Recurrent Miscarriage Treatment

Treatments for recurrent miscarriages may include changes to your diet, prescription drugs, surgery, or genetic testing to improve the chances of a successful pregnancy.

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What is threatened miscarriage?

Threatened miscarriage is not the focus of this article but we want to clearly define it here.

A threatened miscarriage is when a newly pregnancy woman in her first trimester experiences period-like cramps or begins to bleed vaginally. This is understandably very scary to experience, and is a legitimate concern from a women health point of view. Less than 20% of threatened miscarriages end up as miscarriages; more than 80% proceed into the second trimester

We treat threatened miscarriage at Soma Clinic. You can find out more at Soma threatened miscarriage.

What is recurrent miscarriage?

When you have experienced three or more consecutive miscarriages, this is when you receive the diagnosis of recurrent miscarriage or recurring pregnancy loss (RPL). It is very frustrating to miscarry repeatedly, and it doesn’t help that your risk of miscarrying yet again increases as you age.

Recurrent Pregnancy Loss (RPL) is a deeply concerning issue, and we want to empower you with knowledge from both biomedicine and Chinese medicine to make informed decisions about your health and future attempts to conceive.

I am about to miscarry. What should I do?

In TCM, we talk about the “stirring fetus” (胎动不安), and there is often mention of obvious signs of Fire like that seen during a threatened miscarriage.

However, it is just as common to have the fetal not develop, as corroborated by fetal size and heartbeat, WITHOUT any apparent signs of Fire.

If you are seeking an option that is beyond bedrest, watchful waiting, and even more progesterone, do consider Chinese Medicine.

Chinese herbs to prevent miscarriage?

Chinese herbs have been used through the centuries to intervene in situations of Fetal Growth Restriction (FGR), otherwise known as Intra Uterine Growth Restriction (IUGR). These are situations where the growth of the fetus slows down or even stops during pregnancy, or when the fetus is smaller than its gestational age.
Chinese herbs have adapatogenic qualities that help strengthen a body so that it can hold a pregnancy.
Chinese herbs also have the potential to increase microcirculation, which is crucial for oxygen supply to the fetus. Chinese herbs also may have heat-clearing effects, especially in situation of inflammation in the body.
FGR is important because it is a common precursor to pregnancy loss. If there is pregnancy loss before 20 weeks of pregnancy, it is called miscarriage; pregnancy loss after 20 weeks is termed still birth. If you experienced stillbirth, and need support, consider https://thepathtomotherhood.com/
On this other page, you can read up in more detail about the top 10 Chinese Herbs used to prevent miscarriage.

I have miscarried more than once. What should I know?

Recurrent Pregnancy Loss (RPL) is a medical label that requires 2 pregnancy losses to confirm that it is indeed possibly recurrent. The definition of RPL used to require 3 pregnancy losses but this definition has be prudently discard in favor of 2.

Each pregnancy loss is a distressing experience that can result from various factors, both genetic and non-genetic. It is possible after one pregnancy loss that the next pregnancy is viable to term.

It is also possible that there is a pattern. E.g. for some women it would be the 8th week mark where she finds out if the existing fetus will or will not survive.

It is paramount that you consult with a reproductive endocrinologist or an autoimmune fertility specialist to undergo a thorough medical evaluation. These might include:

  1. Biopsy to determine genetic cause of spontaneous abortion
  2. Imaging to confirm completion of miscarriage and to look for possible structural causes
  3. Thorough review of your medical history
  4. Panel of hormonal, autoimmune and/or genetic bloodwork

We lay out below some possible factors to be looking out for:

  1. Genetic Factors: Chromosomal abnormalities in either partner can lead to miscarriages. Genetic testing, such as karyotyping or chromosomal microarray analysis, can identify potential issues. Pre-implantation genetic testing (PGT) of embryos during in vitro fertilization (IVF) can help select healthier embryos for implantation.
  2. Thrombophilias and Immune Disorders: Blood clotting disorders and immune system imbalances can contribute to RPL. Testing for these conditions can guide treatment options, which might include anticoagulant medications or immune modulating therapies.
  3. Structural Abnormalities: Structural issues with the uterus, such as fibroids, polyps, or a septum, can hinder successful implantation and growth of a fetus.
  4. Hormonal Imbalances: Disorders like polycystic ovary syndrome (PCOS) and thyroid dysfunction e.g. Graves can increase the risk of miscarriage. Balancing hormones through medication or lifestyle changes may be recommended.
  5. Lifestyle Factors: Maintain a healthy lifestyle by managing stress, maintaining a balanced diet, exercising moderately, and avoiding harmful substances like smoking and excessive alcohol.

