Recurrent Pregnancy Loss
	Psychologic Impact
	Investigations
	Treatment

Recurrent Pregnancy Loss

Recurrent pregnancy loss (RPL) is generally defined as having had three or more consecutive pregnancy loses prior to 20 weeks gestation. RPL affects between 3% and 5% of couples. RPL becomes more prevalent with increasing female age, with an incidence of 10% to 15% in women in their twenties, rising to over 33% for women in their forties. In at least 50% of miscarriages, the fetus is chromosomally or genetically abnormal. It is nature’s way of preventing an abnormal baby from being born. Genetic abnormalities of the embryo may occur due to chance or secondary to chromosome aberrations in the parents. Other causes of RPL include abnormalities in the shape of the uterus. These uterine abnormalities may be due either to an abnormality present at birth or caused by benign tumors such as fibroids. Miscarriages may also occur as a result of intrauterine scarring caused by surgery and/or infections. A common cause of pregnancy loss is inadequate hormonal preparation of the lining of the uterus for pregnancy, caused by a “luteal phase defect”. In a small percentage of cases, antiphospholipid antibodies may be found in the maternal blood or alternately other coagulation disorders which when present can predispose to blood clotting in the afterbirth site, causing pregnancy loss.

Psychologic Impact

It is known that one miscarriage can cause significant psychologic grief for a couple and it is particularly difficult when a number of miscarriages happen. This may be made even worse if RPL is associated with infertility and increasing maternal age. It is common for couples to feel a sense of significant loss, emotional upset and helplessness after miscarriage. It can often be helpful for a couple in this situation to attend a self-help group or see a counselor. A referral will commonly be made to the RPL clinic after two or three consecutive losses. This RPL clinic is a service offered at the Regional Fertility Program. It is important in this context, to be followed carefully during subsequent pregnancies with serial ultrasounds and frequent clinic visits. This is particularly helpful from a psychologic viewpoint, as well as in determining the well-being of the pregnancy and discovering any factors that may contribute to future loss.

Investigations

The following investigations may be ordered by your physician: An x-ray of the uterus or hysterosalpingogram may be performed to ensure the uterine cavity is normal. A small portion of tissue from the lining of the uterus, called an “endometrial biopsy”, may be taken to ensure the lining of the uterus is appropriately primed for the embryo to implant. This is analogous to the “soil” and “seed”; the soil being the lining of the uterus and the seed being the embryo. A genetic test or chromosomal test may be obtained from both partners to ensure there is no genetic abnormality, which is being passed on to the fetus that may cause RPL. This is a relatively uncommon cause of loss and is found in approximately 3% of couples. Tests may be performed for blood clotting antibodies and blood clotting coagulation disorders. It is important to understand that in 50% of cases of RPL, no apparent cause will be found.

Treatment

In many cases, when a uterine abnormality is found, it may be corrected by surgery. If an implantation problem is present, this can be corrected with medication (i.e. clomiphene citrate or progesterone suppositories). If a genetic problem is found in one parent a referral will be made to a specialist in genetic medicine for counselling. If clotting antibodies or an increasing coagulation tendency is present, blood thinners called heparin will be given during future pregnancies to prevent blood clots forming around the afterbirth.