Introduction: What is pregnancy loss?
Pregnancy loss is the loss of a pregnancy before the 20th week of gestation. This condition is one of the most stressful and emotionally difficult situations for expectant parents. Although many cases of pregnancy loss occur due to random chromosomal abnormalities, recurrent pregnancy loss (two or more episodes) requires a thorough medical examination to identify potential causes. Understanding the etiology, timely diagnosis, and adequate treatment play a key role in improving outcomes for women facing this problem.
The complexity of pregnancy loss lies in the diversity of possible causes, which can range from hormonal imbalances to rare systemic diseases. Often, symptoms indicating serious pathologies can be mistaken for normal manifestations of pregnancy, leading to underdiagnosis and delays in receiving necessary care.
The diversity of causes: from hormones to rare pathologies
The causes of pregnancy loss can be numerous and varied. Let us consider some of them, based on modern scientific data:
Hormonal imbalances
- Gestational diabetes insipidus: This condition often remains underdiagnosed because increased urination (polyuria) may be perceived as a normal phenomenon during pregnancy. However, clinicians observing pregnant women should consider screening for gestational diabetes insipidus, as it may be associated with a serious underlying pathology [1]. Timely detection and treatment of this condition are critical for preventing complications.
- Thyroid diseases: Thyroid dysfunction during pregnancy can lead to serious complications for both the mother and the child. Overt hypothyroidism, as well as subclinical hypothyroidism, are associated with obstetric complications and neurocognitive impairment in offspring [6]. Although universal screening for thyroid dysfunction during pregnancy is not always recommended, a targeted approach to testing high-risk women may miss up to 30-55% of hypothyroidism cases [6]. Neonatal hypothyroidism is the most common treatable cause of intellectual disability, requiring immediate initiation of therapy to prevent abnormal brain development [8].
Hematological disorders
- Thrombotic thrombocytopenic purpura (TTP): This is a rare but potentially life-threatening thrombotic microangiopathy that presents significant diagnostic and therapeutic challenges during pregnancy due to its similarity to conditions such as HELLP syndrome and preeclampsia. Early detection of TTP requires timely diagnosis of unexplained thrombocytopenia, hemolysis, and neurological symptoms in the absence of hypertension [2].
Infectious factors
- Toxoplasmosis: Infection with Toxoplasma gondii during pregnancy, although rare, can lead to vertical transmission to the fetus. Congenital toxoplasmosis can cause severe neurological or ocular diseases (leading to blindness), as well as cardiac and cerebral anomalies. Prevention of toxoplasmosis through patient education is an important part of prenatal care. However, routine screening is not recommended due to the low prevalence of the disease and limitations in diagnostics and therapy [3].
Structural and vascular anomalies
- Cerebral arteriovenous malformations (AVMs): Pregnancy can increase the risk of hemorrhage in cerebral AVMs. In the event of an AVM rupture during pregnancy, active treatment is required. After an intracranial hemorrhage, pregnant women need to undergo cerebral angiography with adequate protection to clearly define the characteristics of the AVM. For unruptured AVMs without risk factors for bleeding (e.g., absence of concomitant aneurysm, smooth venous drainage, absence of venous ectasia), conservative management is recommended [4].
- Non-immune hydrops fetalis: This condition, characterized by abnormal fluid accumulation in two or more fetal compartments, requires thorough examination and management. The goal is to identify treatable or recurrent etiologies for better counseling and management of cases diagnosed prenatally [5].
Comprehensive examination: the key to accurate diagnosis
Diagnosing the causes of pregnancy loss requires a systematic and comprehensive approach. It is important not only to identify obvious problems but also to pay attention to less common conditions that may be underestimated.
Anamnesis collection and physical examination
A thorough collection of medical history, including information about previous pregnancies, chronic diseases, family history, and lifestyle, is the first and one of the most important steps. A physical examination may reveal signs indicating systemic diseases.
Laboratory studies
- Hormonal profile: Assessment of thyroid function (TSH, free T4 levels) is mandatory, especially for women in the high-risk group [6]. If gestational diabetes insipidus is suspected, especially in the presence of polyuria, screening should be considered [1].