Causes of and Factors affecting Recurrent Miscarriages

A history of recurrent missed miscarriages requires diagnosis and management. A variety of tests are carried out on the mother and father in an effort to pinpoint the cause.  There are many causes of recurrent miscarriage in a woman. Possible factors that could explain your repeated miscarriages include:

  • Endocrine issues
  • Genetic issues
  • Autoimmune Diseases
  • Uterine anomalies
  • Environmental factors
  • Medical Conditions

Some women may have an abnormally shaped uterus from birth, and some women may experience progressive uterine abnormalities. These are all causes of infertility and RPL due to structural causes.

Recurrent pregnancy loss may also be influenced by a woman’s immune system. Hormonal imbalances, genetic abnormalities, and uterine issues are some of the most frequently identified causes.

Inflammation or inadequate blood flow to the womb during pregnancy may be another cause of the miscarriage (read on to find out how you can get treatment for this using Chinese herbs).

How to prevent recurrent miscarriage in Woman?

While you cannot stop miscarriages, you can make healthy pregnancy choices. Some choices include (1) pregenetic testing, (2) supplementing with progesterone and (2) using Chinese medicine.

1. Pregenetic Testing

If you have access to assisted reproductive technologies (ART) like IVF, then you may also have access to PGD or PGT-A. This allows you to bypass possible miscarriages due to genetic reasons.

2. Progesterone Supplementation

Several small trials on progesterone for recurrent miscarriage protocol have suggested that progesterone supplementation and inserts to reduce the risk of pregnancy losses in women with recurrent or threatened miscarriages.

This form of intervention is already routine in most clinics and may not help to prevent a miscarriage, especially if the cause is due to clotting disorders.

3. Chinese Herbal Medicine

Most pregnancies end in miscarriage because of problems with the fetus. Chinese herbs won’t be able to prevent such a situation. However, Chinese herbs can be  useful as an adjunct treatment to enhance microcirculation and possibly increase blood flow to the fetus.

Clotting Disorders in RPL

When a recurrent miscarriage is not due to uterine abnormalities, thyroid disorders or genetic reasons, it is very important to explore clotting disorders.

This is especially so if two consecutive pregnancy losses happen at the same time e.g. at week 10. It could be a pattern of reduced blood flow and oxygen to the fetus and subsequent fetal growth restriction leading to no more heartbeat.

In these cases, no amount of lifestyle changes may be sufficient, and supplements and Chinese herbs may be a hit and miss. Sometimes, even routine employment of baby aspirin and heparin to thin the blood may not be enough.

Important Tests for Clotting Disorders in RPL

Clotting Markers are very important to check for:

  1. Antiphospholipid Antibody: You are testing for Antiphospholipid syndrome (APS), which is an autoimmune disorder that causes abnormal blood clots to form.
  2. Anticardiolipin Antibody: To tighten the diagnosis for APS, anticardiolipin antibodies matter. Anticardiolipin Antibodies are found in around 30-40% of SLE patients, and positive APS positive results may means a predisposition toward clot formations in the arteries or veins, low platelet count (Thrombocytopoenia), or even recurrent pregnancy loss.
  3. Lupus Anticoagulant (LA): This test does not have anything to do with Lupus. It is a test to find out if your body is creating proteins or antibodies that predispose you to clot formation.
  4. Protein C and Protein S: These help to diagnose the cause of a clotting disorder.
  5. Factor V Leiden mutation: This is used to help determine if an individual has inherited a disorder associated with blood clots. It can determine whether the person has one copy (homozygous) or two different copies (heterozygoud) of the mutation.
  6. Factor II mutation (aka Prothrombin G20210A): This is an inherited condition that increases your predisposition to develop abnormal blood clots.
  7. PAI-1 (plasminogen activator inhibitor 1): This is what blocks out plasminogen activator in plasma, leading to decreased clot breakdown and eventually an unwanted blood clot. Increased PAI-1 levels is not good and this could be an inherited condition in some people.

Autoimmune markers further clarify:

  1. ANA: This test helps you find out if you have an autoimmune disorder like Lupus or SLE.
  2. Anti-Ro, Anti-SSA and Anti-SSB: These are important antinuclear antibody (ANA) in patients with systemic rheumatic diseases like SLE and Sogrens.

