Saudi Journal of Biological Sciences 27 (2020) 2809–2817

Contents lists available at ScienceDirect

Saudi Journal of Biological Sciences

journal homepage: www.sciencedirect.com

Original article

Evaluation of etiology and pregnancy outcome in recurrent miscarriage

patients
Shafat Ali a,b,⇑, Sabhiya Majid b, Md. Niamat Ali a,⇑, Shahnaz Taing c, Hamed A. El-Serehy d,
Fahad A. Al-Misned d
a
Cytogenetics and Molecular Biology Laboratory, Centre of Research for Development, University of Kashmir, Srinagar, J&K 190006, India
b
Department of Biochemistry, Government Medical College, Srinagar, J&K 190010, India
c
Department of Obstetrics and Gynaecology, Government Medical College Associated Lalla Ded Hospital, Srinagar, J&K 190012, India
d
Department of Zoology, College of Science, King Saud University, Riyadh 11451, Saudi Arabia

a r t i c l e i n f o a b s t r a c t

Article history: The purpose of this study was to evaluate etiology and pregnancy outcome of recurrent miscarriage
Received 29 April 2020 women. The enrolled patients (280) were evaluated for Triiodothyronine, Thyroxine, Thyroid stimulating
Revised 19 June 2020 hormone, prolactin, chromosomal analysis, Haemoglobin A1C, blood sugar, Magnetic resonance imaging,
Accepted 29 June 2020
3D-ultrasound, auto-antibodies profile (antiphospholipid antibodies, anticardiolipin antibodies, lupus
Available online 3 July 2020
anticoagulant, antinuclear antibodies, anti-thyroid antibodies and b2 glycoprotein1), torch profile
(Toxoplasmo gondii, rubella, cytomegalo virus and herpes simplex virus), blood vitamin D3 levels, psy-
Keywords:
chological factors, Body mass index and thrombotic factors (protein S and C deficiency, Prothrombin
Etiology
Pregnancy
G20210A mutation, anti-thrombin III, Factor V Leiden and Methylenetetrahydrofolate reductase muta-
Recurrent miscarriage tion), uterosalpingography (hysteronsalpingography) and hysteroscopy. The therapeutic regimens either
Pregnancy outcome singly or combined were employed for the treatment of recurrent miscarriage patients on the basis of eti-
Management ology (single or multiple) and include intravenous immunoglobulin, low molecular weight heparin, low
Enocrinopathy dose aspirin, levothyroxine, progesterone, folic acid, human chorionic gonadotrophin, vitamin D3, psy-
chotherapy, genetic counselling. However, patients with idiopathic recurrent miscarriage were treated
with progesterone supplementation, anticoagulation and/or immune modulatory agents. The incidence
of primary recurrent miscarriage was highest and most of the women experienced recurrent miscarriage
during first trimester. Endocrinological disorders (39%) were found as the major pathological factor for
recurrent miscarriage. Other factors include uterine abnormalities (5.7%), vitamin D3 deficiency (3.5%),
psychological factors (3.2%) infection (3.6%), autoimmune abnormalities (1.8%) and protein S deficiency
(1.8%). However, 40% cases were idiopathic. The overall live birth rate achieved after the management
of recurrent miscarriage patients was 75.7%. Enocrinopathy was the major cause of recurrent miscarriage.
The overall live birth rate achieved was 75.7% with highest pregnancy outcome in secondary recurrent
miscarriage patients after the management.
Ó 2020 The Authors. Published by Elsevier B.V. on behalf of King Saud University. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

⇑ Corresponding authors at: Cytogenetics and Molecular Biology Laboratory, The process of reproduction in human beings is characterized
Centre of Research for Development, University of Kashmir, Srinagar, J&K 190006, by inefficiency. Early loss of pregnancy is perhaps the most wide-
India. spread obstetric problem that occurs in over two thirds of human
E-mail addresses: [email protected] (S. Ali), [email protected] conceptions (Silver and Warren, 2006). Clinically recognized preg-
(Md. Niamat Ali). nancy loss is widespread that influences about 15–25% of pregnan-
Peer review under responsibility of King Saud University. cies (ASRM, 2012, D’Ippolito et al., 2020). Miscarriage is the loss of
foetus earlier than the 23rd week of gestation (Kruger and Botha,
2007). Usually recurrent miscarriage (RM) is defined as the failure
of 3 or more successive clinically documented conceptions prior to
Production and hosting by Elsevier 20 weeks of development. However according to American Society