- Hematological indicators: In cases of unexplained thrombocytopenia, anemia, elevated lactate dehydrogenase levels, and the presence of schistocytes in a peripheral blood smear, TTP must be excluded by determining ADAMTS13 activity [2].
- Infectious screening: Although routine screening for toxoplasmosis is not recommended, testing may be required if risk factors or clinical manifestations are present [3].
Instrumental methods
- Ultrasound examination (US): Allows for the assessment of the fetal condition, identification of structural anomalies such as non-immune hydrops fetalis, and determination of its possible causes [5].
- Cerebral angiography: When cerebral AVMs are suspected, especially after an intracranial hemorrhage, angiography is a key method for accurate diagnosis. With proper protection, the radiation dose is considered safe for pregnant women [4].
The importance of early screening
Early detection of conditions such as gestational diabetes insipidus [1] or TTP [2] is crucial for the timely initiation of treatment and improvement of the prognosis. Targeted testing for high-risk groups can be effective, but it is important to remember that it may miss a significant portion of cases, such as hypothyroidism [6].
Modern treatment and prevention strategies
Treatment of pregnancy loss should always be individualized and based on the identified cause. The goal is not only to maintain the current pregnancy but also to prevent future losses.
Individual approach
Each case of pregnancy loss is unique, and the treatment plan should be developed taking into account all factors, including the patient's medical history, examination results, and potential risks.
Drug therapy
- Hormonal correction: For hypothyroidism, levothyroxine is prescribed, which helps normalize thyroid function and prevent complications for the mother and fetus [6, 8]. Treatment of gestational diabetes insipidus is aimed at controlling blood glucose levels [1].
- Immunosuppressants and plasmapheresis: For TTP, the use of corticosteroids and daily plasmapheresis is indicated, which significantly improves the patient's condition and the outcome of the pregnancy [2].
- Antibacterial/antiparasitic therapy: In confirmed toxoplasmosis, specific drugs may be prescribed to reduce the risk of vertical transmission and the severity of congenital infection [3].
Surgical interventions
In cases where the cause of pregnancy loss is structural anomalies, such as ruptured cerebral AVMs, active neurosurgical or endovascular treatment may be required. In this case, it is important to consider the safety of the procedures for the pregnant woman and the fetus [4].
Preventive measures and education
Prevention of toxoplasmosis includes educating pregnant women on hygiene rules, avoiding contact with raw meat and cat feces [3]. For women with unruptured AVMs without risk factors for bleeding, conservative management is recommended [4].
Conclusion: Hope and support
Pregnancy loss is a complex medical and emotional problem that requires a multidisciplinary approach. Timely and accurate diagnosis, based on a thorough examination, is the cornerstone of successful management of such patients. Modern treatment methods, from hormonal correction to complex surgical interventions, offer hope for a favorable outcome. It is important to remember that early diagnosis and adequate therapy can significantly improve the chances of a successful pregnancy and the birth of a healthy child. Support and patient education play an equally important role in this process.
Sources
- Gestational diabetes insipidus: a review of an underdiagnosed condition. (Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC, 2010)
https://pubmed.ncbi.nlm.nih.gov/20500966/ - A rare case of pregnancy-associated thrombotic thrombocytopenic purpura. (Oxford medical case reports, 2026)
https://pubmed.ncbi.nlm.nih.gov/42306559/ - No. 285 — Toxoplasmosis in pregnancy: prevention, screening, and treatment. (Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC, 2018)
https://pubmed.ncbi.nlm.nih.gov/30103893/ - Clinical characteristics and treatment of cerebral AVMs during pregnancy. (The neuroradiology journal, 2015)
https://pubmed.ncbi.nlm.nih.gov/26246089/ - No. 363 — Examination and management of non-immune hydrops fetalis. (Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC, 2018)
https://pubmed.ncbi.nlm.nih.gov/30103882/ - Update on the management of thyroid disease during pregnancy. (Endocrinology and metabolism (Seoul, Korea), 2016)
https://pubmed.ncbi.nlm.nih.gov/27546871/ - Thyroid disease in newborns: testing and management. (Pediatric clinics of North America, 2019)
https://pubmed.ncbi.nlm.nih.gov/30819341/
The information provided in this article is for reference purposes only and cannot replace consultation with a qualified medical professional. All decisions regarding diagnosis and treatment should be made only after consultation with a doctor.