Recurrent miscarriage: what it means and what you can do to help

Recurrent miscarriage is when a woman suffers more than three first trimester losses or more than two-second trimester losses. Unlike most miscarriages which are caused by problems with that particular pregnancy (either in the foetus itself or in the pregnancy implanting outside the uterus), recurrent miscarriages are usually due to problems with one or both parents. Many of these pregnancies may otherwise have been viable. 

Conditions which might contribute to a recurrent miscarriage include: incompetent cervix; autoimmune disorders in the mother; uterine abnormalities and genetic chromosomal defects. 

There are recurrent miscarriage clinics run in Auckland, Wellington and Christchurch to help women who have experienced recurrent miscarriage. Services they provide include prenatal testing to exclude genetic abnormalities, screening for autoimmune/antibodies and post-loss testing to try and establish the cause of the recurring miscarriages. They also provide support and resources for women during subsequent pregnancies to minimize the risk of miscarriage. 

If you have suffered from recurrent miscarriages and wish to be referred to one of the recurrent miscarriage clinics, talk to your GP or specialist.

Recurrent Miscarriage (RPL)

Recurrent Miscarriage, a devastating condition is also known as ‘Recurrent Pregnancy Loss’ (RPL). It is associated with reproductive problems with the parents, resulting in the loss of viable pregnancies. According to scientists from the Monash Institute of Medical Research and Sydney’s St Vincent’s Hospital, 5% of women will suffer two miscarriages or more.

Defining recurrent miscarriage

The recurrent miscarriage figures in NZ start from 3 miscarriages and are defined as being after 3 or more consecutive early miscarriages (before 13 weeks), or 2 late miscarriages (13 – 20 weeks) and all pregnancies must be by the same partner, which affects between 2%-3% of women. Only 1%-2% of these women do not go on to have a family according to statistics from various sources. The internet information can be confusing because in American they use two definitions of multiple miscarriages: Recurrent Miscarriage is; 3 consecutive losses (causes – immunological, haematological, physiological etc.). Recurrent Pregnancy Loss is; two miscarriages and is positively correlated to maternal/paternal age (i.e. egg/sperm quality). The first may be treated for, the second may eventually require IVF screening tests and development of a viable egg outside the womb – especially when time is running out e.g. either partner is over 35 years of age. 

Even with a second miscarriage, it is not generally a precursor to future problems and there is around a 72% chance that a third pregnancy will be fine. However, if you wish to take positive action, have some basic diagnostic tests done and treated when appropriate. It could be helpful and prevent further trauma, especially if the miscarriage is with the same partner and you suspect that you or he suffer from one or more of the listed ‘Why Miscarriages Happen’. You may need to be persistent and ask around for a medical professional who agrees.

After 3 consecutive miscarriages

After three consecutive miscarriages, testing is essential for chances of a normal pregnancy. In his report ‘Recurrent Miscarriage’, published in the medical journal The Lancet, UK Obstetrician Professor Gordon Stirrat wrote: ‘The risk of miscarriage increases with each successive pregnancy loss, however, some studies report a pregnancy ending in live birth reduces the risk of miscarriage in the subsequent pregnancy.’ His report gives the risks as 14-21% after one miscarriage; 24-29% after two miscarriages; 31-33% after three miscarriages. 

In many cases of recurrent miscarriage, the reason is found; however, in around 50%, nothing is ever discovered as the definitive cause. In one research study on this 50%, no specific treatment was offered except asking participants to remove as many stress factors as possible in their lives. How this was achieved is not described and the resulting 80% success rate is controversial. Scientists have also identified the gene NOS3 which appears to trigger repeated unexplained miscarriages in some women.  

15-minute procedure could end misery of miscarriage

The agony of repeated miscarriages may be prevented by a 15-minute procedure already being routinely offered in IVF clinics. In the technique, a tool called a pipelle is inserted through the cervix and used to scratch the surface of the womb – the endometrium.

