Recurrent Miscarriage & Treatment

Recurrent Miscarriage & Treatment

Recurrent miscarriage is defined as two or more consecutive clinical pregnancy losses, after which thorough examinations and tests are strongly advised to determine the cause. While the chance of miscarriage stands at 10-25%, the occurrence of recurrent miscarriage is much lower at 1-2%. The risk is relatively higher, however, for women over 35 or who’ve had previous miscarriages.

Recurrent miscarriage is different from infertility, which is an inability to conceive.

What Causes Recurrent Miscarriages?

Determining the primary cause enables the obstetrician or fertility doctor to provide the appropriate treatment plan to increase chances of future pregnancy and live birth. Possible causes of recurrent miscarriages are many and vary from case to case. These include:

  • Genetic Abnormalities – In around 50-80% of first-trimester pregnancy losses, the cause is a chromosomal abnormality affecting the embryo during the fertilization phase. It is a completely random occurrence not influenced by medical conditions or activities. It is also found that a small number of these cases stem from translocation in either the male or female partner, in which a piece of a chromosomal pair breaks off and attaches to another pair.
  • Congenital Disorders – Recurrent miscarriages may be caused by anatomical abnormalities such as a septate uterus, in which a septum (tissue wall) forms in the middle of the uterus and divides it into two sections, increasing the risks of a breech birth or miscarriage. An irregular-shaped womb or a weak and incompetent cervix also increases the chances of premature birth or miscarriage.
  • Medical and Gynecological Conditions – Certain medical conditions increase a woman’s risk of having one or multiple miscarriages. These include autoimmune illnesses such as thyroid problem, lupus and antiphospholipid syndrome that can produce sticky blood or clots that prevent blood from flowing to the placenta, thereby blocking the delivery of oxygen and nutrients to the baby. Hormonal imbalances can also affect the development of the uterine lining, which holds and sustains the embryo. Other conditions that affect probability of miscarriage are diabetes, fibroids, polyps, ovarian cysts and Asherman’s syndrome.

How Are Recurrent Miscarriages Diagnosed?

To determine the possible cause of multiple miscarriages, the specialist starts by assessing the patient’s medical history and previous pregnancies. A complete physical exam, which includes a thorough pelvic exam, must be done. In cases where tissue is passed during the miscarriage, the woman may be encouraged to preserve and send it immediately to the doctor for laboratory tests.

If a genetic abnormality is suspected to be the cause of miscarriage or infertility, a discussion as to which DNA tests are appropriate, a Comparative Genenomic Hybridisation or Karyotype testin is usually recommended. Carrier Screening for rare genetic diseases could also be offered especially if the family history is suggestive. Blood tests from both parents are collected and assessed to identify the number, size and shape of the chromosomes and the presence of absence of small additions or loss of DNA along the chromosomes. The current state of the art also offers the couple the chance to understand their risk of carrying genes which cause may cause genetic syndromes which are not necessarily identifiable at birth.

Imaging tests such as an ultrasound or MRI are done if miscarriages occur because of problems with the structures of the uterine or cervix. For instance, a hysterosalpingogram, which captures an X-ray image of the uterus and fallopian tubes, can show if the uterus has an irregular shape. Conversely a 3D ultrasound of the uterus is a possible optional imaging tool.

Additionally, blood tests are conducted to detect hormonal imbalances and autoimmune illnesses.

It is important to note, however, that despite the number of tests done, the percentage of patients who receive a clear and accurate diagnosis for recurrent miscarriage is only about 50%. The remaining half typically don’t get a definite diagnosis. Regardless of a diagnosis or the absence of one, chances of full-term pregnancies and live births after miscarriages can be as high as 80%, depending on the mother’s age.

What Are the Treatment Options for Recurrent Miscarriages?

For recurrent miscarriage cases with a clear diagnosis, treatment options range from simple lifestyle changes to major surgeries.

Genetic counselling is recommended for couples in cases where chromosomal errors play a huge part in miscarriages. In the case where translocation is involved, an effective solution for couples is in vitro fertilization (IVF). IVF in Singapore particularly entails preimplantation genetic diagnosis (PGD), in which an unaffected embryo is selected for implantation. This also reduces the risk of the baby inheriting a genetic condition such as Huntington’s disease, thalassaemia or cystic fibrosis.

For congenital defects such as an abnormally-shaped uterus or septate uterus, surgery may be recommended to correct them. This is also suitable for removing fibroids, polyps and scar tissue that endangers pregnancy outcome. Cervical weakness or incompetence is usually addressed by a cerclage, in which a suture or synthetic tape to support the hold of the cervix.

Medicines are prescribed for patients with autoimmune or hormonal conditions. Lupus and antiphospholipid syndrome, which cause blood clots, can be treated with blood-thinning prescriptions like aspirin. Hormonal imbalances are remedied with progesterone supplements or dopamine activators.

Lifestyle changes, including maintaining a healthy weight and stopping smoking and drinking alcohol and caffeine, and drug use, can greatly reduce the risk of miscarriages.

After miscarriages, a lot of couples can get pregnant naturally. However, in some situations, medically assisted fertilization such as IVF may increase their chances of conceiving and preventing miscarriages or other complications especially where age and time is becoming more urgent.

Dr. Ann Tan from Women Fertility & Fetal Centre offers comprehensive diagnostic and treatment options in the fields of obstetrics, gynaecology and infertility to help mothers achieve a successful pregnancy. Schedule an appointment today. Call 6734-8188.


Dr Ann Tan
Dr Ann Tan, PBM
Obstetrician & Gynaecologist
MBBS (S'PORE), FRCOG (LONDON),
M MED (O&G) FAM (SINGAPORE)
Dr Ann Tan is the first Singaporean to hold the Diploma of Fetal Medicine from the Fetal Medicine Foundation. She presently serves on the Women’s Health Advisory Committee at the Health Promotion Board. Dr Ann Tan was a Public Service Commission Scholar, and has won several prestigious awards in her field of specialization.
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