Patient Silk Rain, 32 years old, has been married for six years. During these six years, I have had five miscarriages and have not had any children. The first pregnancy was at the end of 1999, during our honeymoon. I didn’t even know I was pregnant at that time. One day I was cleaning the house and I climbed up high to clean the windows. I felt very tired that day, and that night I saw redness in my vagina. I didn’t care about it because it was the day I was supposed to have my period in the past. But after 10 days or so, my lower body never cleared up, so I went to the hospital. The doctor said I was 40 days pregnant, but I had a preterm miscarriage. I was happy and worried. At that time, the doctor prescribed me several shots of progesterone, and the bleeding still didn’t stop after a few days of injection. At that time, someone said to me, “You’ve been bleeding for so long, maybe the baby will have a disability later! I was terrified, and after discussing with my family, I thought I couldn’t take any chances, and thought I was still young enough to have a healthy one later, so I went to the hospital and had an abortion. A year and a half later, I got pregnant again, but I didn’t expect to see red again in the first trimester and was again diagnosed with preterm miscarriage. This time, I was immediately admitted to the hospital for treatment of the fetus and remained absolutely bedridden all day. The doctor gave me oral antiretroviral pills and intramuscular injections of HCG (chorionic gonadotropin) every day. But all these measures seemed to have no effect, as the blood flow from my lower body increased and I became more and more nervous. On the 60th day of pregnancy, I had an ultrasound and the result was that the embryo had stopped developing on the 36th day. I had no choice but to undergo an abortion. The physical and mental pain made me worried about my future fertility. Afterwards, my husband and I underwent a comprehensive fertility test, which revealed that I was positive for antiphospholipid antibodies, which the doctor said was probably the main cause of my two fetal deaths. From her medical history, examination report and treatment, the cause of her spontaneous abortion was related to antiphospholipid antibody positivity, which is called antiphospholipid antibody syndrome. Antiphospholipid antibodies can lead to the formation of blood clots in the blood vessels around the embryo, affecting the blood supply to the embryo and stopping its development, which is one of the main causes of recurrent miscarriage (two spontaneous miscarriages) and habitual miscarriage (three or more spontaneous miscarriages). Phospholipids are important components of cell membranes, and the formation of antiphospholipid antibodies destroys the endothelial cell membranes of placental villi and stimulates intravascular coagulation, causing thrombosis of these capillaries. Depending on the earliest and extent of thrombosis, cessation of embryonic development can occur in early pregnancy or in the middle of pregnancy. In some cases, fetal development becomes delayed although it does not stop. Phospholipids are also involved in the adhesion and implantation of the fertilized egg in the uterine wall, while antiphospholipid antibodies interfere with this adhesion and implantation, causing the embryo to implant very superficially in the uterine wall and leading to the occurrence of miscarriage. Miscarriage due to antiphospholipid antibody syndrome requires anticoagulation therapy, such as heparin and aspirin. After six months of recuperation, I became pregnant for the third time. The doctor asked me to take oral aspirin and prednisone (prednisone) for three months, and to be absolutely bedridden, eating, drinking, and pooping in bed. After the fourth month, I started to get out of bed and move around the house slowly, and then my husband would take me for a walk in the yard after dinner every day. I lived on the sixth floor, so my husband carried me up and down the stairs. One day after dinner, I was resting on the bed and suddenly I felt a pain in my stomach and something in my vagina. I called my mom to come and see, but she didn’t see anything after half a day, and I felt more and more uncomfortable inside my belly. My family rushed to take me to the hospital. That night, the doctor took emergency measures to protect my fetus, intravenous injection of magnesium sulfate and other drugs. After a night of painful struggle, the next morning, the amniotic sac that had slipped into my vagina finally fell out, causing me to hold my stomach and cry. The doctors and nurses rushed in and I was wheeled into the delivery room and shortly afterwards, I gave birth to a stillborn baby that had already taken shape. My husband, who witnessed everything, couldn’t help but cry out loud. At that moment, I felt that my abdomen was empty all of a sudden. The next step was to clean up the remaining placenta, and the nurse reached into the uterus and pulled it out little by little, causing me so much pain that I wanted to