| from
the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani,
MD.
Previous page:
Secondary Infertility -- Caught Between Fertile And
Infertile Worlds
Next page: Understanding
Your Medicines
Table of Contents
How
are abortions classified medically ?
How
often do abortions occur ?
What
are the causes of repeated abortions ?
How
do chromosomal abnormalities cause miscarriages ?
How
do hormonal imbalances cause miscarriages ?
Which
illnesses can cause repeated abortions ?
How
does PCOD cause repeated miscarriages ?
How
do immune problems cause repeated abortions ?
How
do antiphospholipid antibodies cause repeated abortions
?
How
do uterine problems cause repeated abortions ?
Can
lifestyle factors cause repeated abortions ?
What
about the emotional aspects of dealing with repeated
abortions ?
What
should you know about planning your next pregnancy after
you have had an abortion ?
What
are the treatment options for women who have had repeated
abortions ?
What
are the chances of having a healthy baby after repeated
abortions ?
How are abortions classified
medically ?
An extended definition
of infertility includes women who conceive but cannot
carry a pregnancy to term - women who have repeated
miscarriages. The technical term for this is recurrent
pregnancy loss. This is one of the most frustrating
problems in reproductive medicine medicine today , because
we still do not understand it well. Patients with repeated
miscarriages have hundreds of questions - and we still
do not have the answers !
The medical term for a miscarriage is
an abortion. Most miscarriages start with vaginal bleeding
which is initially slight and painless. This is called
a threatened abortion, because the pregnancy is threatened
by the bleeding. This bleeding is from the mother, and
is not fetal blood. About half the time this stops spontaneously
and results in no harm to the pregnancy. At this stage,
the most useful test is an ultrasound scan (usually
done with a vaginal probe). If a fetal heartbeat can
be seen, this means that there is a 95 % chance that
the pregnancy will proceed normally. On the other hand,
if the ultrasound scan shows that the fetus has not
developed properly ("blighted ovum " or anembryonic
pregnancy when no fetus can be seen; or a missed abortion
or intrauterine fetal death when the fetus is seen but
the heart is not beating, then nothing can be done to
save the pregnancy.
In such cases, the bleeding progresses,
and the uterus starts contracting. This is felt as painful
cramps, and the mouth of the uterus ( the cervix) opens.
This is called an inevitable abortion (because it cannot
be stopped). If some of the pregnancy has already been
pushed out by the contractions, this is called an incomplete
abortion.
In patients with a blighted ovum, missed
abortion, inevitable or incomplete abortion, the treatment
is a uterine curettage (D&C) - a short surgical
procedure which is performed to empty the uterus and
remove the pregnant tissue.
Abortions which occur in the first twelve
weeks of pregnancy are called first trimester abortions.
Those which occur between the 13th to 20th weeks are
called second trimester abortions.
How
often do abortions occur ?
Perhaps 20-30% of all women spot, bleed or suffer cramps
during their first twelve weeks of pregnancy, and about
10% miscarry. This figure may be an underestimate, because
there are a number of women who miscarry unknowingly,
thinking that their period was late or heavy. It is
very common for women to have one miscarriage during
the first twelve weeks of their pregnancy . The commonest
reason for a first trimester miscarriage is a genetic
defect in the embryo. This is actually Nature's defense
mechanism, to prevent the birth of a baby with a birth
defect. The genetic error is a random event which
happens by chance , and occurs because a genetically
abnormal egg or sperm gets fertilised. This is not a
sign that they have a health problem, because
most of them will probably have a healthy baby the next
time they get pregnant without any treatment. This is
why most doctors will not do any testing for couples
who have had a single first trimester miscarriage -
the testing is usually not cost effective, and rarely
provides any useful information.
If however, a patient has had two or
more miscarriages consecutively, this is called repeated
or habitual abortion. Now although the risk of miscarrying
again does increase, this risk is still quite small,
and increases from the 15% risk a normal woman has to
35% - which still means there is a 65% chance that they
will not have a miscarriage again.
Most women who miscarry do so only once.