What to do after fetus stops growing?

If you are told by your gynecologist obstetrician that there is not fetal heartbeat, or that beta-hcg levels are not where they are supposed to be, the usual thing is to wait for the tissue to pass.

This is a very sensitive time, and there may be decisions to make like:

  1. Do I wait a little longer?
  2. Do I proceed with using mifepristone to block progesterone levels?
  3. Do I use misoprostol to help expel uterine contents?
  4. Should I do a D&C?

We also have patients writing in to ask about how Chinese medicine and acupuncture can help. The main reason to consider Chinese herbs and acupuncture is when you have decided to complete the miscarriage and you want to do so in a more gentle way.

At Soma Clinic, we have been supporting patients in this area. We also support patients after the miscarriage is complete, to ensure that there is ample circulation and healing in the uterus.

3 Decisions to make with Pregnancy Loss

The first decision to make is how to complete the process.

Depending on which stage in the pregnancy you are in, you may want to choose from the following:

  1. Mifepristone
  2. Misoprostol
  3. D&C
  4. Acupuncture
  5. Chinese herbs

All of the abovementioned choices can be used together. The aim is to expedite clearance of retained products of conception (RPOC) from your womb

It is very helpful to use Chinese herbs that enhance circulation in the pelvis and reproductive areas once a miscarriage is complete. A common formulation is called Sheng Hua Tang, which has the following effects:

  1. Increase blood circulation
  2. Increase uterine contraction
  3. Alleviate abdominal pain
  4. Complete the miscarriage and expel lochia
  5. Facilitate womb recovery and healing

The second decision to make is what to test for.

You may not want to think about this during this time of intense grieving, but it is important to consider:

  1. Biopsy of tissue to see if miscarriage was due to genetic abnormalities. Karyotyping identifies and assesses for chromosomal abnormalities in the tissue of the fetus and confirms if there was indeed a genetic defect causing the miscarriage.
  2. Panel of blood tests to check for possible blood clot and autoimmune causes

The third decision to make is how to recover.

This is often neglected, but two important decisions to make are:

  1. How do I release the grief? Will resting in and not thinking about this big event helpful? Will social gatherings or alone time help? Who can I speak to and pour my heart out to about this? Do I need to see a professional counsellor or psychotherapist?
  2. How to recover physically? Do I want to use Chinese herbs or acupuncture? How do I want to space out the treatments? Will massage help? How do I implement self-care?

Herbs for Womb Recovery

Substantial research has been done to inform us about how the key components of Sheng Hua Tang may help with clearing the uterus and accelerating recovery:

  • Dang Gui (当归) is the main ingredient of Sheng Hua Tang: We know that Angelicae Polysaccharides isolated from 当归 may stimulate bioactivity of bone marrow macrophages to accelerate the synthesis and secretion of hematopoietic regulation factors – put simple, it literally helps with production of blood!
  • Rhizoma Ligusticum Chuanxiong (川芎), when paired with Dang Gui, is able to regulate uterine contractions (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3771465/). The two effective components in these two herbs are ferulic acid and tetramethylpyrazine. In combination, they regulate uterine contractions so that they are not too intense.
  • Semen Persica (桃仁) possesses antithrombotic effects which promote uterine contractions and improves uterine bleeding.
  • Licorice (甘草) is a potent antispasmodic through inhibition of phosphodiesterase 3.
  • Old dried Ginger(干姜): Ginger constituents may reduce inflammation by interfering with the inflammatory cascade, bringing the body back to homeostasis.

Using Sheng Hua Tang after Miscarriage

When Sheng Hua Tang is used in treating postpartum women, it is able to increase contractile activity of the uterus. It also facilitates uterine involution and helps the uterus in returning to its anteverted position. In dairy cows, Sheng Hua Tang increases myoelectrical activity of the uterus after calving. On top of that, it promotes endometrial involution and early discharge of uterine fluid.

What is even more amazing is this: Sheng Hua Tang caused the first postpartum ovulation to occur earlier than in control, which may be an early index for recovery of normal ovarian function and subsequent reproductive performance the context of fertility after miscarriage. In high producing dairy cows SHD promotes uterine involution and ovarian activity in postpartum dairy cows

Intervention to induce medical abortion includes the use of mifepristone and misoprostol. When Sheng Hua Tang was also used, the result was improved outcome in the following parameters:

  • Complete abortion
  • Induction-abortion time
  • Duration of vaginal bleeding
  • Menstrual recovery time

If you use Sheng Hua Tang after early medical abortion, it can accelerate uterine involution by improving successful abortion, shortening duration of bleeding and induction-abortion time, and speeding up menstrual recovery time.

