Counseling Couples with Recurrent Pregnancy Loss (RPL) Part 1

By: William H. Kutteh, M.D., Ph.D.
Director of Reproductive Endocrinology
Director of Reproductive Immunology
Department of Obstetrics and Gynecology
The University of Tennessee, Memphis

Couples who have experienced multiple pregnancy losses often feel a significant lack of control over their lives. Generally, after introducing myself to new patients who are seeking medical advice concerning pregnancy loss, we start the session by allowing the couples to tell me their story. It is important that they first have an opportunity to relate the information that they feel is most important in the order they feel is most appropriate. The next 30 minutes to an hour are spent reviewing available records and asking questions to clarify and enhance those reports. Couples usually participate in their evaluation and care by accumulating all past medical records for review (see Medical History).

Medical History and History of all Pregnancies

Covering as many of these bases as possible at the first visit will enable a reproductive specialist to narrow the different diagnosis for RPL. The couple should accumulate and organize all relevant material prior to their office visit to enable efficient transfer information.

1. Pregnancy history, including objective documentation of previous pregnancies (pregnancy test results, ultrasound reports).
2. Details of signs and symptoms associated with previous miscarriages, such as cramps or bleeding, or any changes in pregnancy symptoms (nausea, breast tenderness).
3. Pathology, autopsy, and genetic reports on any prior miscarriages and placenta.
4. Medical records and x-ray films of all other tests previously performed (such as hysterosalpingograms, blood tests, operative notes).
5. Gynecologic conditions or previous surgery (especially on the uterus and cervix).
6. Chronic or acute infections and diseases (chlamydia, mycoplasma).
7. Physical and emotional stress (work or home related, job changes, recent relocations, other losses in the family).
8. Prescription and over-the-counter medications (including "natural" or herbal medicine).
9. Alcohol (more than four drinks per week), tobacco (more than 10 cigarettes per day), and illicit drug use.
10. Occupational factors (exposure to toxins, x-rays, chemicals, changes in responsibilities).
11. Family history of miscarriage, stillbirths, congenital anomalies, DES use and serious illnesses (such as cancer, systemic lupus erythematosus, diabetes).
12. Ethnic background (for genetic diseases particular to specific groups).

Bereavement counseling is discussed with every couple, taking a more directive approach with those in whom problems are evident. It is important to emphasize that their relationship with each other is just as important than the bond either or both may feel with their unborn child. In many cases the stresses associated with pregnancy loss may serve to strengthen the bond of marriage. In other couples, there may be the false hope that a child will help to save a failing marriage. One partner may place blame on the other, or one partner might believe the other is placing blame on him or her. Marital counseling may be appropriate in these few cases. It is important to direct these couples to appropriate bereavement resources for support and counseling.

The Causes of Loss

After a complete evaluation, we are able to determine the cause or causes of recurrent pregnancy loss in two-thirds of cases. We cannot guarantee that we will be able to determine why the couple has had repeated miscarriages. Furthermore, on a more optimistic note, several studies indicate that 70 percent to 75 percent of all couples who have recurrent pregnancy loss will eventually have successful pregnancies. However, those successful delivery figures vary significantly from cause to cause (see Laboratory Evaluation).

Laboratory Evaluation

1. To evaluate genetic causes: chromosome analysis (karyotypes) of patient and husband.
2. To evaluate hormonal causes: midluteal progesterone levels or endometrial biopsy. In many cases tests of prolactin and thyroid stimulating hormone are indicated.
3. To evaluate uterine causes: hysterosalpingogram or hysteroscopy.
4. To evaluate immunologic causes: immunologic evaluation (lupus anticoagulant, antiphospholipid antibodies).
5. To evaluate infectious causes: cervical cultures for Mycoplasma and Chlamydia.