Their risk for miscarrying again is not increased and
is the same as that of a normal woman's - about 15%
Women who are over thirty five are no
more liable to miscarry
Travelling, lifting weights and sex
does not threaten a healthy pregnancy. As the old saying
goes, " You cannot shake a good apple off a tree."
If you've had a previous miscarriage,
it is very normal to be frightened and worried during
your next pregnancy. It is important to understand that
exercise, working and intercourse do not increase the
risk of pregnancy loss. Likewise, staying at home and
resting in bed probably do not prevent miscarriage.
What are the causes
of repeated abortions ?
Repeated miscarriages can happen because of any of the
following:
- Chromosomal abnormalities
- Hormone imbalance
- Physical Illness
- Polycystic Ovary Syndrome
- Immune problems
- Antiphospholipid antibodies
- Problems in the uterus
- Life style of the woman
Let's discuss these in detail.
How do
chromosomal abnormalities cause miscarriages ?
Chromosomal Abnormalities
At least 60% of spontaneous miscarriages occur because
of a chromosomal abnormality at conception. This means
that a genetically (chromosomally) defective sperm or
ovum gives rise to a genetically abnormal fetus. The
miscarriage is Nature's defense mechanism, which aborts
a defective fetus, rather than giving birth to a defective
baby. Since most of these genetic defects are chance
occurrences, the risk of it being repeated again in
the next pregnancy is very small.
In order to establish the diagnosis
of a genetic cause for repeated pregnancy loss, a karyotye
(study of the chromosomes) of the fetal tissue (if available)
may be done. It is expensive, and often the cells fail
to grow in culture, so that the study may not be possible.
Moreover, since little can be done even if a defect
is detected, it has little impact on patient management.
However, it does provide an explanation for some patients
with recurrent pregnancy loss.
In about 5 % of couples, a chromosome
abnormality found in one of the parents explains recurrent
miscarriage. This is detected by doing a chromosomal
study on the parent's blood. The commonest problem is
a structural defect (break or loss of a piece of the
chromosome, called a deletion; a rearrangement of a
bit of a chromosome, called a translocation ) .
If the karyotype is normal, then the
patient can be reassured that the miscarriages were
a chance genetic event, and they can feel comfortable
continuing with their efforts to have a baby. However,
if the karyotypes are abnormal, this is a permanent
situation, which indicates an increased risk of miscarriage.
Genetic counselling should be sought to discuss the
degree of risk. Depending upon the individual problem,
this risk may be anywhere from 25% to 100%. Since chromosomal
rearrangement at conception (when the sperm fertilises
the egg) is a random event, there is little which can
be done to treat this. Options may include: continuing
to try to conceive a baby naturally; adoption; donor
eggs (if you have the genetic problem) or donor sperms
(if the husband has the genetic problem).
How do hormonal
imbalances cause miscarriages ?
Hormone Imbalance
Patients may miscarry because they have a luteal phase
defect - that is, the amount of progesterone hormone
produced after the egg is released is reduced. Progesterone
is the hormone which supports the pregnancy. It helps
implantation of the embryo in the uterus and if this
is deficient, there can be a problem with the embryo
lodging itself in the uterine lining.
A luteal phase defect is suspected if
the menstrual cycles are short - especially if the luteal
phase (the time of the menstrual cycle between ovulation
and the next menstruation) is shorter than 12 days.
This diagnosis can be confirmed by a
blood test (a serum progesterone level done one week
after ovulation is low) and an endometrial biopsy (which
will show that the endometrium is "out of phase").
The doctor can help provide luteal support
by prescribing progesterone during the last two weeks
of the menstrual cycle after ovulation. If the woman
is already pregnant, treatment may be with vaginal suppositories
of natural progesterone for the first twelve weeks of
the pregnancy; or progesterone injections intramuscularly.
However, this treatment is controversial.
Which illnesses
can cause repeated abortions ?
Illnesses
Health problems that can cause repeated miscarriages
are:
- Uncontrolled thyroid disease, especially
hypothyroidism
- Severe heart, liver or kidney disease
- Systemic lupus erythematosus an illness
in which the woman produces antibodies against her
own body tissues.
