In recurrent miscarriages; As in normal life, factors such as lack of physical activity, unhealthy diet, smoking and alcohol consumption are factors that interfere with the results obtained. Medical understanding and the ability to listen to patients about their obstetric history are fundamentally important to treatment. Genetic research is controversial and consists of the chromosomal evaluation of conception products and the karyotype of the couple. The aim is to determine the etiology of the loss and may be useful for the couple’s future guidance. There is no consensus on the application of IVF-PGT and this option should be discussed on a case-by-case basis. In extreme cases, IVF using donated gametes may be the last option.
Patients with RPL without other thrombosis risk factors should not be screened for hereditary thrombophilia, and those with positive screening do not benefit from current therapy. APS is the only thrombophilia that should be routinely investigated for early abortion. The recommended treatment is the use of low-dose AAS preconception and LMWH at a prophylactic dose initiated at the time of pregnancy diagnosis.
Screening for immunological factors is not recommended for patients with RPL. Also, the empirical use of venous immunoglobulin or corticosteroids is not recommended. Only antinuclear antibody can be ordered for prognostic purposes, according to ESHRE. Screening for congenital uterine anomalies is part of the study of women with a history of RPL. Nuclear magnetic resonance is the gold standard for diagnosis. The only finding that can be surgically corrected and whose prognosis can be improved is the septate uterus.
The diagnosis of cervical insufficiency is based on the clinical history. The classic treatment is transvaginal cerclage 12 to 16 weeks after first trimester morphological ultrasound. Patients with RPL should undergo an endometrial cavity evaluation. The gold standard is hysteroscopy. Despite limited evidence linking submucosal fibroids, endometrial polyps, and synechiae with RPL, surgical correction is recommended in patients with RPL without other identifiable factors.
There is no research and treatment benefit for PCOS patients and their associated endocrine disorders. Thyroid evaluation should be done with serum TSH and anti-TPO and clinical hypothyroidism should be treated. Testing for prolactin is not indicated in the absence of signs of hyperprolactinemia, but treatment is indicated if this condition is diagnosed. Vitamin D testing is not routinely recommended, but prenatal counseling in women with RPL may include prophylactic vitamin D supplementation due to the high prevalence of hypovitaminosis D in this population.
Recurrent pregnancy loss (RPL) affects 0.8-1.4% of couples, and this prevalence increases with age. However, the etiology is generally unknown, and most treatments are not supported by strong evidence. There are many reviews investigating the causes of RPL. Hormonal status, spermatozoa morphology and DNA fragmentation, immunological status, uterine evaluation, thrombophilia and others. Recently, different types of treatments have emerged, most of which do not have good evidence. For example, we can talk about the use of anticoagulants, aspirin, corticosteroids, progesterone and antioxidants, and psychological support. It is argued that some procedures such as pre-implantation genetic testing and intracytoplasmically selected sperm injection for aneuploidy will affect the results and aid in RPL management.
Certain personal factors such as lifestyle and even environmental exposure may be associated with obstetric complications and pregnancy loss. Advanced maternal age is one of the best known risk factors for RPL in the literature. Approximately 50-70% of early pregnancy losses are associated with chromosomal abnormalities, and their incidence increases with maternal age, reaching 50% in women over 40. The European Association of Human Reproduction and Embryology (ESHRE) recommends that women be informed about the highest risk of miscarriage after age 40.
Obesity also has an important effect on women’s reproductive health. High body mass index (BMI) is associated with worse outcomes and higher incidence of pregnancy loss in infertility treatments. In a study with obese women, euploid miscarriages were higher than non-obese women (58% versus 37%). This is probably due to the association of obesity with various endocrine disorders such as diabetes, hypothyroidism and polycystic ovary syndrome, and possibly endometrial changes.
Royal College of Obstetricians and Gynecologists (RCOG) recommends prenatal weight loss due to an increased risk of miscarriage, stillbirth, preeclampsia, diabetes and postpartum hemorrhage. Regular physical activity practice improves the obstetric outcome; however, there are no studies investigating the effect of exercise on patients with RPL. Smoking appears to be associated with defects in trophoblastic function, thus increasing the risk of pregnancy loss in addition to poor obstetric prognosis.
Assisted reproductive societies recommend smoking cessation because of its negative effect on the chance of live birth. Several studies have shown that drinking alcohol during pregnancy also increases the risk of pregnancy loss. Although more studies are needed to determine if there is a safe dose for drinking during pregnancy, there are recommendations for couples with RPL not to drink alcohol.
Caffeine abuse can also affect fertility and be a risk factor for pregnancy losses. Ingestion of high caffeine levels (500 mg per day or> 5 cups per day) is associated with reduced fertility. Drinking 200 to 300 mg (2-3 glasses) a day during pregnancy can increase the risk of miscarriage. Therefore, it seems logical to guide this population to reduce caffeine consumption.
Few studies assessing environmental exposure as a risk factor for RPL, one of which suggests that exposure to heavy metals and micronutrient deficiency can lead to pregnancy loss. Another study suggests that intake of high concentrations of organochlorine pesticides may be associated with RPL.
It has been suggested in the past that stress may be associated with worsening of reproductive outcomes. There is a higher prevalence of depression in RPL patients. However, it is not known whether this picture is the cause or effect of RPL. The American Society of Reproductive Medicine (ASRM) offers psychological support to women who are more prone to feelings of grief, sadness, depression, anxiety, and guilt.
Author: Ozlem Guvenc Agaoglu