Miscarriage

Miscarriage is a very common problem that many women will experience. Miscarriage is more common with advancing age: 15% of all pregnancies under 35, 28% age 35-45, and 50% over 45. Many miscarriages can be prevented. A thorough medical evaluation can be helpful, especially for women who have suffered recurrent pregnancy loss. Monitoring the cycle through NFP can uncover abnormalities that can lead to miscarriage. Preventing the heartbreak of miscarriage is preferable to waiting until one or more pregnancy losses have occurred! This discussion will emphasize first trimester pregnancy loss, but many of the concepts are applicable to loss later in pregnancy.

Hormonal abnormalities are among the most treatable causes of miscarriage. Deficiencies in progesterone as a cause of infertility and pregnancy loss have been known since the late 1940’s. The very name progesterone was developed because of its necessity for supporting pregnancy – the hormone is PRO GESTational. Progesterone rises in the last half of the menstrual cycle and prepares the uterine lining for pregnancy. During pregnancy, progesterone levels increase, preventing uterine contractions, and having an autoimmune effect. To prevent pregnancy loss in vulnerable women, it is best if progesterone therapy is begun in the conception cycle, but it can often be helpful when begun later and can even rescue a troubled pregnancy.

There has been confusion because some recent medical studies have concluded that progesterone is not useful when given indiscriminately in threatened miscarriage. But there is no question that progesterone is therapeutic for women with low progesterone levels. The most useful research on progesterone levels in normal pregnancy and pregnancy loss have been done by Dr. Thomas Hilgers of the St Paul VI Institute in Omaha, NE. When progesterone levels are measured, there is a large range of “normal” which reflects 90% of women. But “optimal” levels are higher, above the 50th percentile. Levels must be in higher ranges to guarantee that pregnancy loss will not occur; some loss will occur at low “normal” levels and certainly at abnormally low levels, though. some embryos will have the ability to survive abnormally low progesterone levels.. The gold standard for progesterone treatment during pregnancy is the Hilgers protocol using progesterone injections. However, vaginal and high dose oral progesterone can also be used. Over-regulation of pharmacies has made progesterone injections more difficult to obtain, so oral and vaginal progesterone have become more common. Often supplementing progesterone in the first trimester is sufficient. In the late first trimester progesterone production shifts from the ovary to the placenta (the “luteo-placental shift”)and it is often assumed that the placenta will produce adequate progesterone. However, there is no guarantee that this shift will be adequate, so it is better to measure progesterone levels until there is more certainty adequate levels are being maintained.

The hormone Estrogen, present throughout the menstrual cycle, builds up the uterine lining, and is also important for miscarriage prevention. A thin uterine lining from low estrogen may lead to early pregnancy loss. This is more common after age 35 or in very thin women with less than 17% body fat.

Adequate regulation of the blood sugar and insulin is also important. “Insulin resistance” often goes unrecognized. This pre-diabetic state with high insulin levels can cause extreme blood sugar shifts. It is common in overweight women and those with PCOS. Metformin, a medication used for PCOS (and diabetes), lowers insulin and blood sugar levels and is known to prevent first trimester miscarriage. In addition, high blood sugar or insulin levels can indirectly lead to pregnancy loss by diminishing ovarian progesterone production, or by preventing testosterone from converting to estrogen.

Abnormal Thyroid hormone levels can contribute to miscarriage. One common condition, Hashimoto’s or autoimmune thyroiditis, in which anti-thyroid antibodies are present, is often under treated in reproductive age women. At times Hashimoto’s can appear benign when thyroid hormone levels are normal (“euthyroid Hashimoto’s”) even though antibodies are present. Watchful waiting is often recommended in such cases. However, pregnant women with “euthyroid” Hashimoto’s have more miscarriages unless they are treated with thyroid hormone. Thyroid hormone requirements rise very rapidly in early pregnancy. If a woman with Hashimoto’s is not on thyroid medication before pregnancy, preventable early pregnancy loss may occur even before the pregnancy is recognized.

Autoimmune conditions are a common cause of pregnancy loss. In many of these conditions, antibodies from the woman’s blood cause miscarriage and blood clots., or sometimes poor fetal growth. Antiphospholipid syndrome* is the most widely recognized and agreed upon cause of miscarriage. The most common treatment is enoxaparin (Lovenox), a blood thinner. There is also a large category of other antibodies which are less well understood.** Sometimes these disorders are treated with Lovenox or baby aspirin, but opinions vary widely among physicians. Corticosteroids (prednisone or prednisolone) for abnormal natural killer cell response are another controversial treatment for implantation failure and very early pregnancy loss, often thought to be of immune origin. Anecdotal reports of Low Dose Naltrexone indicate this treatment can be helpful for immune pregnancy loss. Additionally, abstaining from foods provoking an immune response, such as gluten, can be helpful in women with celiac disease and sometimes other food sensitivities. This is a rapidly evolving field and there is still much that is not well understood.

Infections are a treatable cause of miscarriage. Ureaplasma and Mycoplasma are microorganisms known for causing early miscarriage, premature delivery, and infections of the placenta and fetal membranes, as well as other genital infections in women and men. Sometimes these organisms merely colonize and do not cause infection, but always have the potential create inflammation or pregnancy loss. Testing and treatment should be more frequently utilized. In addition, bacterial vaginosis (BV) is known as a cause of late miscarriage, ruptured membranes and premature delivery. It should be vigorously treated before and during pregnancy. The rate of miscarriage in women with BV is almost doubled. Sometimes repeated courses of oral or vaginal medication may be necessary to eradicate BV, as well as efforts of increase normal vaginal bacteria through probiotics or other means. . For successful implantation of the embryo and a good start to pregnancy, the uterine lining (endometrium) must be smooth. Anatomical abnormalities such as polyps, submucus fibroids or a uterine septum can disrupt an early pregnancy or prevent it from taking hold. Although these conditions can cause irregular bleeding, they can also be asymptomatic. A good test is a saline sonohysterogram, to make sure the endometrium does not have defects. Fibroids in other locations are usually not a problem. A hysteroscopy, a minor operation in which the gynecologist inspects the endometrium, can be performed to look for abnormal growths, and the offending polyp or fibroid removed if it is present.

Chromosomes are a frequent cause of first trimester miscarriage, and abnormal chromosomes are the main culprit for the age related increase in miscarriage rates. Until recently loss from chromosomes was thought to be untreatable, but more recently some measures have been found to help. A woman’s eggs lie dormant for decades, since fetal life, until they are ovulated. In the weeks before ovulation, they must undergo a shift from 46 chromosomes to 23 (meiosis), in order to merge with 23 chromosomes from the sperm. If a woman takes DHEA (a hormone) during these weeks, some studies have shown that she will produce a higher percentage of embryos with normal chromosomes, with a 20% increased live birth rate. Additionally, improving the follicular fluid surrounding the egg – by attention to blood sugar, nutrition, and elimination of toxic substances – cam impact chromosomes and egg quality to some degree. In the past, testing the chromosomes of a miscarried embryo required complicated techniques of growing cells and inspection with a microscope. But now new technologies of DNA analysis are much more rapid and accessible. Couples should request chromosomal tests of miscarriage remains whenever possible.

Women are frequently told to just wait and try again after pregnancy loss. But especially for recurrent miscarriage, diagnosis of treatable causes will result in more successful pregnancies. Knowledge brings the power to heal.