This is likely due to

  1. Increased and regulated hormone levels
  2. Enhanced microcirculation
  3. Optimized endometrial cell renewal
  4. Better management of inflammation

More than that, it is the inflammation piece that TCM may be more helpful with, which is why the five herbs in Sheng Hua Tang is never going to be enough.

These are some other considerations we have in mind, so as to improve outcomes after miscarriage:

  • Autoimmune factors: the moment we know that there are autoimmune factors involved, there is usually a situation of chronic local or systemic inflammation that has to be addressed. We can address this by including herbs that bring down systemic inflammation without relying on a high and consistent dosage of oral steroids like prednisone.
  • Use to herbs to enhance and regulate uterine contraction: Sheng Hua Tang only has two to three herbs that assist in this area. We prefer to add on many other herbs, which may include two types of peony root, some citruses and other herbs that promote and regulate uterine contraction.
  • Use of herbs to further enhance blood circulation and eliminate blood stasis: There are other herbs to use when a patient presents with a pattern of blood stasis.

What Next After Womb Recovery?

For patients recovering from miscarriage, whether recurrent or for the first time, the first phase is recovery of the uterus.

Subsequently, the focus will be on building up the body, enhancing circulation and regulating hormonal function. More on this is covered in the Use of Herbs for Confinement.

Why Recurrent Miscarriage Treatment at Soma Clinic?

If you have a recurrent miscarriage, you should know that the TCM doctor at Soma Clinic understands the emotional toll of pregnancy loss. Dr. Mark is dedicated to supporting you through the challenges, finding the cause, and helping you have a healthy baby. If you’ve had recurrent miscarriages in Singapore, please schedule a consultation and let an expert help you overcome recurrent pregnancy loss.

FAQs

Can underactive thyroid cause recurrent miscarriage?

Low thyroid hormone levels can potentially prevent women from getting pregnant or lead to miscarriages. A women with low thyroid levels can also be tested for antibodies which may then diagnose her with autoimmune hypothyroidism, also called Hashimotos.

There are many presentations of hypothyroidism that resemble pregnant symptoms. For instance, both share the same symptoms of weariness, weight gain, and irregular periods.

The converse is also true, that an over-active thyroid can be a risk factor for infertility and recurrent baby loss. When there is an autoimmune component to an over-active thyroid, it is called autoimmune hyperthyroidism or Graves.

Can endometriosis cause recurrent miscarriage?

Endometriosis, which affects one in ten women and results in inflammation and lesions inside the womb lining, is a common risk factor for recurrent miscarriages.

This condition is complex, and biomedical treatment is usually through drugs to suppress hormones or surgery (which has better outcomes).

What increases the risk of recurrent miscarriage in the first trimester?

Miscarriage risk may also be increased by exposure to specific chemicals, medications, x-rays, etc. Some of these elements have to do with your job, while others can have to do with your way of life. Both partners’ excessive consumption of alcohol, caffeine, and tobacco (both first- and second-hand) may have an effect on the pregnancy’s outcome.

Does aspirin help treating recurrent miscarriage?

A low-dose aspirin tablet, also called baby aspirin, is 81mg, although it can vary from 75 to 100mg.

This is the first line of medicine for pregnant women with antiphospholipid syndrome, a disorder marked by recurrent miscarriages.

Those with positive Anti-phospholipid antibodies will also use another blood thinner called heparin.

How can I prevent recurrent miscarriage naturally?

It is difficult to determine what the possible causes of RPL are on a case by case basis. Every is different and even women with RPL go on to conceive a healthy baby.

The first thing you should consider doing is to see an autoimmune fertility specialist. This specialist will do a panel of autoimmune tests on you and consult with you on adding on use of blood thinners, steroids as well as intralipids.

The next thing to consider is regular acupuncture to help with hormonal balance, immune regulation as well as circulation to the pelvic. It is important for some patients to also consider the use of Chinese herbs for regulating immunity.

Why would a baby stop growing at 24 weeks?

The usual cause is IUGR or FGR. This is when the blood supply from the placenta to the baby is not sufficient. While we don’t always know, and  why FGR happens. While genetics or infections like CMV or toxoplasmosis are possible causes, you must not rule out clotting disorders.

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