What about TORCH Infections? Certain
infections called TORCH ( which stands for TOxoplasmosis,
Rubella, Cytomegalovirus and Herpes) , may be a cause
for a single miscarriage, but are NOT a cause for repeated
miscarriages. While a number of specialists will do
these tests, and even start treatment based on the results,
these tests are not worthwhile for patients who undergo
habitual abortion. They just waste a lot of the patient's
time and money.
A positive TORCH test simply means the
patient has positive antibody levels against that particular
infection. Thus, a positive Toxo IgG test means that
the patient has anti-toxoplasmosis antibodies which
protect her against a repeat toxoplasmosis infection.
This means a positive test is actually a good sign and
suggests that the patient is protected against that
infection because she has been exposed to that infection
in the past. Unfortunately, many doctors do not know
how to interpret these results and scare the patient
into thinking that the positive test result means she
has an active infection which can cause her to miscarry
again. In fact, some doctors will even attempt to "treat"
the "infection" ! This wastes time and causes needless
distress. If your doctor asks you do a TORCH test after
a miscarriage, you should refuse and find a better doctor
!
Although infections of the uterine cavity
(for example, due to mycoplasma) are frequently thought
to be a cause of recurrent pregnancy loss, substantial
proof of this is lacking. Studies have in fact failed
to indicate a greater incidence of infection in women
with a history of miscarriage when compared to normal
fertile women.
How does PCOD cause
repeated miscarriages ?
Polycystic Ovary Syndrome
Exciting research done recently by Dr Howard Jacobs
at the Middlesex Hospital, London, shows that polycystic
ovary syndrome can also be a cause of recurrent miscarriages.
In PCOS, the ovaries produce a large amount of the LH
hormone. PCOS patients also have insulin resistance,
and the high LH levels and high insulin levels have
a detrimental effect on the egg, so that at the time
of ovulation, the egg which is released is overripe
and unhealthy. If such an egg is fertilised, the embryo
is also likely to be unhealthy, and is consequently
rejected by the body after 6-8 weeks as a miscarriage.
Treating the abnormal insulin resistance in PCOD patients
who have had repeated miscarriages with metformin helps
many of them to have healthy babies . The interesting
point of these studies is that it tells us that we should
also be focussing on what is happening at the time of
fertilisation - and not just what goes on after the
pregnancy. Problems with the eggs and sperms at the
time of fertilisation will manifest themselves as a
miscarriage later on, but these are often neglected
by the doctor.
How do immune
problems cause repeated abortions ?
Immunity problems
The immune system plays an important protective role
in maintaining health throughout life, by defending
against infection. It "rejects " the foreign invaders
(bacteria, viruses) which are recognised by the body
as being "outsiders". It is now becoming evident that
inappropriate activation of the mother's immune system
may cause early first trimester miscarriages.
Current theory suggests that during
a normal pregnancy, the fetus, which carries the father's
foreign genes (and is therefore immunologically foreign
to the mother) can nevertheless survive in the mother'
uterus because of a special protection from the mother's
immune system - the uterus is a "privileged" site. This
is why it is not "rejected" like other foreign tissues
(such as kidney transplants) are. This means that in
the normal course of events, the fertilised egg somehow
stimulates a protective maternal immune response which
allows implantation and growth. For certain couples,
this protective response does not occur, and the maternal
immune system rejects the father's foreign material
in the fetus, resulting in miscarriage. Tests are available
to check for this, but these are still in the experimental
stage. Treatment is in the research phase too, and includes
sensitising the mother to the father's genes, by injecting
his blood cells into her skin, the theory being that
exposure to the foreign cells will stimulate her immune
system to provide the normal protective immune response
when she gets pregnant.
How
do antiphospholipid antibodies cause repeated abortions
?
Antiphospholipid antibodies
Some women produce antibodies against the circulating
substances that cause blood clotting. These are called
lupus anticoagulant or anticardiolipin or antiphospholipid
antibodies. They severely inhibit fetal development
(by blocking off the blood supply to the fetus by causing
clots in the maternal-fetal circulation) and cause miscarriages.
