Microsoft word - rec-miscarr treatment.doc
Treatment options available in the
Recurrent Miscarriage Clinic
Whatever the cause of recurrent miscarriage identified by investigations, it is only normal
that women will be very anxious in any future pregnancy. Research has shown that
psychological support reduces the risk of miscarriage. The Recurrent Miscarriage Clinic
provides such support in the form of frequent clinic visits when required, access to
telephone support, and ready access to ultrasound facilities. Many women find weekly
ultrasound scans at specific times during what they consider their "danger" periods very
reassuring. Both on the NHS and in the private sector, the facility is readily available.
1. Treatment for the antiphospholipid syndrome.
The current most widely used treatment involves low dose (baby) aspirin andlow molecular weight heparin. Recent research suggests that aspirin alonemay be just as good as the combined therapy. Some women may beapprehensive about self-administering daily injections of heparin. In fact onceyou have been shown how, it is very easy, virtually painless, and safe. It issimilar to giving one-self insulin injections in diabetics, but of course it isshort-lived. For the baby, both medications are safe.
2. Treatment when a thrombophilia is identified.
While it may be a subject of debate as to whether thrombophilias causerecurrent miscarriage or not, they increase the risk of blood clots in thoseaffected. Pregnancy itself without thrombophilia increases the risk of bloodclots 6-fold. Therefore our general approach to women with thrombophilia isto treat them with a combination of low molecular weight heparin and lowdose aspirin. Since the risk of blood clot formation is particularly high in thesix weeks following childbirth, treatment is continued during this time. Specialprecautions are taken during labour and delivery to minimize the risk ofexcessive bleeding.
3. Treatment for a positive NK cell test.
Strong research evidence points to increased NK cell activity in subsets ofwomen with recurrent miscarriage, or implantation failure in womenundergoing IVF treatment. "Immunosuppression" with steroids appears to bea promising treatment, and is under evaluation in some centres both in theUSA and the UK. In the Recurrent Miscarriage Clinic, the steroid used isprednisolone at a dose of 25mg given from mid-cycle and continued to 12weeks if pregnancy occurs. Side-effects are minimal, and may includereversible weight gain, mood changes, sleep disturbance, skin changes andraised blood pressure. Only trace amounts of the steroid will reach the baby,and therefore the treatment poses no significant problems for the fetus in thewomb._The steroids are usually supplemented with low molecular weightheparin and low dose aspirin, but the need for the latter is currently beingevaluated.
4. Treatment for a weak cervixWhere a "weak cervix" has been diagnosed, the standard treatment is
cervical cerclage, the insertion of a "stitch" around the cervix at 12-14 weeksgestation. The vast majority of stitches are inserted via the vagina. Veryoccasionally, where a woman has had prior surgery to the cervix and wherethe cervix has become very short and is damaged and / or scarred, the stitchmay need to be inserted through the abdomen (trans-abdominal cervicalcerclage). In the latter, a caesarean section delivery will be required, and thestitch will usually be left in place until the woman completes her family. Thestandard stitch inserted via the vagina is removed at 38 weeks and a vaginaldelivery anticipated.
5. Management of chromosomal abnormalitiesThere is of course no cure for chromosomal abnormalities, but theidentification of an abnormality allows for a more accurate counselling andassessment of prognosis. Other couples may need prenatal diagnosis in anyfuture pregnancy. The Recurrent Miscarriage Clinic has ready access to aGenetic Counselling Service.
6. Treatment when bacterial vaginosis is identifiedIt is well established that bacterial vaginosis (BV)is associated with anincreased risk of late miscarriage and preterm birth. Research from our Unitrecently showed that early treatment of BV significantly reduces both risks.
We also have as yet unpublished evidence to suggest that BV increases therisk of early miscarriage. In the Recurrent Miscarriage Clinic, all women whoscreen positive for BV are therefore given a short course of oral clindamycin,the antibiotic we used in our research and which we consider the mostappropriate to eradicate BV. Treatment is repeated if later screening duringthe pregnancy shows a recurrence of BV.
7. Other treatments available: Progesterone & Metformin_Once upon a time progesterone supplements were widely used to treatwomen with recurrent miscarriage. They fell into disrepute when a meta-analysis failed to show any benefit. However, a meta-analysis is only asgood as the studies that are included, and many have since questioned thequality of the studies included in the meta-analysis. In addition, recentpowerful research has shown that progesterone supplementation preventslate miscarriage and preterm birth in a subsets of women at risk of both.
Extrapolations are therefore being made to earlier pregnancy loss, and somewomen are being offered progesterone supplementation. We are certainly re-evaluating this treatment in the Recurrent Miscarriage in two groups ofwomen: those with polycystic ovarian disease and miscarriage, and thosewhere no cause for the recurrent miscarriage has been established.
Metformin is being evaluated in women with polycystic ovaries where noother pathology has been identified as a potential cause of the recurrentmiscarriages.
8. When investigations fail to identify a causeSome couples are disappointed when investigations fail to identify a causefor their recurrent miscarriages. In fact, not finding a cause should be seenas a very positive outcome, because then the chance of a subsequentsuccessful pregnancy is very high. Where a couple have only had twoconsecutive miscarriages, when no cause is found they have at least a 70%chance of having a successful. While the figure is slightly lower where therehave been three consecutive miscarriages, nevertheless the chances of a
successful pregnancy remain higher than those of further miscarriage.
Psychological support is an important therapeutic strategy in thesecircumstances.
9. Alternative / complementary therapiesThe Recurrent Miscarriage Clinic has no expertise in alternative orcomplementary investigations and therapies. The approach in the Clinic is toadopt a pragmatic approach. Certainly where no cause for the recurrentmiscarriages has been established, some couples opt to pursue thecomplementary therapy route. We support such approaches, while making itclear that it is not an area in which we have any expertise. It is to be hopedthat some of the complementary treatments will be subjected to formalevaluations along standard research methodology. While it is difficult toenvisage how treatments such as Aromatherapy and Reflexology could curerecurrent miscarriage, nevertheless they are unlikely to cause any harm, andare certainly relaxing and soothing for women who are otherwise fraught withanxiety, stress and tension. Some investigations identify trace mineraldeficiencies using hairs, and attribute miscarriages to these deficiencies,usually of zinc, magnesium or selenium. The treatment usually suggestedinvolves dietary supplementation. It seems unlikely that a packet of multi-vitamin supplements purchase from a local pharmacy could be harmful, andwe therefore do not discourage this approach.
10. General measuresWhile there may be no hard scientific evidence for some of the generalmeasures we advise, they appeal to common sense. We therefore advisethe following to all couples undergoing investigation and treatment forrecurrent miscarriage:
Avoidance of excess caffeine, alcohol and recreational drugs
Avoidance of stress (probably easier said than done)
During early pregnancy avoidance of sexual intercourse: there is a linkbetween sexual activity and BV, and sexual activity does alter vaginal flora,even if only transiently.
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