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Obstetrics and Gynecology / Reproductive Endocrinology and Infertility: Recurrent Pregnancy Loss (Recurrent Miscarriage)

Recurrent pregnancy loss - also known as recurrent miscarriage - is medically defined as the loss of three or more pregnancies within the first 20 weeks of gestation. However, many patients seeking treatment for recurrent pregnancy loss at Washington University School of Medicine often consult one of the school's physician specialists in reproductive endocrinology after experiencing two miscarriages.

FOR AN APPOINTMENT, CALL 314-286-2400, extension 1.

Patients may be referred by their primary care physician or obstetrician/gynecologist or may be self-referred.

The Washington University Infertility and Reproductive Medicine Center at Barnes-Jewish Hospital was the first such center established in the Missouri area to provide assistive reproductive treatment using in vitro methods. Personal case studies and information on what to expect can be found at their web site.

Specialists who diagnose and care for patients experiencing recurrent pregnancy loss include:

Randall Odem, MD- Director
Amber Cooper, MD
Emily Jungheim, MD
Sarah L. Keller, MD
Kelle H. Moley, MD
Valerie Ratts, MD
Where are patients seen?

Patients are seen in a private office building located at 4444 Forest Park Ave., Suite 3100, in St. Louis (at the corner of Forest Park and Newstead avenues.) Complimentary surface parking is available. Patients are issued a parking sticker.

What is the Washington University advantage ?
Washington University reproductive endocrinologists have wide experience in treating recurring miscarriage. They have the diagnostic skill and the technological resources to help with even the rarest problem.

They and their nursing staff are keenly aware of the physical and emotional stresses experienced by couples who have undergone recurrent pregnancy loss. Ample time is allotted in office appointments to address patient concerns and to offer support. Our staff is very much aware of the fear associated with this medical problem.

As a teaching and research institution, Washington University School of Medicine has participated in many multi-center trials of therapies used to treat recurrent pregnancy loss. Most recently, researchers at Washington University were able to disprove the efficacy of immunotherapy, an expensive treatment for recurrent pregnancy loss that is not covered by most medical insurance plans (See Drug Not Helpful)

COMMONLY ASKED QUESTIONS ABOUT RECURRENT PREGNANCY LOSS

What is recurrent pregnancy loss?

As described above, the strict medical definition of recurrent pregnancy loss is the loss of three or more pregnancies within the first 20 weeks of gestation. At Washington University School of Medicine, medical work-ups for recurrent pregnancy loss are offered on an individualized basis to patients who have experienced two miscarriages. Medical work-ups are strongly advised for patients who have experienced the loss of three or more pregnancies. To be considered recurrent pregnancy loss, the lost pregnancies do not have to be consecutive.

How often does pregnancy loss occur?

A woman's chance of miscarriage increases with her age. With increasing age, it not only becomes more difficult for a woman to get pregnant but to stay pregnant as outlined below:
  • In women ages 15 to 35, the incidence of miscarriage is between 10% and 12%.
  • In women ages 35 to 39, the incidence of miscarriage is 18%.
  • In women ages 40 to 44, the incidence of miscarriage is 33%.
  • In women ages 45-plus, the incidence of miscarriage is greater than 50%.
What is the most common cause of miscarriage in the general population?

Most miscarriages are the result of a random genetic abnormality. It is generally accepted that the earlier the loss, the greater the likelihood that the pregnancy was genetically abnormal in some way.

A recent study of women with recurrent pregnancy loss found their products of conception to be genetically abnormal 57% of the time. This same group conducted a study of women who miscarried without a history of recurrent pregnancy loss and found that 57 % of their products of conception were abnormal as well.

What is the likelihood of recurrent pregnancy loss?

Mathematical models suggest that the rates of recurrent pregnancy loss (the loss of three or more pregnancies) are much higher than what is seen clinically. Patients who have experienced a previous live birth and three pregnancy losses should anticipate a recurrence rate of miscarriage in their next pregnancy of 32%. Patients with no prior live births and three previous losses should expect a recurrence rate of 47%.

