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Miscarriage

Details the treatment of recurrent miscarriages leading to pregnancy loss.


Treatment of recurrent pregnancy loss

The treatment of recurrent pregnancy loss depends on the results of the investigations taken to determine the cause of recurrent miscarriages. When the cause of recurrent miscarriage is unknown which is the case in about 50% of couples with recurrent miscarriage. The RCOG guidelines in the UK do not recommend the use of empirical treatments. Women with unexplained recurrent miscarriage have an excellent prognosis for future pregnancy outcome without any intervention if offered supportive care and regular ultrasound scans in the setting of a dedicated early pregnancy assessment unit. However, because of the emotional difficulties in managing couples with unexplained recurrent miscarriages, some specialists may in certain cases, recommend the use of interventions without proven clinical efficacy. .

  • If karyotyping showed chromosomal abnormalities, genetic counseling should be thought to give the couple enough information to decide whether to attempt another pregnancy with or without a prenatal diagnosis test , use donor sperm (if the male partner has the genetic problem), donated eggs (if the female partner has the genetic problem) and adoption. Furthermore, genetic counselling offers the opportunity for familial chromosome studies.
  • Women with persistently positive tests for antiphospholipid antibodies are offered treatments with low dose aspirin together with low molecular weight heparin during pregnancy and both are discontinued at 34 weeks. Heparin does not cross the placenta and hence there is no potential to cause fetal haemorrhage or teratogenicity. However, heparin can be associated with maternal complications including bleeding, allergic reactions, heparin-induced low platelet, when used long term, and vertebral fractures.
  • Metroplasty (corrective surgery of the uterus) is usually offered if it is thought that the uterine abnormalities is the prime cause of miscarriage. Open uterine surgery is associated with postoperative adhesions, infertility and carries the risk of uterine rupture during labor. These complications are less likely after hysteroscopic surgery.
  • If cervical incompetence is diagnosed, this is usually dealt with by inserting a purse-string suture around the cervix ( cervical cerclage) under a general or spinal anesthetic. at around 14 weeks. The stitch may then be removed at about 37-38 weeks or earlier if labor commences. The suture may be left in place and the baby is delivered by cesarean section. Some gynecologists advocate performing the operation before the woman conceive and through an abdominal cut. Cervical cerclage is associated with potential hazards related to the surgery and the risk of stimulating uterine contractions.
  • Myomectomy should be performed if a fibroid distorts the cavity and the woman has at least one-second trimester miscarriage.
  • Adhesions inside the womb are best treated hysteroscopically.
  • Progesterone or hCG treatment may be offered to women with low progesterone levels. At present, there are no proven benefit of such treatments in women with recurrent pregnancy loss.
  • hCG treatment may improve pregnancy outcome in women with oligomenorrhoea and recurrent miscarriage.
  • Some specialists offer treatments with high dose steroids, immunoglobulins or tumour necrosis factor blocking agents aiming to suppress and neutralise auto-antibodies, reduce natural killer cell activity, and to modifies cytokine production . However, no large randomized studies have confirmed such a benefit.
  • Lymphocyte immunization treatment (LIT) has been advocated by some specialists in the treatment of couples who share tissue type. LIT is made by extracting white cells from blood donated by the male partner or an unrelated donor. The prepared cells are injected under the surface of the skin and immunization will result in the formation of blocking antibodies in the recipient. This treatment is not endorsed by Royal college of Obstetricians and Gynecologists in UK or the Americal College of Obstetricians and Gynecologists. Furthermore, the treatment is expensive. The risks of intradermal LIT are low (Kling et al 2006).
  • Intravenous immunoglobulin infusion (IVIg) is a preparation of antibodies pooled from many blood donors; the serum is washed and processed. Recently Hutton et al reported a positive effect in the likelihood of a successful live birth when IVI g was given after confirmation of pregnancy to women suffering from secondary recurrent miscarriage (women suffering from recurrent miscarriage following at least one successful live birth) BJOG 2007. The infusion is repeated at 3-4 weeks intervals. Furthermore, the treatment is expensive. Although rare, serious and potentially fatal side effects include: anaphylactic reactions, meningitis, acute kidney failure, stroke, heart attack, and blood clotting complications (Hamrock 2006). This treatment is not endorsed by Royal college of Obstetricians and Gynecologists in UK or the Americal College of Obstetricians and Gynecologists.
  • Intravenous Lipid administration. Holschbach and colleagues (ESHRE 2014) reported the treatmnet with intravenous lipid might increase the live birth rates.
  • Preimplantation Genetic Diagnosis (PGS). This technique requires the use of the test tube baby technique (IVF) to test embryos for genetic disorders before it implants in the womb (uterus) have been recommended as an option for women with recurrent miscarriages. However, Gayathree Murugappan and colleagues from Stanford and Seattle USA (Human Reproduction 2016) reported that the clinical outcome including pregnancy rates, live birth and clinical miscarriage were similar in women who underwent GPS and women who received expectant management. This is probably due to the fact that the success rates of GPS is limited by the high incidence of cycles that intended to apply GPS and subsequently cancel it and by the cycles that do not reach embryo transfer.

After a miscarriage the woman may feel very anxious about becoming pregnant again, but it is important to remember that the vast majority of women will have a healthy pregnancy next time without any treatment.

Long-term prognosis after recurrent miscarriage

Two recent studies looked at the long-tem prognosis for prgnancy and live birth in women with recurrent miscariage. The Study by Lund and coleagues showed that 67% of women would experience a livr birth within 5 years. Another study by Kaandorp and colagues showed that 86% would achieve a pregnancy afte 24 months.

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