BOOKS PUBLISHED - Recurrent Miscarriages

















From all over India, wherever we went on lecture tours or for participating in conferences or seminars, there had been a suggestion from many different friends and colleagues to write a book on “Recurrent Miscarriages”. We shuddered at the thought of some student somewhere in the country quoting us in this subject, be given a discredit for his answer. This is not because the answer would be wrong, but may not be agreeable to the examiner. Therefore for nearly twenty years having worked in this field we did not write any book on this subject.

However, over a period of time, there was a constant influx of new treatment modalities and understanding of this subject. Before 20 years when we began our journey in this field much was hidden and very little revealed. The usual approach to cases of miscarriages used to be, give some HCG, give some progesterone, give some aspirin and tie up the cervix. We now know that all of these are never required in one subject and in many none at all may be required. So beautiful is this phenomenon of early pregnancy recognition and tolerance by the maternal system that even an atheist would become a theist. At the same time it is so intricate, so well organized and so profound that even a theist would be converted into a die-hard atheist!

What we intend to do in these pages is make an humble attempt on our part of showing the reader our understanding of why pregnancy fails again and again in the same mother. It is two years now that we started writing this book and we are sure this may still not be the final word after this long period.

We deeply acknowledge with profound gratitude the support of our family members during this stupendous task that ran into two years. We also thank Shri Ramesh Kadam our typist and secretary who though not being a medical person did his utmost to be flawless in his work. We also thank the Dean of Medical College, Baroda, The Superintendent S.S.G. Hospital Baroda and the Professor & Head of our department for their blessings to this work.

We place this work at the feet of The Lord – Almighty, at the service of humanity and mankind.

 BARODA.                                                                                                   DR. Pankaj Desai
July 25, 2003.                                                                                             DR. Purvi Patel




Approach to the couple presenting with recurrent pregnancy loss should be directed at finding an etiological factor. A careful history directed at the fact that were these proved pregnancies by a medical person or just presumed pregnancies by the subject. It is also important to know the timing of these abortions. Early recurrent pregnancy losses are likely to be chromosomal. Also it is now imperative to ask as to whether these were missed abortions or live abortuses. The latter indicates an anatomical cause.

Parental karyotyping will reveal those couples with abnormal chromosome rearrangements. The documentation of an abnormal parental karyotype warrants prompt referral for genetic counseling for an accurate assessment of the future risk of miscarriage. The outlook is often not as bleak as anticipated by the couple and karyotyping of the products of conception from any future miscarriage is mandatory. Prenatal diagnosis in ongoing pregnancies is recommended, as occasionally a pregnancy with an unbalanced karyotype will progress to term, resulting in the birth of an abnormal infant.

A detailed pelvic ultrasound will identify the presence of PCOs and will also assess uterine morphology. Uterine abnormalities detected on ultrasound can be further investigated by hysteroscopy or hysterosalpingography if necessary. As noted earlier, the finding of a uterine anomaly does not necessarily imply causation and surgical treatment may not be indicated.

An assessment of endogenous LH secretion should be performed. A mid follicular serum LH measurement may be elevated, but since LH is secreted in a pulsatile manner from the pituitary gland, daily urinary LH monitoring will be more informative. If hyper secretion of LH is causally related to early pregnancy loss, suppression of endogenous LH secretion should be an effective treatment for this condition. There are some preliminary studies that suggest this to be so. Johnson & Pearce compared the outcome of pregnancy in an ovulatory women with PCO treated with either clomiphene citrate or an LH releasing hormone analogue to suppress pituitary secretion of LH followed by gonadotrophin induction of ovulation. The latter treatment was associated with reduced incidence of early pregnancy loss compared to those pregnancies conceived with clomiphene. Similarly women with PCOs undergoing IVF were more likely to have an early miscarriage when super ovulation was achieved with clomiphene and gonadotropins compared to treatment with LH- releasing hormone analogue and gonadotrophins. However, the tendency for clomiphene to increase basal LH secretion may be contributing to the high early pregnancy loss rate in the control groups of these studies.

Whether pituitary suppression of LH offers an effective treatment in ovulatory women with raised LH and recurrent early pregnancy loss has yet to be determined. Other methods of suppressing LH include ovarian diathermy, pre pregnancy treatment with progesterone and the use of analogues to somatostatin, all of which await further evaluation.
Autoimmune screening should include a search for both anticardiolipin antibodies and lupus anticoagulant, as the crossover between these types of APA is not complete. There is no need to repeat APA testing in cases with moderate and high positive titers. However, repeat testing may be considered for subjects with low positive titers. There is considerable inter-laboratory variation and standardized techniques must be used for the detection of APA. Women with both early and late miscarriages should be tested.  

For those women with no documented abnormality, supportive care, including serial early-pregnancy ultrasonography, is valuable. Studies have shown this type of therapy to improve the prognosis, with the rate of live birth in the subsequent pregnancy up to 86%, although the outcome is age-related.



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