Treatment for Miscarriages

Recommendation for the medical treatment of women with recurrent miscarriage (>3 consecutive miscarriages)

Progesterone

Though studies demonstrating the efficacy of progesterone treatment are lacking, they are usually prescribed to women with Recurrent Pregnancy Loss (RPL). Progesterone is generally prescribed as 100 mg twice daily, vaginally as empiric treatment of unexplained RPL. It starts three days after the LH surge, not to inhibit ovulation, and continued until 10 weeks of gestation, when placental progesterone production should be fully functional. Alternatively, it is used in gel preparation 90 mg vaginally once daily or micronized progesterone 100 mg orally, 2-3 tablets/day. Dydrogesterone, a progesterone derivative is been evaluated as a possible treatment for women with idiopathic RPL which is thought to act by positively immunomodulating the immune system.

Human chorionic gonadotropin

Human chorionic gonadotropin (hCG) therapy in early gestation may be useful in preventing miscarriage since endogenous hCG is known to play a critical role in establishment of pregnancy. The evidence to recommend the use of hCG to prevent pregnancy loss in women with a history of unexplained RPL is insufficient.

In vitro fertilization and pre-implantation genetic diagnosis

a. Oocyte donation: Poor quality oocytes are responsible for 25% of pregnancy losses. The problem could be overcome by ovum donation, and using the male partner’s sperm .

b. Combination therapy: the drugs that are considered in the combination therapy are prednisone (steroids), progesterone, aspirin, and folate.

Surgical management of uterine abnormalities

Women with congenital uterine anomalies, uterine septa, bicornuate uteri, and obstructed hemi-uteri may mainly require surgical repair. In case of bicornuate uteri, pregnancy outcomes are generally reported to be normal, close to that in the general population. However, since some of these women have recurrent pregnancy loss, surgical treatment with uterine reunification via laparoscopy or laparotomy may be indicated after other possible causes of recurrent pregnancy loss are looked into.

Cervical cerclage can help to prevent miscarriage in cases of cervical incompetence.

Antiphospholipid syndrome

Aspirin and heparin appear to improve pregnancy outcome in women with Antiphospholipid syndrome who have recurrent fetal losses.

Suspected immunologic dysfunction

Several immunologic treatments have been advocated to improve the live birth rate in women with previous unexplained RPL
a) Active Immunotherapy – Immune therapy of RPL i.e. injecting the paternal lymphocytes is extremely effective in RPL, unexplained infertility and IVF failures . To know more…
b) IV Immunoglobulins
c) Glucocorticoids – Glucocorticoids have several anti-inflammatory effects, including suppression of natural killer cell activity, and can be effective for preventing RPL.

Thyroid dysfunction and diabetes mellitus

Women with overt thyroid disease or diabetes mellitus should be treated, as medically appropriate, since these disorders can result in serious sequelae.

Polycystic ovary syndrome

Metformin has been used in women with PCOS to decrease the risk, but the effectiveness of this approach is unproven.

Hyperprolactinemia

Treatment of women with Hyperprolactinemia and RPL is suggested even in the absence of overt hypogonadism. Therapy with bromocriptine may be associated with successful pregnancy.

Thrombophilia

Anticoagulation of women with certain inherited and acquired thrombophilias may improve maternal outcome (eg. Prevention of venous thromboembolism), and prevent pregnancy loss.

Unexplained RPL

RPL remains unexplained in approximately one-half of couples even after complete evaluation and is now considered to be due to Immunological rejection. Immunotherapy is A Ray Of Hope for treatment of these couples

Lifestyle Modification

Lifestyle modifications can upsurge fertility potential, although there is no definitive data to support this. These alterations could include eradicating the use of tobacco products, alcohol, and caffeine and reduction in body mass index (for obese women). Also cigarette smoking, high BMI, and alcohol and caffeine consumption can have a significant adverse impact on pregnancy and fetal outcomes. The combined impact of these exposures on both fertility and pregnancy outcome emphasizes the importance of lifestyle interventions for the couple planning a pregnancy. Lifestyle factors affect the duration of time before achieving pregnancy and fertility may be enhanced by modifying these factors. Based on the observational studies, the recommendations are:

  • Sexual intercourse 2-3 times/week to ensure that intercourse falls within the fertile period (up to two days before ovulation) and semen quality is optimal. Couples should be educated that delayed childbearing can decrease the probability of successful conception, and they should take this into account in family and career planning.
  • Smoking cessation for couples who smoke based on the overall health benefits of smoking cessation. Use of tobacco by a female partner, and possibly the male partner, appears to be associated with decreased fertility.
  • A BMI>27kg/m2 or < 17 kg/m2 is associated with an increased risk of an ovulatory infertility. The BMI > 27 kg/m2 is often related to polycystic ovary syndrome and the BMI of < 17 kg/m2 is often related to amenorrhea caused by excessive exercise or poor caloric intake. The ideal BMI is between 18.5-25 kg/m2. Women in this range are less likely to have ovulatory dysfunction compared to women at either extreme of BMI.
  • Moderate to heavy drinking in females may take longer to achieve a pregnancy and are at a higher risk of undergoing an infertility evaluation. Women wanting to conceive should keep any alcohols at bay.