidence shows that women who have serious anatomical abnormalities and do not have treatment for them seem to be more likely to miscarry or give birth early. Conversely, minor variations in the structure of a women’s uterus does not appear to cause miscarriages.

  • Cervical insufficiency: In some women the entrance of the uterus, called the cervix, opens too early in the pregnancy causing a miscarriage, this tends to occur around the third to sixth month of the pregnancy. This condition is known as having a weak cervix and the solution is to perform a cerclage. A cerclage is when the cervix is sewn shut during pregnancy. This procedure is usually undertaken between 12-16 weeks into the women’s pregnancy. Our antenatal care program in our foetal medicine department at Bedaya can diagnose the issue using Three-Dimensional Ultrasound Scans (3DUSS) and it is imperative that the condition is diagnosed on time and a cerclage is given as required.
  • Infections: If a serious infection enters a women’s bloodstream it may lead to a miscarriage. If a woman picks up a vaginal infection for instance, bacterial vaginosis, early in the pregnancy, it may increase the risk of having a miscarriage especially around the fourth to sixth month of pregnancy or it may increase the risk of the mother giving birth early.
  • It is not clear, however, whether infections are the reason for recurrent miscarriage. The reason we think this is because, in order for a bacterial infection to cause a miscarriage, the bacteria or virus would need to be able to survive in the women’s system without causing her to exhibit enough symptoms to be noticed. Therefore, early diagnosis of any infection, and treatment with antibiotics may help to reduce the risks of both having a miscarriage or of having a premature birth. Our antenatal care program is designed to closely monitor the mother and any alert the medical team to any possible silent infections in order to eliminate the risk of any miscarriages. During this monitoring process various tests are carried out at specific “danger points” in the pregnancy cycle.  
  • Blood conditions: The Inherited Thrombophilia conditions comprise a group of genetic disorders that affect the blood clotting pathways, leading to abnormal blood clot formation (thrombi). These conditions cause the resistance to a natural anticoagulant called activated protein C (APC) therefore lead to the formation of blood clots. These diseases have been shown in several studies to cause vascular complications that lead to miscarriages, intrauterine foetal death, pre-eclampsia (bacterial infection during pregnancy), and the HELLP syndrome which is a severe form of pre-eclampsia characterized by haemolysis (blood cells breaking up), elevated levels of liver enzymes, and thrombocytopenia (a low platelet count).
    Women who carry the genes for Inherited Thrombophilia are more 2 – 4 times more likely to have a clotting problem that leads to a miscarriage, compared to women without the gene.

 

The three major gene mutations that lead to Inherited Thrombophilias are:

  • Factor V Leiden mutation
  • Factor II (Prothrombin) G20210 gene mutation
  • Methylene-tetrahydrofolate reductase (MTHFR) mutation, leading to hyperhomocytseinemia

 

The most common cause of resistance to APC arises from a DNA mutation at the cleavage site of factor V, called factor V Leiden. It is the most common cause of the Inherited Thrombophilias, with a prevalence of approximately 10% in the Caucasian population. The mutation has been discovered in 60% of patients who experience a clot formation during pregnancy, and it is also a major cause of blood clots that are associated with oral contraceptive use.
The Prothrombin (factor II) gene mutation has been shown to occur in 7.8% of women who experienced foetal loss due to a clotting disorder. Factor II is one of the major players in the human clotting pathway therefore when it is not functionally properly this lead to frequent blood clots.

Homocysteine is an amino acid that is normally present in low levels in the bloodstream. It is derived from dietary methionine, an amino acid and the enzyme methylene-tetrahydrofolate reductase (MTHFR) turns methionine into homocysteine. A gene mutation in the MTHFR enzyme leads to a build-up of homocysteine in the bloodstream and this condition is called hyperhomocytseinemia. Hyperhomocytseinemia results in blood clot formation and hardening of the arteries, even in childhood. Lack of nutritional vitamins such as vitamins B6, B12 and folic acid also aggravate this condition and pregnant women are very susceptible to becoming deficient in these nutrients, which is why prenatal vitamins and carefully monitoring a pregnant mother’s diet is of vital importance.  

 

Women who have the homozygous form (both of her alleles having the mutation) of the MTHFR gene mutation have more than two-fold increased risk for having a miscarriage. Our experienced medical team at Bedaya Hospital is well trained and skilled to deal with these kinds of haematological issues and know how to successfully manage the pregnancy from conception through to the delivery of a healthy baby.

 

What do we offer at Bedaya Hospital? 

Supportive antenatal care

Women who have supportive care from the beginning of their pregnancy have a better chance of a successful birth. Bedaya Hospital hosts a team of gynaecologists, andrologists, embryologists and genetic counsellors to safely guide you through your pregnancy and delivery.

 

recurrent-miscarriage