Miscarriage

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. The treatment options include aspirin, heparin, drug treatment by progesterone or hCG, insertion of a purse-string suture around the cervix, myomectomy, hysteroscopic surgery or metroplasty. When the cause of recurrent miscarriage is unknown, regular ultrasound scans, and tender love and care provide adequate support.

• If karyotyping showed chromosomal abnormalities, genetic counseling should be thought to give the couple enough information to decide whether to attempt another pregnancy, use donor sperm (if the male partner has the genetic problem), donated eggs (if the female partner has the genetic problem) and adoption.
• 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.
• 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 under general 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.
• 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 treatment with high dose steroids, immunoglobulins or tumour necrosis factor blocking agents for women that are found to have a high level of NK cells. 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).

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.

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