In the absence of evidence that suggests a particular etiology, many couples tend to ascribe recurrent pregnancy loss to genetic factors, so it is important to emphasize a couple of basic points. There are two broad types of chromosomal abnormalities, with the first and most common kind occurring in the baby. This generally involves a problem unique to the particular union of egg and sperm that resulted in a baby that was not capable of survival. This finding usually has no bearing on future pregnancies. The second kind of chromosomal abnormality exists in the patient or her partner and may be of concern in all of their future pregnancies. Fortunately, this type of genetic abnormality is discovered in only three to five percent of couples with RPL.

Abnormal ovarian function with decreased progesterone production has been termed a "luteal phase deficiency" and is found in five to eight percent of women with recurrent pregnancy loss. Other hormonal deficiencies that are infrequently associated with pregnancy loss include hypothyroidism and an excess in production of a hormone called prolactin. These conditions can be treated medically.

Uterine anomalies, or abnormalities in the anatomical structure of the female reproductive tract, are found in 15 to 20% of women with a history of recurrent pregnancy loss. These abnormalities may be congenital (that is, from birth) or acquired in the course of the woman's lifetime. Many of the congenital and acquired abnormalities can easily be treated with a surgical procedure called operative hysteroscopy. This day-surgical procedure can be used to treat uterine septum, intrauterine scar tissue or adhesions, and growths of smooth muscle (leiomyomas) or glands (polyps). Infection of the uterine lining or endometrium with slow growing bacteria such as mycoplasma or ureaplasma has also been associated with pregnancy loss. These infections can be cultured and treated with antibiotics.

Certain habits and occupations may be related to pregnancy loss. It is known that tobacco use of greater than 15 cigarettes per day or alcohol use of greater than 4 drinks per week will increase the chance of pregnancy loss 11/2 to 2 times. Also some studies have suggested that airline attendants and women who are exposed to chemicals in their work environment (such as hair stylists) may have an increased risk of miscarriage. Nontraumatic exercise, intercourse, and normal daily activity do not cause miscarriages.

The area of immunology has become one of the most controversial in the assessment of pregnancy loss. The causes are divided into the autoimmune group (immune reaction against ones self) and the alloimmune causes (immunologic reaction against another). An example of an autoimmune disease is rheumatoid arthritis and an example of an alloimmune problem would be rejection of a kidney after transplantation. Tests for lupus anticoagulants and antiphospholipid or anticardiolipin antibodies are clinically indicated diagnostic tests. Many other tests are currently still under investigation. (A subsequent article will be devoted entirely to the immunologic factors that have been postulated to cause recurrent pregnancy loss).

Finally, the couple is counseled not to become pregnant while the reason for their past pregnancy losses is being investigated. The couple is advised to use barrier contraception until all test results are back and any necessary treatment plans are made. The entire process requires four to six weeks, which approximates the time of physical healing after a loss. The emotional healing may take considerably longer. While resolution of a loss should occur before attempting another pregnancy, many are not able to fully integrate these losses for many months or years.

Making Decisions "For Now"

Some patients decide they do not want to conceive again, most commonly because they feel that they cannot deal with another loss. I respect that decision and their absolute right to make it, but also note that their decision can be "for now," not "forever." They may want to take a few months to sort out their feelings. The key is to present all of the patient's options in a non-directive way. Couples with recurrent pregnancy loss usually have a psychological state far different from that of infertile couples. Many with infertility tend to be chronically depressed and ride an emotional roller coaster every menstrual cycle. Fear can become the predominant emotion among couples with RPL. Often, an infertile couple welcomes the news of a pregnancy with joy and expectation; while a couple that has been through several miscarriages may have a greater sense of fear anticipating what might occur.

If the couple already is pregnant, they are instructed not to engage in any activity for which they will blame themselves if they have another loss. This includes travel, certain work related activities, and even intercourse in early pregnancy. Optimal medical care and support are important early in pregnancy especially in the cases of multiple early losses. As a pregnancy progresses, interventions which are appropriate based on the prior history and risk level should continue. It is important that the physician and staff provide emotional support throughout the pregnancy. Finally, reassurance is important. Over 70% of the 1,800 couples that I have had the opportunity to work with, who had a history of multiple pregnancy loss, have ultimately had a successful pregnancy.