By Dr. Elisabeth Blanchi *

A single miscarriage during the first term of pregnancy is not a rare occurrence. Indeed, this happens to 15 per cent of women. However, just one or two per cent of couples experience Recurrent Early Spontaneous Abortion (RESA), usually defined as three miscarriages before the 12^th week of amenorrhea (1^st term).

We will list possible causes and look at the specific tests required for each of these etiologies (cause or sets of causes). A thorough check up must be conducted right away not to lose time and to avoid another miscarriage. Indeed, some doctors recommend the check up as early as after the second early miscarriage.

The most frequent cause for RESA is chromosomal abnormality; therefore, we will ask for a “karyotype” which is a study of both parents’ chromosomes. Today, we know that, even if all chromosomes are apparently normal, there may be some partial abnormalities that are only disclosed with a more sophisticated technique of investigation (FISH).

Some are of the view that there could be hormonal disorders responsible for RESA and it is therefore useful to check all hormonal levels of the ovarian function. We tend to link hormonal causes with thyroid imbalance, which must accordingly be explored with particular focus on anti-thyroid antibodies. We will also have to look for possible diabetes or diabetes tendency (tolerance test, insulin).

We also know that uterus malformations may be responsible for recurrent pregnancy loss, whether it is congenital (mother born with an abnormal shape of her uterus: septum, uni or bicornuate, arcuate fundus (also known as heart-shaped uterus) or whether it is acquired (a fibroid distorting the uterine cavity or a traumatic scar on the uterine wall disturbing proper implantation of the embryo). Some of these malformations can be surgically repaired. We must therefore perform a pelvic ultrasound and hysteroscopy before a new pregnancy.

Some vaginal infections, generating endometritis (an infection inside uterine cavity) may also trigger miscarriages. Vaginal swab to search for chlamydia trachomatis and mycoplasma (different kinds of bacteria) must thus be part of the screening.

Environmental causes should also be considered, such as smoking, drugs, excessive consumption of coffee and/or alcohol as well as exposure to chemical toxics.

It is recommended that multivitamins, especially folic acid, be taken, starting one month before pregnancy and throughout the first trimester.

Recently, scientific advances have permitted major progress in the treatment of couples affected by Recurrent Early Spontaneous Abortions.

- First, we have discovered that some auto-immune disorders are related to that pathology. These are evidenced through the screening in the blood for the antiphospholipid antibodies (mostly anticardiolipin). Lupus with its lupus anticoagulant factor is included in this category.

- Second, we have also found that some coagulation disorders could trigger a small thrombosis in the future placenta responsible for subsequent miscarriage. We will accordingly order specific factors of coagulation such as mutation factor V Leiden or factor II, Plasma homocysteine levels and plasma protein C and S.

For both these etiologies, treatment combining Aspirin-Heparin has shown excellent results.

In spite of such thorough screening and tests, almost 50% of RESAs remain unexplained. Proposed treatments will be adapted to the underlying pathology identified through the checkup or will be adjusted empirically if no apparent cause could be identified.

Lastly, another significant factor must also be taken into consideration: the anxiety level of the patient, as stress is a factor that might induce spontaneous abortions. Indeed, we must not forget that psychological problems may develop in a woman whose first pregnancy ends in spontaneous abortion or who has a second or third consecutive spontaneous abortion. Usually sympathetic discussion and proper counseling, creating a climate of confidence between the couple and the medical team will contribute greatly to positive results.

In conclusion, one must keep in mind that very significant progress has been made and that with proper monitoring and support, risks of Recurrent Early Spontaneous Abortions may be significantly reduced. —Family Medical Practice Hanoi

* Dr Elisabeth Blanchi is an experienced Gynecologist / Obstetrician at Family Medical Practice Hanoi. She obtained her MD at University of Marseille, France in 1976 with a specialization in Gynecology Obstetrics in 1980. Before coming to Việt Nam, Dr. Elisabeth worked at the maternity ward at various public and private hospitals in France, Egypt, the Philippines, and Italy. She has been working in Việt Nam with FMP Hanoi for over five years.   For more advice on medical topics, visit Family Medical Practice Hanoi on 298 Kim Mã, Ba Đình or call (04) 3843 0748. Email: hanoi@vietnammedicalpractice.com.