https://doi.org/10.1016/j.sjbs.2020.06.049
1319-562X/Ó 2020 The Authors. Published by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
2810 S. Ali et al. / Saudi Journal of Biological Sciences 27 (2020) 2809–2817

for Reproductive Medicine (ASRM) RM is defined as two or more and heparin and administration of progesterone, anticoagulation
consecutive pregnancy losses recognized by ultrasound or and/or immune modulatory agents in patients with unexplained
histopathology (ASRM, 2008, 2012). Nevertheless, less than 5% of RM. Even if these treatment protocols over the years have been
conceived human females undergo 2 consecutive miscarriages found to improve the outcome of pregnancy in RM patients
and merely 1% experiences 3 or more (ASRM, 2008, Stephenson (Kolte et al., 2015) but have not completely solved the problem.
and Kutteh, 2007, Branch et al., 2010, ASRM, 2013, Grimstad and This necessitates further investigation in the etiology and manage-
Krieg, 2016). Clinically apparent RM among Indian women is ment of RM. The study was undertaken due to the lack of research
observed to be 7.46% (Patki and Chauhan, 2016). RM is considered data on the etiology and management of RM in the present popu-
as a significant reproductive health matter since it affects a large lation and to determine major contributing factors as well as to
number of pregnancies. The frequency of RM differs broadly among reduce the ambiguity of idiopathic RM that causes mental trauma
research reports due to variations in the meaning and decisive fac- in affected couples and clinicians. The present study may serve as
tors used, in addition to the distinctiveness of populations. The risk an assisting guide for the clinicians during study and treatment of
of pregnancy loss subsequent to first two, three and four successive RM.
miscarriage is 30%, 33% and 40% respectively in patients with no
previous live birth (Ford and Schust, 2009). Primary RM stands
for the collapse of several pregnancies in a woman without any 2. Materials and methods
previous live birth while secondary RM means multiple pregnancy
failures in a woman after at least one successful pregnancy (Silver 2.1. Study design
et al., 2011, Kolte et al., 2015, El Hachem et al., 2017). The various
known set of causes associated with RM include parental chromo- This was a prospective outpatient clinic-based cohort study car-
somal aberrations, uterine malformations, infectious diseases, ried out in 280 RM patients enrolled for the study. Majority of the
endocrine problems, and autoimmune defects; nevertheless, the women (196) experienced two consecutive miscarriages and the
causes remain idiopathic in around 50% of RM cases (Ford and remaining 84 had undergone more than two successive miscar-
Schust, 2009, Fritz and Speroff, 2012, Jeve and Davies, 2014, riages. The patients who visited the antenatal clinics for regular
Arias-Sosa et al., 2018, Ali et al., 2020) (Fig. 1). Many chromosomal health check were screened for eligibility criteria and data avail-
anomalies have been reported to be connected with unexplained ability. The clinical details were obtained from RM patients via
RM and these anomalies include skewed X inactivation, sperm keen observation of their diagnostic investigations and prescrip-
DNA fragmentation, length of telomeres and micro deletions in tion cards as well as interview as per the pre-structured question-
the Y chromosome that are not identified by conventional cytoge- naire for the study to properly record the details as per hospital
