Recurrent Pregnancy Loss - Naturopathic Perspectives

www.samanthabellnd.com/

A miscarriage is defined as a pregnancy loss occurring during the first 20 weeks of pregnancy. An early pregnancy loss is defined as a pregnancy loss that occurs during gestational weeks 0–12 (the first trimester). About 15–20% of pregnancies end in pregnancy loss, with the majority—approximately 80%—occurring in the first trimester. Early pregnancy loss is most commonly caused by fetal chromosomal abnormalities.[1] With individuals dealing with recurrent pregnancy loss, the loss often occurs prior to 10 weeks’ gestation.[2]

Majority of individuals with recurrent pregnancy loss will often have limited insight as to what causes the miscarriages, but many (approximately 75%), even without intervention, can achieve successful pregnancies after their recurring miscarriages.[2] As naturopathic doctors, we are well-equipped to investigate potential causes and provide support for the prevention of pregnancy loss. Several conditions can predispose to recurring pregnancy loss and should be investigated by an individual’s health-care team.

Progesterone Deficiency

If the pregnancy loss is due to low or insufficient progesterone, the loss typically occurs at 6 weeks or earlier.[2]

Polycystic Ovarian Syndrome (PCOS)

Many studies suggest that the relationship between PCOS and miscarriage is weak, but some suggest that the insulin-resistance factor of PCOS is the greatest concern for increased miscarriage risk.[2] Diet and exercise are considered first-line treatments for individuals with PCOS and can greatly improve insulin sensitivity.

Poorly Controlled Diabetes Mellitus (Type I or II)

Again, insulin resistance is of concern and has been associated with increased risk of pregnancy loss in women with poorly controlled type I or II diabetes.There is a direct correlation between hemoglobin A1C (HbA1C; a marker of average blood glucose level) and the rate of pregnancy loss.[3] Therefore, diet and exercise will also be crucial to the care of diabetic patients dealing with pregnancy loss.

Antiphospholipid Syndrome (APS)

Antiphospholipid syndrome is an autoimmune disorder associated with recurrent pregnancy loss and is characterized by moderate to high levels of antiphospholipid antibodies. Two main clinical features of APS include vascular thrombosis and varying forms of recurrent pregnancy loss.[2] As discussed, most recurrent early pregnancy loss occurs before 10 weeks’ gestation, but individuals with APS often have loss after this gestational period.

Celiac Disease

Not only is celiac disease associated with an increased risk of pregnancy loss, but it can also increase the risk of intrauterine growth restriction and stillbirth.[2] Suppression of antibodies through dietary control can decrease the incidence of miscarriage.[2] Guiding individuals through strict gluten-free eating guidelines is of utmost importance in patients who have celiac disease.

Thyroid Disease

Hypothyroidism (including Hashimoto’s thyroiditis) and even subclinical hypothyroidism are associated with increased risk for miscarriage.[2] The 2012 American Society for Reproductive Medicine (ASRM) guidelines for treatment of recurring pregnancy loss states that TSH levels above 2.5 mIU/L are considered outside of the normal range. Additionally, the Endocrine Society advises that individuals with recurrent pregnancy loss are treated appropriately so that their TSH levels remain between 1 and 2.5 mIU/L.[2] As naturopathic doctors, we also know that using an extended thyroid panel (including thyroid antibodies, free T3, and free T4) is also of great use in patients who are dealing with recurring pregnancy loss.

Hyperprolactinemia

Elevated prolactin levels can result in luteal-phase defects, resulting in miscarriage. When prolactin levels are elevated, this will cause ovulatory dysfunction, and therefore can also cause problems with becoming pregnant.

Thrombophilia

Thrombophilia can cause both early and late pregnancy loss, but most pregnancy losses caused by inherited thrombophilias tend to occur in the second or third trimesters. As naturopathic doctors, it’s important to assess if a patient’s thrombophilia is caused by a genetic mutation of the methylenetetrahydrofolate reductase (MTHFR) gene.