But individuals have their own body rhythm, family history, stresses and circumstances. You may wish to address those that can be altered and make lifestyle adjustments to help yourself. Experiment with relaxing techniques and eat organic foods. Avoid as much stress as possible and perhaps stop work or shorten your hours. Generally, coddle yourself to whatever level you feel comfortable. It would only need to be for a short period and could be life-changing.

Miscarriage is also self-correcting to some degree with a spontaneous cure rate of 30%-50% so there is hope. Women who have suffered as many as six or seven miscarriages, can and do still go on to have a successful pregnancy. We also know of women with as many as 17 miscarriages who have had babies but that is not a situation that many would have the tenacity, courage or will to endure.

How to be tested for Recurrent Pregnancy Loss 

Testing for Recurrent Pregnancy Loss can usually be achieved through your local LMC or GP. Some NZ Public Hospitals have a specialised area now for women’s health which can include RPL testing and treatment like Wellington and Auckland – the latter has the ‘Recurrent Pregnancy Loss Clinic’ or you may wish to consult a private specialist or a clinic where payment is required.

The collation of test areas listed here for consideration may differ with each medical professional, facility or country and may not be offered to you or even be available in NZ for instance. Reading this information may help you and your partner participate in discussions with your LMC (Lead Maternity Carer). It gives you some understanding of the relevant options in your own personal situation and what may be medically involved. We have had contact with women with RPL (Recurrent Pregnancy Loss) who have gone to other countries when local testing wasn’t available or extensive enough.

NZ Midwives are now more likely to care for women who may lose their baby in early pregnancy. However a GP will probably still be the medical professional with the most helpful advice about your options for testing if you do not wish to consult a specialist.

• To assess the anatomy of the uterus and fallopian tubes, tests can include an hystersalpingogram or hystroscopy a laparoscopy or pelvic ultrasonography
• Ovum tracking with serial ultrasound scans and serial serum progesterone assays can help in diagnosing ovulatory factors (corpus luteum failure) – relative to a woman’s menstrual cycle.
• Complete Blood Cell count also known as Full Blood Cell count (CBC & FBC)
• evaluation for a hormonal deficiency in progesterone production (by either endometrial biopsy or blood tests)
• a maternal history which includes environmental and/or other toxin exposure
• analysis of the Karyotype, maternal and paternal chromosomes (by blood tests) for Down’s, Patau, Edwards and Turner’s Syndromes.
• mapping of chromosomes to detect genetic defects like cystic fibrosis, phenylketonuria and hyperthyroidism.
• a vaginal ultrasound and an endometrial biopsy 09.09
• testing for thyrotropin, antithyroid antibodies, prolactin, renal function and liver function
• lupus anticoagulant
• anticardiolipin
• autoantibody screen
• thrombocytopenia (low platelets)
• thyroid – Hyperthyroidism or Hypothyroidism. (LMC will ask relevant questions before activating tests)
• screening for genetic blood clotting disorders (paphyria and haemophilia)
• TORCH screening which means Toxoplasmosis, others, rubella, cytomegalumia, herpes and sometimes Hep. B.
• hair analysis to detect mineral deficiencies and or heavy mineral content
• sperm testing
• sperm DNA fragmentation test
• testing for chromosomal abnormalities in miscarriage tissue when available
• megar dilator paternity test
• AIDS

The following is an example of a reasonably standard GP’s work-up in NZ;

• CBC (complete blood count)
• Liver Function Tests
• Renal
• Thyroid function
• Glycaemic control
• Autoantibodies to ANA/ANF and dsDNA
• Anticardiolipin antibodies – IgG & IgM
• Thrombophilia Screen
• Chromosone Analysis (Karyotyping) – both you and your partner
• Antithrombin III
• Protein C
• APC resistance test
• Protein S

Additional suggestion (which costs to be tested for in NZ) is MTHFR – an enzyme responsible for methylation and many other health difficulties.

Frustratingly, there will always be some cases of recurrent miscarriage that will still remain unexplained; however, the prognosis for subsequent pregnancies in the unexplained group is often better than it is for couples where a cause has been found. So, if there are no abnormal test results it can often be good news.

Content supplied by Miscarriage Support