netic techniques. However, the association of these abnormalities protocol. The patients were tested for T3 (Triiodothyronine), T4
with idiopathic RM is still controversial due to variations in results (Thyroxine), TSH (Thyroid Stimulating Hormone), prolactin, chro-
among different studies, populations as well as definitions of the mosomal analysis, HbA1C (Hemoglobin A1C), blood sugar, MRI
disease (Arias-Sosa et al., 2018). Conversely, immunological rejec- (Magnetic Resonance Imaging), 3D-ultrasound, auto antibodies
tion may account for most of these unexplained cases of pregnancy profile (antiphospholipid antibodies, anticardiolipin antibodies,
loss (Ghaebi et al., 2017). RM is an extremely heterogeneous con- lupus anticoagulant, antinuclear antibodies, anti-thyroid antibod-
dition (Ali et al., 2020). The success of pregnancy depends on ies and b2 glycoprotein1), torch profile (Toxoplasmo gondii,
proper and balanced communiqué between the mother and fetus rubella, cytomegalo virus and herpes simplex virus), blood VD3
by means of placental and decidual tissue. Any interruption or (Vitamin D3) levels, psychological factors, BMI (body mass index)
deviation in the signaling may bring about the pregnancy failure and thrombotic factors (protein S and C, Prothrombin G20210A
(Rull et al., 2012, Grimstad and Krieg, 2016). RM is a challenging mutation, antithrombin III, factor V Leiden and MTHRF
reproductive condition that leads to psychological stress in (Methylenetetrahydrofolate reductase) mutation), uterosalpingog-
affected couple, their families and physicians. Different treatment raphy (hysterosalpingography) and hysteroscopy. All the tests
regimens have been employed for the management of this critical were performed in accordance with relevant guidelines and regu-
reproductive problem such as correction of uterine alterations by lations by following the guidelines of ESHRE (European Society of
surgery, treatment of antiphospholipid syndrome with aspirin Human Reproduction and Embryology), November 2017. Psycho-
logical assessment for stress was performed using validated scales
such as Fertility Problem Inventory (FPI), Hospital Anxiety and
Depression Scale (HADS), and Perceived Stress Scale (PSS). Polycys-
tic ovarian syndrome (PCOS) was diagnosed on the basis of criteria
established by ESHRE and ASRM. According to these scientific soci-
eties PCOS diagnosis requires at least two of the three criteria:
oligo-ovulation or an-ovulation, biochemical and/or clinical
hyper-androgenism, and polycystic ovaries as visible on
ultrasound.
All the patients were given different RM management therapies
during their pregnancy period for carrying the gestation success-
fully to full term. The therapies include levothyroxine, proges-
terone, folic acid, hCG (human chorionic gonadotrophin), LMWH
(low molecular weight heparin), LDA (low-dose aspirin), VD3 (vita-
min D3), intravenous immunoglobulin (IVg), psychotherapy,
genetic counselling. The therapeutic regimens were given either
singly or combined on the basis of etiology (single or multiple).
However, patients with idiopathic recurrent miscarriage were trea-
ted with progesterone supplementation, anticoagulation and
Fig. 1. Etiology of RM. Showing the proportion of various known and unknown immune modulatory agents (Table 1). Informed consent in both
causes of RM (Ford and Schust, 2009, Jeve and Davies, 2014). English and vernacular was taken from the participants. This study
 S. Ali et al. / Saudi Journal of Biological Sciences 27 (2020) 2809–2817 2811