Their presence can be detected by a blood test. Treatment
is possible, either with low doses of aspirin (which
decreases the clot formation); or with a steroid (prednisone)
which suppresses the mother's abnormal immune system.
How do uterine
problems cause repeated abortions ?
Problems in the Uterus
Miscarriages because of uterine problems usually occur
after the twelfth week. These could be because of :
- A congenital abnormality of the uterus,
which the woman is born with, but which does not cause
any problems, until she gets pregnant . The common
types of uterine anomalies include: a septate uterus
( in which a wall divides the uterine cavity); a unicornuate
uterus, in which the uterus has only one horn , because
only one half has developed properly; and a bicornuate
uterus, in which the uterus has two halves or horns,
because the two did not fuse normally during their
development in utero). This abnormal uterus
cannot grow normally to hold and retain the pregnancy
and this is consequently expelled. In women with a
septate uterus , if the embryo implants on the abnormal
tissue of the septum, the pregnancy may miscarry because
the septum cannot support a pregnancy.
- Fibroids, which are growths of smooth
muscle tissue inside the uterus. While most fibroids
will not mar a pregnancy, if the fibroid is very close
to the lining of the uterus ( submucous fibroid),
it will interfere with the implantation of the embryo
in the uterus, and will cause its expulsion.
- Intrauterine adhesions ( Ashermann's
syndrome). These are uncommon, and are fibrous bands
of scar tissue in the uterus, which interfere with
implantation of the embryo. They may be formed after
a uterine curettage (after an abortion) and can be
diagnosed by hysteroscopy or hysterosalpingography.
They can be removed by hysteroscopic surgery, allowing
uneventful pregnancies in the future.
- Incompetent os, in which the cervix
(mouth of the womb) is weakened. When the growing
fetus presses on it, the weakened cervix opens, leading
to expulsion of the growing foetus. This condition
may be congenital; or because of a cervical tear or
injury during previous pregnancy or miscarriage; or
could be a result of over enthusiastic surgical dilatation
of the cervix during previous surgery. The insertion
of a cervical stitch, called the Shirodkar stitch
after the Indian doctor who discovered this condition
and invented the surgical operation to correct it,
can be very effective. The cervical stitch is a simple
surgical operation, usually done after 12 weeks of
pregnancy after an ultrasound shows that the baby
is healthy ; and it helps by strengthening the weakened
cervix. The stitch is removed two weeks before the
baby is due, or when labor starts, whichever is first.
Diagnosis of these anatomic defects
can be made by hysteroscopy or hysterosalpingography.
An ultrasound examination can suggest a problem exists,
but usually cannot provide a definitive diagnosis. Newer
imaging techniques such as 3-D ultrasound or MRI scanning
can also provide useful diagnostic information.
Can lifestyle
factors cause repeated abortions ?
Lifestyle
If patients are regularly exposed to toxic fumes and
chemicals (example, workers in chemical factories ;
or nurses and anesthetists in operating rooms) these
could damage the developing fetus (which is very sensitive
to poisons) and cause a miscarriage. Recent studies
show that even men exposed to environmental toxins can
cause their partner to miscarry a fetus (presumably
because their sperms are damaged by the toxins). Smokers,
alcoholics and drug abusers also have an increased incidence
of miscarriages.
What
about the emotional aspects of dealing with repeated
abortions ?
Human society still tends to dismiss miscarriage complacently;
it is a subject which is rarely discussed. A foetus
for most people is a non-person and a miscarriage is
a non-event. But, to the would be parents, the developing
fetus is a baby with an identity, especially if you
have seen it on the ultrasound screen and heard its
heart throbbing with a Doppler. When the child is lost,
it is a bereavement and your sense of loss, tinged with
pain, anger, isolation and depression, can be profound
- especially when it follows a long period of infertility.
After a miscarriage, it is normal to
experience a period of grief. Find support from each
other; and from others who have had a similar experience.
Healing does happen in time. Focus on getting through
the grieving rather than on the suffering.
What
should you know about planning your next pregnancy after
you have had an abortion ?
After a miscarriage, making the decision to go in for
another pregnancy is difficult. Collect as much information
as possible to try to find out the possible causes of
the loss and whether they might influence a future pregnancy.
