Recurrent abortion/ Habitual Abortion

Overview of Recurrent abortion

This distressing problem is affecting approximately 1% of all women of reproductive age. The risk increases with each successive abortion reaching over 30% after three consecutive losses.

Indian epidemiology then other

This refers to the initiating factors that trigger a disease process.

• Examples of causes include:
  
  • Pathogens: Viruses, bacteria, fungi, parasites (infectious diseases)
  • Genetic mutations: Inherited or spontaneous changes in genes (genetic diseases)
  • Environmental factors: Toxins, radiation, nutritional deficiencies
  • Lifestyle choices: Smoking, unhealthy diet, lack of exercise (contributing factors)

Causes of Recurrent abortion

The causes of recurrent abortion are complex and most often obscure. More than one factor may operate in a case. Factors may be recurrent or nonrecurrent. There are known specific factors which are responsible for early or late abortion and they are grouped accordingly.

FIRST TRIMESTER ABORTION:

Genetic factors (3–5%):

• Parental chromosomal abnormalities are a proven cause of recurrent abortion.

• The most common abnormality is a balanced translocation.

• Risk of miscarriage in couples with a balanced translocation is greater than 25%.
• However, the chance of a successful pregnancy even without treatment is 40–50%.

Endocrine and metabolic:

• Poorly controlled diabetic patients do have an increased incidence of early pregnancy failure.
• Presence of thyroid autoantibodies is often associated with an increased risk but it is likely that this finding is secondary to a generalized autoimmune abnormality rather than a specific endocrine dysfunction. Thyroid function is usually normal.
• Luteal phase defect (LPD) with less production of progesterone is too often related but whether the diminished progesterone level is the cause or effect is not clear.
• Polycystic ovary syndrome (PCOS)—exact mechanism of increased miscarriage is not known. Besides elevated serum LH levels, the other factors responsible are: insulin resistance, hyperinsulinemia and hyperandrogenemia.

Infection:

• Infection in the genital tract may be responsible for sporadic spontaneous abortion but its relation to recurrent fetal wastage is inconclusive.
• Transplacental fetal infection can occur with most microorganisms. Infection with bacterial vaginosis is risk factor.

Inherited thrombophilia

• Causes both early and late miscarriages due to intravascular (spiral artery), and placental intervillous thrombosis.
• Protein C resistance is the most common cause.
• Protein C is the natural inhibitor of coagulation. Other factors are—deficiencies of protein C, S and antithrombin III.
• Hyperhomocysteinemia and prothrombin gene mutation are also the known causes of recurrent miscarriage.

Immune factors (10–15%) Autoimmunity

• Presence of autoantibodies causes rejection of early pregnancy (15%) in the second trimesters mainly.
• Antibodies responsible are: antinuclear antibodies, anti-DNA antibodies (double or single stranded) and antiphospholipid antibodies.
• Antiphospholipid antibody-positive women demonstrate a tendency to miscarry at progressively lower gestational ages.
• Antiphospholipid antibodies are: lupus anticoagulant, anticardiolipin antibodies and anti b glycoprotein-I.

Causes of miscarriage are:

• Inhibition of trophoblast proliferation and function.
• Release of local inflammatory mediators (cytokines) through complement pathway.
• Spiral artery and placental intervillous thrombosis.
• Decidual vasculopathy with fibrinoid necrosis.
• In the majority, the cause remains unknown.

SECOND TRIMESTER MISCARRIAGE:

• Anatomic abnormalities are responsible for 10–15% of recurrent abortion. The causes may be congenital or acquired.
• Congenital anomalies may be due to defects in the Müllerian duct fusion or resorption (e.g., uni cornuate, bicornuate, septate or double uterus). Congenital cervical incompetence is rare.
• Acquired anomalies are: intrauterine adhesions, uterine fibroids and endometriosis and cervical incompetence.
• Defective Müllerian fusion—such as double uterus, septate or bicornuate uterus. The association is about 12% cases of recurrent abortion.
• Abortions tend to recur beyond 12 weeks and the successive pregnancies are carried longer. Implantation on the septum leads to defective placentation.
• The diagnosis is confirmed either by hysterography or hysteroscopy combined with laparoscopy in nonpregnant state or during digital exploration following abortion.
• OTHER CAUSES OF SECOND TRIMESTER MISCARRIAGE: Chronic maternal illness—such as uncontrolled diabetes with arteriosclerotic changes, hemoglobinopathies, chronic renal disease. Inflammatory bowel disease, systemic lupus erythematosus.
• Infection—Syphilis, toxoplasmosis and listeriosis may be responsible in some cases.

CERVICAL INCOMPETENCE (CERVICAL INSUFFICIENCY)- 20% Causes:

The retentive power of the cervix (internal os) may be impaired functionally and/or anatomically due to the following conditions:

• Congenital Uterine anomalies.
• Acquired (iatrogenic)— common, following: (i) D and C operation, (ii) induced abortion by D and E (10%), (iii) vaginal operative delivery through an undilated cervix and (iv) amputation of the cervix or cone biopsy of trachelectomy.
• Others—multiple gestations, prior preterm birth. Cervical incompetence is considered as a biological continuum of spontaneous preterm birth syndrome.

