2 spontaneous miscarriages occurring in the same gestational week or with similar tutorials are called recurrent miscarriages, and 3 or more occurrences are called habitual miscarriages.
I. There are many reasons for multiple spontaneous abortions, the common ones are
① genetic factors mainly chromosome number and structure abnormalities, accounting for 50% to 60% of miscarriages, often leading to early embryonic development arrest, degeneration and shrinkage of pregnant eggs, a way to eliminate undesirable offspring.
②exposure to external toxic substances such as lead, organic mercury, DDT, radiation, etc.
③ endocrine abnormalities such as luteal insufficiency, hyper- or hypothyroidism, and diabetes affecting the development of the meconium, placenta and fetus leading to miscarriage
④genital malformations or tumors such as bicornuate uterus, uterine longitudinal septum, uterine fibroids, ovarian tumors, etc.
⑤ abnormal cervical function manifested by relaxation of the internal cervical opening.
(6) mechanical stimulation during pregnancy such as abdominal surgery or trauma that can easily cause uterine contraction leading to miscarriage.
(7) Immunological factors: recent studies on reproductive immunity have shown that about 50%-60% of habitual miscarriages are related to immunity. One third of them are related to autoantibodies, especially antiphospholipid antibodies, which are mainly lupus anticoagulation factor (LAC) and anti-cardiolipin antibody (ACL)), as well as anti-nuclear antibody (ANA) and anti-nuclear extractable antigen antibody (anti-ENA antibody).
The other 2/3 are unexplained miscarriages, which are thought to be related to maternal hypo-recognition and/or hyporeactivity to fetal paternal antigens during pregnancy, resulting in failure to produce sufficient protective or containment antibodies and fetal rejection.
⑧ maternal systemic diseases, especially acute infectious diseases, can lead to fetal abortion
(9) Fetal hemolysis due to parental blood group incompatibility can lead to late miscarriage.
Don’t be overly sad and worried after miscarriage, adjust your mind in time, maintain a cheerful mood and positive attitude towards life, don’t have intercourse too early, and contraception for six months, during this period, consult an experienced physician to actively search for the cause, generally need to carry out the following aspects of the examination.
① chromosome examination of both spouses, semen examination of the male partner, and preferably, chromosome examination of the aborted embryo.
(ii) ultrasound, hysterosalpingography or hysteroscopy to understand the anatomy of the genitalia such as the presence of uterine fibroids, uterine malformations, uterine adhesions, etc.
③Some viral infections during early pregnancy can lead to miscarriage and fetal malformation, so serum anti-cytomegalovirus antibodies and anti-rubella virus antibodies should be examined.
(iv) Examination of luteal function: basal body temperature measurement, progesterone measurement, ultrasound examination and endometrial biopsy are applied to understand luteal function.
⑤ Examination of autoantibodies such as lupus anticoagulation factor (LAC), anti-cardiolipin antibody (ACL)), anti-nuclear antibody (ANA) and anti-nuclear extractable antigen antibody (anti-ENA antibody). Given that the level of antiphospholipid antibodies is fluctuating in the body and false positives can occur, and false positives can occur in cases such as fever and infection, clinical confirmation of the diagnosis may require three consecutive positive test results with a 3-month interval.
(vi) The presence of hypercoagulable state and easy embolism tendency.
(vii) Thyroid function tests, tests of blood glucose to exclude thyroid disease and diabetes mellitus, etc.
⑧ endocervical examination, if the habitual abortion caused by cervical insufficiency often occurs in middle or even late pregnancy, manifested as painless early water breakage followed by paroxysmal abdominal pain fetal abortion, some of these patients can show wide endocervical opening after abortion by ultrasound examination, while some of them show normal, and only when they are pregnant again, they show abnormal, so they need to be monitored closely when they are pregnant again.
More than half of the patients can find the cause of miscarriage after the above mentioned tests, but in some patients the exact cause cannot be found. It is currently believed that pregnancy is a successful semi-identical transfer process, and because 1/2 of the fetus is genetically derived from the paternal line and the couple is HLA antigen incompatible, the maternal immune system is subject to a series of regulation, no immune rejection of intrauterine embryo grafts occurs, and the continuation of pregnancy is maintained, in this immune regulation HLA antigens play a very important role in this immune regulation process. The paternal HLA antigens (on the surface of trophoblast cells) carried by the embryo stimulate the body’s immune system and produce a class of IgG-type antibodies, called confinement factors or confinement antibodies.
If the pregnant woman has low recognition and reactivity to the embryonic semi-identical antigens and fails to produce the appropriate containment and protective antibodies during pregnancy, the embryo may be rejected and miscarried. This type of unexplained habitual abortion is also called homozygous immune habitual abortion, which mainly refers to patients with a history of three or more consecutive miscarriages without a history of live births, stillbirths or stillbirths, and no chromosomal or anatomical abnormalities are found by routine etiological screening, and no infectious, endocrine or autoimmune diseases.
Third, after finding the exact cause, symptomatic treatment should be given.
①If it is a chromosomal abnormality of the couple, if it is sex chromosome dominant, then pregnancy should not be carried out. If it is sex chromosome recessive or autosomal inherited disease, third generation IVF i.e. pre-laying diagnosis after artificial insemination can be performed at present to obtain normal embryos to be transferred into the uterus.
②If it is a reproductive tract abnormality or tumor it can be corrected by surgical treatment.
(iii) Luteal insufficiency can be corrected by medication to improve luteal function.
④If it is a viral infection, it should be distinguished whether it is a current infection or a permanent antibody produced after a previous infection; if it is the former, antiviral treatment can be given, while the latter can be left untreated.
(5) In case of combined thyroid disease and diabetes mellitus, the medical condition should be treated actively, and after the condition is stabilized, the internal medicine physician and obstetrician should decide together whether pregnancy is possible.
(6) If there is no clinical symptom of cervical insufficiency during the non-pregnancy period, ultrasound endocervical measurement should be performed at about 12 weeks after pregnancy, and endocervical suturing should be performed if abnormal delivery is detected.
(7) Autoimmune type of habitual abortion can be treated by immunosuppressive methods, usually with a combination of adrenocorticotropic hormone and aspirin, which is taken from the time of pregnancy determination until the end of pregnancy.
(8) Hypercoagulable state and embolism-prone tendency can be treated with aspirin alone. Platelet agglutination (PagT) tests were performed periodically during the course of drug administration to adjust the aspirin dose. No adverse effects of the drug on the offspring were detected by follow-up.
9 The unexplained type of habitual abortion can be treated with active immunotherapy, using lymphocytes, monocytes or trophoblast syncytium membranes from the husband or unrelated individuals, with lymphocytes being more commonly used. The course of treatment starts before conception with 2 sessions at 3-week intervals, with a pregnancy success rate of 87%. At the end of the course, patients are encouraged to become pregnant within 3 months, and if pregnancy is obtained, a further 1-month course of treatment is performed. If pregnancy is not achieved, tubal lavage should be performed and 1 course of active immunotherapy should be repeated if infertility is ruled out.
Patients with habitual miscarriage should not carry a heavy psychological burden, as with the progress of medical science, most patients can have a successful pregnancy through treatment, so be confident and actively cooperate with your physician to achieve a successful pregnancy as soon as possible.