What are the common causes of recurrent pregnancy loss?

The list of causes of recurrent pregnancy loss (the loss of three or more pregnancies) and the incidence of each problem varies considerably, most likely because physicians tend to see patients with the types of problems that fall into their special area of interest. An attempted unbiased distribution of the causes of recurrent pregnancy loss follows:
  • Parental chromosomal abnormalities - 4%
  • Anatomic abnormalities - 20%
  • Luteal phase abnormalities - 20%
  • Autoimmune abnormalities - 10%
  • Thyroid abnormalities - 1%
  • Infectious/environmental reasons - unclear if relevant
  • Unexplained - 45%
What medical evaluations and treatments are offered for recurrent pregnancy loss?

Chromosomal abnormalities - Karyotyping (examining the chromosomes) of both parents to determine if they are predisposed to produce a genetically abnormal pregnancy is recommended for patients who have had three or more losses, even if they have a history of a prior normal child.

Even though chromosomal abnormalities may be identified, it does not mean that these patients will never be able to have a child. Karyotyping results may explain why a couple has experienced multiple miscarriages, but it is the rare genetic finding that eliminates any chance of success.

Anatomic abnormalities - Anatomic abnormalities include uterine duplications, intrauterine adhesions, fibroids and diethylstilbestrol (DES). Patients whose mothers took DES during pregnancy are at higher risk of anatomic abnormalities. Depending on the individual case, many of these abnormalities may be treated with hysteroscopic surgery.

Luteal phase abnormalities - An endometrial biopsy may be performed to diagnose a luteal phase abnormality. A small tissue sample is removed from the endometrium to confirm that the uterine lining is capable of supporting a pregnancy. The endometrial biopsy is performed one to three days before a menstrual period is expected to begin. Abnormal biopsies could provide an explanation for recurrent pregnancy loss. Persistent abnormalities may be treated with medications.

Autoimmune abnormalities - Tests may be ordered to screen for anticardiolipin (IgG and IgM) antibody and lupus anticoagulant. Abnormal results require that these tests be repeated several weeks later in a lab that is reliable for these assays. The diagnosis of Antiphospholipid Antibody Syndrome requires that both clinical and laboratory abnormalities are confirmed. Treatment usually consists of aspirin and/or heparin.

Thyroid abnormalities - Levels of thyroid-stimulating hormone (TSH) may be measured to determine if the thyroid gland is under- or over-functioning, either of which may lead to the loss of a pregnancy. Thyroid disease may be treated with medication; however, it is infrequently diagnosed as the cause of recurrent pregnancy loss.

Infectious/environmental/other causes - No infectious agent has yet been implicated as a cause for recurrent pregnancy loss in humans, but many practitioners recommend prophylactic doxycycline. Other than obvious environmental causes, such as radiation exposure, there is little data to link environmental factors to recurrent pregnancy loss.

Patients must be cautioned about smoking, alcohol and caffeine consumption. Medical research has found that women who smoke 14 or more cigarettes a day experience a significant increase in spontaneous loss. Alcohol use two or more days a week significantly increases the loss rate, with daily use causing the largest increases.

Many patients have been advised to avoid caffeine entirely; however, moderate consumption (two cups of coffee per day) is believed to be safe. One publication has suggested that caffeine consumption should be limited to less than three cups daily pre-conceptually.

Unexplained losses Nearly half of all patients who complete the above-described tests have no detectable abnormalities and are assigned the diagnosis of unexplained recurrent pregnancy loss. Options for these patients include stopping their attempts to become pregnant, adoption or trying again.

Most couples elect to try again and often turn to therapies that have been promoted as helpful but are unsupported by rigorous data, such as the immunotherapy treatment described above.

See Infertility: Finding Safe Therapies.











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Copyright 2013 Washington University School of Medicine