Recurrent miscarriage

Division of Reproduction

Incidence

• 10–15%

of all clinically recognized

pregnancies end in a miscarriage

• theoretical risk of three

consecutive pregnancy losses
should be

0.34%.

• true incidence is actually greater

than that: recurrent miscarriage
affects

1%

of all women

Affecting factors

• Previous

obstetric
al
history

• First pregnancy

5%

• Last pregnancy terminated 6%
• Last pregnancy a live birth 5%
• All pregnancies live birth 4%
• 1 previous miscarriage 20%
• 2 previous miscarriages 28%
• 3 previous miscarriages

43%

But 1 out of 36 women who have

miscarried 2 times have no

underlying cause

Affecting factors

• Maternal

age

• <35

6,4%

• 35-40

14,7%

• >40

23,1%

Maternal age and obstetric

history

• A 20 year old women with 2

miscarriages has 92% chance of
success in next pregnancy

however

• A 40 year old women with 3

miscarriages has only 64% chance
of success

Causes

• Genetic
• Anatomic
• Endocrine
• Coagulation
• Immunologic
• Infection

Genetic causes

• 3-5% of patients with recurrent

miscarriage are carriers of
balanced structural
chromosomal anomaly

• Reciprocal translocation

• Robertsonian translocation

(13,14,15,21,22)

Genetic causes

• Risk of having a life birth with

unbalanced translocation is 1-15%

• Depends upon

» Type of chromosome
» Size of the segment involved
» Family history
» Sex of the parent

• With 1 carrier of translocation the

risk of S.A. is 25-50%

Anatomic causes

• Uterine anomalies – 1,8-37,6%

• Myomas – 25% of women of

reproductive age

• Polyps

• Cervical weakness

Uterine anomalies

Uterine anomalies

Uterine anomalies

Myomas

Polyps

Cervical weakness

• Definition

• Obstetrical history

Endocrine causes

• Diabetes mellitus

» Not in well controlled; asymptomatic

women

• Thyroid anomalies

» Mostly antibodies

• Luteal phase defect

» Biopsy

• PCO

» 41%

in RSA vs 22% in general population

» High LH

Thrombophilic causes

• Activated protein C resistance
• Factor V Leiden mutations
• Deficiencies of C/S proteins
• Deficiency of antithrombin III
• Hyperhomocysteinemia
• Prothrombin mutations

Immunologic causes

• Autoimmunologic

» LA and ACA
» Antithyroid antibodies

• Alloimmunologic

» HLA sharing/incompatibility

Infection ?

• TORCH

• Acute phase of a disease

How to test?

• Genetic

» Peripheral blood karyotyping
» Cytogenetic studies of the fetuses

• Anatomic

» US (2D, 3D)
» HSG
» Hydro-sonohysterography

• Endocrine

» DM and thyroid if symptomatic
» biopsy

How to test?

• Thrombophilic

» Symptomatic women
» Asymptomatic?

• Immunologic

» ACA always
» HLA – doubtful

What to do?

• Genetic

» referral to clinical geneticist
» Oocyte/sperm donation programs
» PGD

• Anatomical

» Uterine surgery – hysteroscopy
» Cervical cerclage

• Endocrine

» DM and thyroid – control

• Thrombophilic

» ASA, LMWH

What to do?

• Immunological

» ASA, LMWH
» IV antibodies?
» HLA therapy?

Tender Loving Care

Despite all the diagnostic test still in

about

40-60% of RSA patients

we can not find a cause

Attendance at dedicated miscarriage

clinic has a beneficial effect