Case 14: Recurrent miscarriage

 

Case 14: Recurrent miscarriage

CASE 14: RECURRENT MISCARRIAGE

History

A 34-year-old woman is referred from the emergency room with vaginal bleeding at 6 weeks

and 5 days’ gestation. Bleeding started 2 days ago and was initially spotting but has now

increased so that she needs to change a sanitary towel regularly. There is a mild dull lower

abdominal pain.

She normally has a regular 28-day cycle. In the past she has used the combined oral contraceptive pill but stopped 3 years ago when she and her partner decided to start a family.

She is gravida 3 para 0. Her first pregnancy ended in a complete miscarriage 2 years ago. Five

months ago she had a missed miscarriage at 9 weeks and underwent surgical management.

There is no gynaecological history of note. Medically she is fit and healthy, except for mild

asthma for which she takes inhalers.

The woman’s mother died from a pulmonary embolism after her last child. Her brother also

had a deep venous thrombosis at the age of 29 years. Her sister has two children, both born

preterm because of severe pre-eclampsia.

Examination

The abdomen is non-distended but tender suprapubically. The cervical os is open and products of conception are removed from the os and sent for histological examination.

The bleeding subsequently settles.

INVESTIGATIONS

Normal range for

pregnancy

Haemoglobin 11.1 g/dL 11–14 g/dL

White cell count 3.9×109/L 6–16×109/L

Platelets 201×109/L 150–400×109/L

Anticardiolipin antibody: positive

Lupus anticoagulant: positive

Histology report: chorionic villi are seen, confirming products of conception.

Questions

• What is the likely underlying diagnosis for the recurrent miscarriages?

• What further investigation should be performed?

• How should this patient be managed?100 Cases in Obstetrics and Gynaecology

34

ANSWER 14

Raised anticardiolipin antibodies and lupus anticoagulant are suggestive of antiphospholipid syndrome.

! Diagnosis of antiphospholipid syndrome

• The presence of one of the clinical features:

• three or more consecutive miscarriages

• midtrimester fetal loss

• severe early-onset pre-eclampsia, intrauterine growth restriction or abruption

• arterial or venous thrombosis

• And haematological features:

• anticardiolipin antibody or lupus anticoagulant detected on two occasions

at least 6 weeks apart

Thus in this case the diagnosis must be confirmed by a second positive anticardiolipin test

after at least 6 weeks. She should also be tested for antinuclear and anti-double-stranded

DNA antibodies as antiphospholipid syndrome may be secondary to systemic lupus erythematosus (SLE).

Management

Oral low-dose aspirin and low-molecular-weight subcutaneous heparin from the time of a

positive pregnancy test should be given in subsequent pregnancies to improve the likelihood

of a successful live birth.

In the case of this woman, with such a strong family history of thrombosis and proven

antiphospholipid syndrome, she would also be recommended thromboprophylaxis throughout the pregnancy and postnatal period.

There is as yet no proven benefit from progesterone in women with recurrent miscarriage.

Psychological support should be given with regular reassurance ultrasound scans in the first

trimester. There is some evidence that shows repeated ultrasound scans for reassurance alone

improve the outcome after recurrent miscarriage.

! Causes of recurrent miscarriage

• Parental chromosome abnormality (3–5 per cent, e.g. balanced translocation)

• Antiphospholipid syndrome

• Other thrombophilia (e.g. activated protein C resistance)

• Uterine abnormality (intracavity fibroids, uterine septum)

• Uncontrolled diabetes or hypothyroidism

• Bacterial vaginosis (usually associated with second-trimester loss)

• Cervical weakness (‘incompetence’, second-trimester loss only)

KEY POINTS

• Only a minority of women with recurrent miscarriage will have a cause identified.

• Aspirin and heparin are effective in women with antiphospholipid syndrome.

• Reassurance ultrasound scans and support may improve outcome for women with

recurrent loss.