Table 1
Therapeutic interventions for preventing recurrent miscarriage and increasing 4. Exclusion criteria for patients:
pregnancy outcome.

S. Etiology of RM Therapeutic and preventive  Patients with a history of only one miscarriage.
NO interventions  Patients with a history of two or more induced abortions.
1. Uterine Bicornuate uterus Metroplasty
abnormalities Fibroids/ Myomectomy
myometrial fibroids Polypectomy 5. Statistical analyses
Cervical polyps Cerclage
Cervical weakness The data collected was statistically analyzed using SPSS version
2. Endocrinological Hypothyroidism Levothyroxine 20.0 (Chicago, IL, USA). The groups were compared using
disorders Hyperprolactinemia Bromocriptine/cabergoline
Diabetes mellitus Insulin
Chi-square test and t-test. Results were assumed statistically
Polycystic ovarian Metformin significant at p < 0.05.
syndrome Surgical intervention
Single ovarian cysts
3. Genetic Maternal Pre-conceptional genetic 6. Results
abnormalities Paternal counselling
Embryonic
4. Autoimmune Antiphospholipid Low molecular weight
The mean age of enrolled RM patients was 30.5 (±5) years. Mean
defects antibodies (APA) Heparin, height, weight and parity of these patients are given in Table 2.
Lupus Low-dose aspirin, Majority of the women experienced RM during the first trimester,
anticoagulant (LAC) Intravenous some women had second trimester RM and a large percentage of
Anti thyroid immunoglobulin
women undergo RM in either trimesters (Fig. 2). It shows that early
antibodies (ATA) Levothyroxine
Antinuclear supplementation gestational months are the most unsafe period for women that suf-
antibodies (ANA) fer from RM. Additionally, we observed that most of the first trime-
5. Infections Toxoplasma Antiviral drugs ster miscarriages remained unexplained (idiopathic). In this study
gonodii the RM patients with known etiology were 60%. Among these
Cytomegalovirus
Herpes simplex
known causes endocrinological disorders were found as the major
virus pathological factor for RM. They were statistically significant
6. VD3 deficiency VD3 supplementation (p = 0.01) and account for 38.9% cases. Subsequently uterine abnor-
7. Psychological Social trauma, Fear Psychotherapies malities accounted for 5.7% of cases and were highly significant
disorders related to
(p = 0.001). The genetic variances that bring about the first trime-
Pregnancy
8. Obesity Life style interventions/ ster pregnancy losses were found responsible for RM in 0.7% of
Pharmacotherpy cases. Autoimmune abnormalities and Protein S deficiency each
9. Thrombophilic Protein S deficiency Anticoagulants accounted for 1.8%. The auto antibodies have been associated with
factors late first and second trimester abortions. Vitamin D3 deficiency
10 Idiopathic Progesterone
and psychological factors each accounted for 3.5% and 3.2% cases
supplementation, Aspirin,
and immune modulatory respectively. Obesity was found to affect 0.7% RM patients. In addi-
agents tion, infections (p = 0.01) distressed 3.6% cases of RM. However,
40% cases in our study were idiopathic (Table 3). Single defect
was found in 39.3% (110/280) RM women and multiple defects
was approved by Institutional Ethical Committee of Government (two, three or more) were observed in 60.7% (170/280) cases.
Medical College, Srinagar, Jammu and Kashmir, India under the ref-
erence No.121/ETH/GMC.
6.1. Comparison between primary and secondary RM patients

2.2. Study site The women that experienced primary RM had lesser mean age
(30 ± 5) as compared to secondary RM women (31.6 ± 4.7). Simi-
Study was carried out at outpatient antenatal clinics at the larly the mean parity was lesser in primary RM, however, the mean
Department of Obstetrics and Gynecology in Government Medical height and weight was lesser in secondary RM women (Table 4).
College associated Lalla Ded Hospital Srinagar, Jammu and Kash- Most of the women suffered from primary RM. The incidence of
mir, India, during last three years where RM patients come across primary vs. secondary RM found is shown in Fig. 3. Uterine abnor-
from Kashmir for regular checkup. The study site was approval by malities were seen more prevailing in secondary RM (7%) com-
the Institutional Ethics Committee of Government Medical College, pared to primary RM (5.2%). Endocrine defects, chromosomal
Srinagar, Jammu and Kashmir, India. disorders were equally prevalent in both categories. VD3 defi-
ciency was higher in primary RM group (4.3%) as compared to sec-
2.3. Study participants ondary RM group (1.4%). However, autoimmune defects, infections
(p = 0.04), psychological disorders, obesity and thrombophilic fac-
The study included only those antenatal RM cases who fulfilled tors were present only in primary RM cases. Additionally, higher
the below given inclusion and exclusion criteria. proportion of cases was idiopathic in secondary RM group
compared to primary RM group (Table 5).
3. Inclusion criteria for patients:
Table 2
 Gravida 3 women or more with at least two consecutive miscar- Basic demopo; graphic and anthropometric characteristics of RM patients.
riages, primary or secondary  24 weeks of gestation.
Age Height(cm) Weight (kg) Parity
 All patients were Kashmiri women population.
30.5 ± 5 144 ± 14.6 72 ± 11.8 0.23 ± 0.5
 The age of patients ranged between 18 and 45 years.
 Patients who willingly signed the consent form. Values are presented as mean ± SD
2812 S. Ali et al. / Saudi Journal of Biological Sciences 27 (2020) 2809–2817

6.2. Comparison between patients with two and more than two
consecutive miscarriages

The mean age of women with two consecutive miscarriages

and more than two miscarriages was similar. Similarly the mean
parity was higher in the group with two miscarriages compared
to the group with more than two miscarriages. The mean height
was almost similar in both groups. However, mean weight was
higher in the group with two miscarriages. The rate of miscar-
riage was higher in women with two miscarriages compared
Fig. 2. RM in different trimesters. Shows the incidence of first trimester, second to those with more than two miscarriages (70% vs. 30%)
trimester and both trimester RMs. (Table 6).