Endometriosis

A 2017 systematic review determined that endometriosis is a risk factor for miscarriages in spontaneous pregnancies.[4]

Infections

Several infections are associated with pregnancy loss (but not necessarily recurring pregnancy loss), including rubella, parvovirus B19, cytomegalovirus, herpes, Toxoplasma gondii, Listeria monocytogenes, Chlamydia trachomatis, Mycoplasma hominis, and Ureaplasma urealyticum.[3] Bacterial vaginosis can also increase the risk of late miscarriage.[2]

There are also many modifiable factors to consider when preventing pregnancy loss.

Smoking

Smoking appears to increase the risk of miscarriage in a dose-dependent manner— the more cigarettes smoked, the greater the risk—and this risk was increased with as little as 10 cigarettes per day.[2] Paternal smoking may also increase the risk of miscarriage. If both parents smoke, some studies have identified a significantly greater (four-fold) risk of miscarriage, when compared to the nonsmoking participants.[5]

Alcohol Consumption

Women who drank alcohol at least two days a week had a greater risk of miscarriage than those who did not drink at all during pregnancy.[7]

Weight

Being underweight or obese prior to pregnancy can increase the risk of miscarriage. The risk of pregnancy loss is increased with either maternal or paternal obesity.[6]

Caffeine

Moderate consumption (considered to be no more than a total of 200 mg/d) does not appear to increase miscarriage rates, but there appears to be a threshold effect with consumption of a total of 300 mg/d or more, causing a modest increase in risk for pregnancy loss.[2] There isn’t a clear causal relationship between caffeine and miscarriage, but it is advisable to limit caffeine intake while pregnant. Those limiting caffeine intake should be aware of products containing caffeine, such as energy drinks, preworkout drinks, chocolate, and tea (black, green, and white).

Substance Use

Cocaine
The use of cocaine during pregnancy increases the risk of miscarriage, among other prenatal concerns, as cocaine can decrease uterine blood flow. The greater the cocaine abuse, the greater the risk.[8]

Cannabis
There have been no safe threshold limits established for cannabis use, and prenatal use of cannabis can have significant, negative long-term effects on a developing fetus.[9]

Exercise

Exercise is recommended by the American College of Obstetricians and Gynecologists (ACOG), but recommendations vary (and have exceptions) depending on individual cases:[10]

• Exercise is not recommended if a woman has risk factors for vaginal bleeding, preterm labour, or premature rupture of membranes.
• If the pregnant individual did not exercise before pregnancy, the following are deemed safe: swimming, walking, cycling, and aerobics. If a pregnant individual begins exercise while pregnant, she is encouraged to start with 5 minutes of exercise per day, adding 5 minutes per week, until reaching 30 minutes per day of tolerable activity.
• If the pregnant individual was active prior to becoming pregnant, the following are safe in moderation: running, racquet sports, and strength training.
• In all pregnant women, all contact sports, scuba diving, and skiing should be avoided.
• The ACOG recommends avoiding exercises that require the individual to lie on their front (ventral) side after the first trimester.
• The ACOG also encourages women to be aware of (and avoid) exercises that may cause them to overheat or become dehydrated.

Night Work

Fixed night-work shifts have been shown to increase the risk of pregnancy loss, especially during the first trimester. Compared with individuals who work day shifts, women working rotating shifts (rotating between day and night) appeared to have no increased risk for pregnancy loss.[11]

Conclusion

We should always start foundationally. We should investigate and address potential conditions/diseases that are contributing to the risk of pregnancy loss, and guide individuals to improve modifiable risk factors. By optimizing one’s health, we can increase the chances of a healthy, sustained pregnancy. Recurring pregnancy loss can create significant emotional, physical, and even financial strain for individuals/couples who are trying to conceive, and it is important to address the stress and grief that accompany pregnancy loss. Quite simply, this is just as important as addressing all other risk factors. Additionally, it is of critical importance to consider a multifactorial approach to a successful pregnancy—an approach that addresses physical and mental health. When utilizing a multifactorial approach, respectful and synergistic collaboration between health-care professionals and treatment modalities is key.