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Risk factors are things that make you more likely to develop a disease in the first place.

Pathogenesis refers to the development of a disease. It’s the story of how a disease gets started and progresses.

This is the entire journey of a disease, encompassing the cause but going beyond it.

Pathophysiology, on the other hand, focuses on the functional changes that occur in the body due to the disease. It explains how the disease disrupts normal physiological processes and how this disruption leads to the signs and symptoms we see.

Imagine a car accident. Pathogenesis would be like understanding how the accident happened – what caused it, the sequence of events (e.g., one car ran a red light, then hit another car). Pathophysiology would be like understanding the damage caused by the accident – the bent fenders, deployed airbags, and any injuries to the passengers.

In simpler terms, pathogenesis is about the "why" of a disease, while pathophysiology is about the "how" of the disease’s effects.

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Sign & Symptoms of Recurrent abortion

Most miscarriages occur before the 12th week of pregnancy.

Signs and symptoms of a miscarriage might include:

• Vaginal spotting or bleeding
• Pain or cramping in your abdomen or lower back
• Fluid or tissue passing from your vagina

If you have passed fetal tissue from your vagina, place it in a clean container and bring it to your health care provider’s office or the hospital for analysis.

Most women who have vaginal spotting or bleeding in the first trimester go on to have successful pregnancies.

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Diagnosis of Recurrent abortion

A thorough medical, surgical and obstetric history with meticulous clinical examination should be carried out to find out the possible cause or causes as mentioned previously.

Careful history taking should include—

• The nature of previous abortion process.
• Histology of the placenta or karyotyping of the conceptus, if available.
• Any chronic illness.

(1) Blood-glucose (fasting and postprandial), VDRL, thyroid function test, ABO and Rh grouping (partners), toxoplasma antibodies IgG and IgM.

(2) Autoimmune screening—lupus anticoagulant and anticardiolipin antibodies

(3) Serum LH on D2 /D3 of the cycle.

(4) Ultrasonography—to detect congenital malformation of uterus, polycystic ovaries and uterine fibroid.

(5) Hysterosalpingography in the secretory phase to detect—cervical incompetence, uterine synechiae and uterine malformation.

(6) This is supported by hysteroscopy and/or laparoscopy.

(7) Karyotyping (partners).

(8) Endocervical swab to detect chlamydia, mycoplasma and bacterial vaginosis

Complications are what happen after you have a disease. They are the negative consequences of the disease process.

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Treatment of Recurrent abortion

INTERCONCEPTIONAL PERIOD:

• To alleviate anxiety and to improve the psychology—While counseling the couple, they should be assured that even after three consecutive miscarriages, the chance of a successful pregnancy is high (70%). However, the success rate depends on the underlying etiology as well as the age of the woman.
• Hysteroscopic resection of uterine septa, synechiae and submucous myomas improves the pregnancy outcome. Uterine unification operation (metroplasty) is done for cases with bicornuate uterus.
• Chromosomal anomalies—If chromosomal abnormality is detected in the couples or in the abortus, genetic counseling is undertaken. Additionally, Karyotyping of the products of conception from future miscarriage is mandatory. Couples with chromosomal translocations or inversion are counseled for preimplantation genetic diagnosis (in other words; PGD) or prenatal diagnosis (DNA, amniocentesis or CVS) in subsequent pregnancy or pregnancy with donor gametes (sperm or oocyte).
• Women with PCOS are best treated for their insulin resistance, hyperinsulinemia and hyperandrogenemia.
• Metformin therapy is helpful.
• Endocrine dysfunction: Control of diabetes and thyroid disorders is done. Subclinical diabetes and/or thyroid disease may be treated when no other factor is present.
• Genital tract infections are treated appropriately following culture of cervical and vaginal discharge. Empirical treatment with doxycycline or erythromycin is cost-effective.

DURING PREGNANCY:

• Reassurance and tender loving care (in other words, TLC) are very much helpful. Probably this removes the stress and improves uterine blood flow.
• Ultrasound should use at the earliest to detect a viable pregnancy. This will influence further management. If the fetus is viable ultra sonographically at 8–9 weeks, only 2–3% are lost thereafter and similarly fetal loss is only 1% after 16 weeks of viable fetus.
• Rest—Patient should take adequate rest and to avoid strenuous activities, intercourse and traveling.
• Progesterone therapy in cases with luteal phase defect and recurrent miscarriage is given with natural micronized progesterone 100 mg daily as vaginal suppository. It start 2 days after ovulation.
• Once pregnancy confirm, progesterone supplementation continue until 10–12 weeks of gestation.
• Progesterone is necessary for successful implantation and continuation of pregnancy. This is due to its immunomodulatory role.