die. Afterwards, the doctor suspected that I had a loose muscle at the cervical opening, but the ultrasound confirmed that the opening was not loose. Later, we also sent the stillborn baby we had miscarried for a pathological autopsy, but there was nothing wrong with it – it was a normally developed baby boy, which made us even more heartbroken. In August 2003, I became pregnant for the fourth time. At five and a half months, I had a repeat of my third miscarriage: the same baby boy, who cried twice when he was born, and then was silent. After this time, I went for a special hysteroscopy, which revealed a loose cervical opening. I was advised to have a cervical stitching procedure done during my next pregnancy, between the third and fourth trimesters, and to remove the stitches before delivery. At that time, I was hopeful that there would be a solution if I could find the cause. Expert’s comment: It was obvious that the cause of Silhouette’s third and fourth miscarriages was due to the relaxation of the endocervix (also called cervical insufficiency). The endocervix is a portal with an on/off function and remains closed until the delivery. Under normal circumstances, its opening depends on the contraction and pull of the uterus during labor. However, if the tissue of the endocervical os is weak or damaged and the sphincter of the uterine os loses its function, when the embryo develops to a certain size, due to the increased pressure in the uterine cavity, the endocervical os will gradually open unknowingly even without contractions, resulting in the bulging of the amniotic sac and rupture of the membranes, leading to miscarriage or preterm labor in late pregnancy. The clinical features of cervical insufficiency are that miscarriage occurs after the fourth trimester, the fetus survives at delivery, and there are no contractions before miscarriage. Based on the above history, the diagnosis of endocervical laxity is confirmed by the ability to pass the cervical canal dilation strip over size 7 into the cervix during the non-pregnant period. Ultrasound examination during non-pregnancy is not very helpful. Causes of cervical insufficiency include congenital cervical dysplasia, repeated uterine operations, and vaginitis and cervicitis. An effective treatment is cervical cerclage after the fourth month of pregnancy. Therefore, the hospital’s management of Silhouette after pregnancy was correct. In April 2004, I became pregnant for the fifth time. During my early pregnancy checkup, the doctor said my progesterone level was not high, so I was given intramuscular HCG and progesterone daily. On the 64th day, I heard the sound of a beating fetal heart through Doppler ultrasound, and I couldn’t tell you how happy I was to see hope. I didn’t expect to hear the fetal heartbeat again the next day, and my little life died again. The first four pregnancies, the fetus unfortunately died, and it was easy to find out the cause and get targeted treatment, but I did not expect the fifth pregnancy before the cervical cerclage, the fetus died in early pregnancy, which is undoubtedly another fatal blow to Siyu. This time, the miscarriage was probably due to antiphospholipid antibodies or to a more serious reproductive immune disorder. Although anticoagulation therapy can be effective in miscarriages caused by antiphospholipid antibodies, the causes of antiphospholipid antibodies are complex and not easy to identify clinically. Anticoagulation therapy cannot remove the cause, so recurrence is entirely possible. In addition, there are other types of immune abortion besides antiphospholipid antibody syndrome, and all types of disorders eventually lead to disruption of NK cells (natural killer cells). By the time this occurs, it becomes more difficult to keep the baby. Looking back on these six years, I spent half of my days in bed and my work and life were greatly affected. Every pregnancy required absolute bed rest, and I was in bed for months at a time, accompanied by constipation, edema and other unpleasant reactions. My family was also physically and mentally exhausted trying to take care of me. We were full of hope and disappointment again and again, saw countless doctors and worshipped countless bodhisattvas, and were on the verge of collapse from the physical and mental pain we had to endure. Whenever we saw the lovely babies in other families and thought of the coldness in our own family, my husband and I would feel a sorrow in our hearts, and our parents were also white with worry about this. We were overwhelmed by the many failures. How could it be so difficult to be a mother again? Expert comment: Although Siyu has had five miscarriages and her condition is complicated, there is still treatment available. What she needs to do now is to undergo a comprehensive reproductive immune examination to find out the real cause of the miscarriages so that she can arrange targeted early pregnancy pregnancy settling treatment. And of course, don’t forget to have a cervical cerclage in the third or fourth month of pregnancy.