While we have all probably heard the numbers a dozen or more times throughout life, it often isn’t until a woman experiences a miscarriage herself that she begins to wonder about and investigate the frequency of this difficult situation. After a miscarriage, most women feel sad and frightened about their prospects of carrying a healthy pregnancy to term and those with additional health problems, such as an autoimmune disease, may have further questions about the role of their disease in miscarriage.
It is essential to first understand and believe the truth about miscarriage: this is a very normal part of reproduction and it is extremely common. Estimates vary but it’s possible that up to 40% of all conceptions (across all populations regardless of age, health etc.) end in miscarriage. If you think about the miracle of creating a little human out of your own body, you must also respect that the miraculous female body recognizes early when something isn’t going well and terminates the pregnancy.
This is NOT to say that it’s not heartbreaking – only that it is truly an essential part of how we create so many perfect children. In clinical practice we see that most women have one or two miscarriages in their reproductive years. Another important piece of information is that the ability to get pregnant is mostly unrelated to the ability to stay pregnant – that is to say if you’ve had trouble conceiving you will not necessarily have problems with miscarriage.
So, when is it reasonable to worry that something else might be going wrong?
The general rule of thumb is that if a woman has three or more miscarriages, it is time to investigate and treat the cause, if possible. There are some variations on this. Providers tend to act more slowly in women who have already had successful pregnancies (if a woman’s had three miscarriages, but has four children, the likelihood of a major problem decreases), and more quickly in women who haven’t had any successful pregnancies, are older or have other conditions such as an autoimmune disease. In these circumstances, investigation often begins after two consecutive miscarriages.
Is the rate of miscarriage higher in women with autoimmune conditions?
Research over the past two decades has provided us an enormous amount of information regarding many of the causes and treatments for recurrent miscarriage and we now know that autoimmunity certainly plays a role. Even when all other possible factors are accounted for (age, weight, drugs/alcohol use, etc.), the rate of miscarriage in women with autoimmune disease is slightly higher than in the general population.
Furthermore, scientists have identified the precise mechanism at fault in certain situations, such as the antiphospholipid syndrome (a blood clotting disorder), lupus antibody, and type I diabetes. In other situations, such as the presence of anti-thyroid antibodies, we have clear evidence of an association between the antibodies and increased miscarriage rates and providers know to regularly check these labs. Experienced fertility specialists and high-risk pregnancy doctors will occasionally try unproven (though considered safe) treatment options to optimize thyroid function and reduce the antibody levels.
But this is likely the tip of the iceberg and we’ve got a long way to go in our understanding. In fact, while it is still in its infancy and likely not available to most patients just yet, there is an emerging field of medicine known as Reproductive Immunology geared at understanding the role of the immune system when a woman’s body repeatedly rejects pregnancy. For now, the approach to recurrent miscarriage is to run all the tests that are available and for which we have solutions (remember, from a medical standpoint, we don’t run tests if we don’t have a way to address the answer we get), treat anything that needs treatment, and then try a host of other interventions such as added hormones, mild anti-clotting agents (such as aspirin), or immune modulating medications. It is mentioned in the fertility article on this website, but it bears repeating here: talented fertility doctors and maternal-fetal medicine specialist (high-risk obstetricians, also called MFM) are experts at working with unknowns and often achieve great things, despite having little clarity on what’s causing the problem.
Is there anything I can do to lower my risk of miscarriage and/or improve my care?
There are many things you can do to lower your risk of miscarriage and optimize your healthcare, but few of them deal directly with your autoimmune disease. Start with those issues that are in your control –
- Try to keep your body weight in the healthy range (a BMI of 19-23 is ideal); both underweight and overweight women miscarry more frequently
- Space pregnancies a minimum of 18 months apart (that’s from delivery to next conception)
- Don’t smoke
- Get adequate folic acid (800mcg/day for at least 3 months prior to conception)
- And – while this is a very difficult one to manage – try to not wait until you’re in your later 30s to have your first child
As for the autoimmune disease(s), discuss pregnancy plans and potential risks with your rheumatologist and midwife/obstetrician well ahead of time so if any additional lab work is warranted, it can be obtained. If you have any of the known high risk situations, you might consider a consultation to an MFM doctor prior to pregnancy. Obtain copies of all of your lab results, medications currently taken or tried in the past and clinic notes from past pregnancies or miscarriages and, whenever possible, send them or bring them to your provider before your next visit so he/she has some time to look through them. If you leave the records request up to a busy office staff, it often takes weeks for records to transfer so take the initiative and get them yourself.
Like many situations, there’s not enough research available to recommend or dissuade any particular alternative health intervention, but many people report pregnancy success with herbal or Chinese medicine, acupuncture, Ayurveda or others. Use these as they fit into your life and your beliefs and just let all your caregivers know what you are doing or taking.
If you do suffer from recurrent miscarriage, it’s usually helpful for people to partake in a pregnancy-loss therapy group or see an experienced therapist to help with the emotional pain. There is no denying that recurrent miscarriage is a challenging, stressful and sad situation but there is good reason to be hopeful as the right combination of time, patience and experienced providers will very often result in a happy ending.
Questions for your provider:
- Given my specific autoimmune disease(s), are there any known issues that need to be addressed or checked prior to attempting conception?
- Can you recommend an obstetrician or maternal-fetal medicine specialist who has an interest or specialization in autoimmune-related miscarriage?
- Are my medications safe for pregnancy and, if not, how will my autoimmune disease be managed and when should I switch medications?
About the Author
Kathi Kuntz, RN, MSN holds a Bachelor’s and a Master’s Degree in Nursing from the University of Pennsylvania. Her specialization is in the healthcare of women and her graduate research thesis was on autoimmune disease in pregnancy. She has over ten years of clinical practice experience. Currently, Kathi is on an adventure living and traveling with her husband and two young sons in Australia.