Benefits of hCG therapy

• Benefits of hCG therapy in recurrent miscarriage are not effective. hCG stimulates corpus luteum to produce progesterone.
• Antiphospholipid antibody syndrome (in other words; APS): Women treat with low-dose aspirin (50 mg/day) and heparin (5,000 units SC twice daily) up to 34 weeks. Unfractionated heparin and low molecular weight heparin (LMWH) are equally effective and safe.
• Cerclage operation for cervical incompetence is to perform.
• Chromosomal anomaly—Prenatal diagnosis by CVS or amniocentesis done. Preimplantation genetic diagnosis in blastomere stage is another option. Only then the few balanced embryos transfer and there is successful pregnancy.
• Immunotherapy: Use of paternal cell (leukocytes) immunization, third party donor leukocytes, trophoblast membranes, corticosteroids or IV immunoglobulins does not improve live birth rate. Immunotherapy is no longer using in women with unexplained recurrent miscarriage. It may increase maternal morbidity (anaphylactic shock).

Prognosis of Recurrent abortion

• The prognosis of recurrent miscarriage is not so gloomy as it was previously thought. The overall risk of recurrent miscarriage is about 25–30% irrespective of the number of previous spontaneous miscarriage.
• The overall prognosis is good even without therapy. The chance of successful pregnancy is about 70–80% with an effective therapy. Reassurance and tender loving care are very much helpful.
• Recurrent miscarriage in itself associate with later development of coronary artery disease with an odds ratio of approximately 2, increased risk of ovarian cancer increased risk of cardiovascular complications, and an increased risk of all-cause mortality of 44%, 86%, and 150% for women with a history of 1, 2, or 3 miscarriages, respectively.
• Women with a history of recurrent miscarriage are at risk of developing preeclampsia in later pregnancies

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Homeopathic Treatment of Recurrent abortion:

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?.

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. No a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improved with homeopathic medicines.

Homeopathic Medicines for Recurrent abortion:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy.

Medicines:

Arnica

• Traumatism of grief. Hemorrhages. Additionally, Tendency to hemorrhage.
• Furthermore, Tendency to tissue degeneration, septic conditions, bruised parts after labor. In detail, Violent after pains.
• Uterine hemorrhage – feeling as if foetus were lying cross-wise.
• Worse – especially least touch, motion, rest, damp, cold. On the other hand, Better – lying down or with head low.

Belladonna

• For violence of attack also suddenness of onset.
• Female – sensitive forcing downwards as if all the viscera would protrude at genitals.
• Dryness also heat of vagina. In detail, Dragging around loins, Pain in sacrum.
• Hemorrhage hot, Cutting pain from hip to hip, Labor pains come and go suddenly.
• Besides this, Badly smelling hemorrhages, hot gushes of blood.
• Worse – touch, noise, specifically lying down. Whereas, Better – semi-erect.

Chamomilla

• Chief guiding symptoms mental/emotional group.
• Moreover, Female – uterine hemorrhages.
• Profuse discharge of clotted, dark blood, with labour-like pains.
• Labour pains spasmodic; additionally press upward.
• Patient intolerant of pain. Worse – heat, anger, especially open air, night.

Sabina

• Sabina has a special action on the uterus.
• Pain from sacrum to the pubis. Additionally; Hemorrhages, where blood is fluid and clots together.
• Recurrent abortion, especially at third month. Violent pulsations; wants windows open.
• Female – Uterine pains extend into thighs. In detail, Threatened miscarriage. Retained placenta; intense after pains.
• Besides this, Menorrhagia in women who aborted easily. Inflammation of ovaries and uterus after abortion. Hemorrhage partly clotted.
• Worse – from least motion, atony of uterus, heat, warm air. On the other hand; Better – cool, fresh air.

Platina

• Generally, It is pre-eminently a woman’s remedy. intense spasms.
• Pains increase and decease gradually. Additionally; Tremulousness.
• Abdomen – pain in umbilical region; extending through to back.
• Pressing also bearing down in abdomen, extending to pelvis.
• Female – parts hyper-sensitive. Tingling internally also externally. Ovaries sensitive also burn.
• Spasms and painful bearing down. Ovaritis with sterility. Abnormal sexual melancholia.
• Worse – specifically; sitting and standing; evening. Whereas; Better – walking.

Plumbum

• Tendency to abortion from non-development of uterus.
• Muscular fibers of uterus do not develop proportionally as the foetus increases in size in uterus also Recurrent abortion.

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References use for Article Recurrent abortion/ Habitual Abortion

[1] DC Dutta’s Text book of OBSTRATICS

[2] Homoeopathic Body-System Prescribing – A Practical Workbook of Sector Remedies

[3]  https://www.mayoclinic.org

Frequently Asked Questions

What is Recurrent abortion/ Habitual Abortion?

Recurrent miscarriage is defined as a sequence of three or more consecutive spontaneous abortion before 20 weeks.

Homeopathic Medicines used by Homeopathic Doctors in treatment of Recurrent abortion/ Habitual Abortion?

• Arnica
• Belladonna
• Chamomilla
• Sabina
• Platina
• Plumbum

What causes Recurrent abortion/ Habitual Abortion?

• Genetic factors
• Endocrine and metabolic
• Infection
• Inherited thrombophilia
• Immune factors Autoimmunity

What are the symptoms of Recurrent abortion/ Habitual Abortion?

• Vaginal spotting or bleeding
• Pain or cramping in your abdomen or lower back
• Fluid or tissue passing from your vagina