If you have had 2 or more miscarriages,
then tests are usually done to try to find a cause.
These include the following:
- Hysterosalpingogram or hysteroscopy
to make sure there are no defects in your uterus (womb)
- Blood tests, such as serum progesterone,
to rule out a luteal phase defect
- Blood tests for antiphospholipid
antibodies (lupus anticoagulant)
- The VDRL (Venereal Diseases Reach
Laboratory) blood test, for sexually transmitted diseases
- Karyotype, for you and your husband,
to rule out chromosomal abnormalities.
The doctor may also want to send the aborted tissue
for chromosomal study, to find out if the fetus was
chromosomally normal or not.
Often many doctors will do what is called
a "TORCH" test - but this is a a waste of money for
most patients, since it provides little useful information.
When to start the testing depends upon
you. While few doctors would do anything after one miscarriage
(since your chance of having a healthy pregnancy even
without tests and treatment is better that 85%), most
would start a workup after two miscarriages. Often,
nothing is found, and this can be very frustrating to
the doctor and patient. But do remember that medical
technology has it's limitations, and we still do not
know a lot about the early embryo and its development.
What
are the treatment options for women who have had repeated
abortions ?
What about treatment? Sometimes it is
possible to treat the underlying problem - for example,
by taking a cervical stitch to treat an incompetent
os; or removing a uterine septum by hysteroscopic surgery.
In our experience, we have found that
many women with recurrent pregnancy loss have occult
PCOD ( polycystic
ovarian disease) , which is usually not diagnosed
correctly. We have found that the following empiric
treatment, based on experience, helps treat many women
who have experienced recurrent early pregnancy losses:
Metformin, 1500 mg daily; folic acid, 5 mg daily; and
low dose aspirin, 50 mg daily. When they conceive, we
continue all the above; and also add 600 mg vaginal
progesterone suppositories daily till 20 weeks.
Often the only option for many women
is to try again. Remember, even if you have had 3 or
more miscarriages, your chance of carrying the next
baby to term is still more than 50 % - even with no
specific treatment, and just tender loving care!
Deciding when to start the next pregnancy
is a decision only you can make. It takes a lot of courage
and both of you need to be ready.
Your next pregnancy probably won't be
as joyful as you would like. Insist that your pregnancy
be monitored carefully. Whenever the slightest problem
occurs, you'll feel vulnerable and terrified - but don't
panic.
Everyone will make suggestions about
what you should do to make your pregnancy successful.
This can be annoying - but remember they are doing it
because they care! The easiest way to handle this is
to listen, and then do what you and your doctor feel
is best for you.
Your child birth experience can be bittersweet
- memories surface about your loss, especially if you
are at the same hospital. You probably will need to
do some grieving in addition to celebrating the new
life.
The experience of miscarriage will also
affect your parenting. Bonding with your child may also
be delayed because you feel the need to protect yourself
from more sorrow - so you wait till you are certain
that all is safe and sure with your baby. Moments of
panic will occur when the baby is ill or too quiet or
with someone else. You are also likely to treat your
children as "extra special" - and be less objective
than other parents.
What
are the chances of having a healthy baby after repeated
abortions ?
If you've experienced recurrent miscarriage,
you may feel hopeless and confused regarding a positive
pregnancy outcome. Remember that miscarriage is not
an uncommon event. Your testing will focus on trying
to find out the known causes of recurrent miscarriage.
But knowledge of this problem is still limited, and
no obvious cause is detected in upto 50% of couples
with repeated pregnancy loss. This can be very frustrating
- both to the patient and the doctor. The encouraging
news is that the spontaneous cure rate is very high;
and successful treatment is available for treating certain
uterine and endocrine causes. So even if your evaluation
does not reveal a treatable cause and you do not undergo
treatment, your chance of achieving a healthy pregnancy
despite having had several miscarriages in the past
is still better than 50% - and the only "treatment "
you need is tender loving care !
Next page: Understanding
Your Medicines
Previous page:
Secondary Infertility -- Caught Between Fertile And
Infertile Worlds
Table of Contents
|