Table 3
Different causes of RM. Illustrating the etiology of RM along with their contributing percentage as well as the proportion of idiopathic RM cases.

Etiology/causes Sub-causes of RM Present Absent Cases in Mean ± SD p Screening Techniques Percentage

of RM each value of each cause
etiology (n %)
(N)
Uterine Bicornuate uterus 2 14 16 8 ± 8.48 0.001 MRI ,3D-ultrasound, (16/280)
abnormalities Fibroids/ myometrial 6 10 8 ± 2.82 Hysterosalpingography, 5.7%
fibroids Hysteroscopy
Cervical polyps 5 11 8 ± 2.82
Cervical weakness 2 14 8 ± 4.24
Utero-placental 1 15 8 ± 9.89
insufficiency
Endocrinological Hypothyroidism 84 25 109 54.5 ± 41.71 0.01 T3, T4, TSH, (109/280)
disorders (TSH  4.0llU/mL) Hb A1C, Blood sugar, 38.9%
Hyperprolactinemia 2 107 54.5 ± 74.24 Ultrasound, Prolactin
(Prolactin  17.9 ng/
mL)
Diabetes mellitus 11 98 54.5 ± 60.10
Polycystic ovarian 5 104 54.5 ± 70.00
syndrome
Single ovarian cysts 7 102 54.5 ± 65.76
Genetic Maternal 2 0 2 1 ± 1.41 0.5 Karyotyping (2/280)
abnormalities Paternal 0 2 0.7%
Embryonic 0 2
Autoimmune Antiphospholipid 1 4 5 2.5 ± 2.12 1.7 Auto antibodies profile test (5/280)
defects antibodies (APA) (APA, ACA, ATA,ANA, LAC, b2 glycoprotein 1) 1.8%
Anticardiolipin 0 5 2.5 ± 3.53
antibodies (ACA)
Anti thyroid 1 4 2.5 ± 2.12
antibodies (ATA)
Antinuclear 2 3 2.5 ± 0.70
antibodies (ANA)
Lupus anticoagulant 1 4 2.5 ± 2.12
(LAC)
b2 glycoprotein1 0 5 2.5 ± 3.53
Infections Toxoplasma gonodii 4 6 10 5 ± 1.41 0.01 Torch profile test (TG,CGV,HSV, Rubella) (10/280)
Cytomegalovirus 2 8 5 ± 4.24 3.6%
Herpes simplex virus 4 6 5 ± 1.41
Rubella 0 10 5 ± 7.07
VD3 deficiency  10 ng/dl 3 7 10 5 ± 2.82 1.00 Blood VD3 Levels (10/280)
 20 ng/dl 7 3 3.6%
Psychological Social trauma 6 3 9 4.5 ± 2.12 1.00 Psychometric tests (9/280) 3.2%
disorders Fear related to 3 6
Pregnancy
Obesity 25 kg/m2 2 0 2 1 ± 1.41 1.00 BMI (body mass index) (2/280) 0.7%
30 kg/m2 0 2
Thrombophilic Protein S deficiency 5 0 5 2.5 ± 3.53 0.2 Thrombotic tests (5/280) 1.8%
factors Protein C deficiency 0 5 (Factor V Leiden, Prothrombin G20210A
Factor V Leiden 0 5 mutation, Protein S activity, Antithrombin
Prothrombin 0 5 activity, Protein C activity)
G20210A mutation
MTFHR mutation 0 5
Idiopathic 112 – 168 No Test positive (112/280)
40%
 S. Ali et al. / Saudi Journal of Biological Sciences 27 (2020) 2809–2817 2813

Table 4
Basic demographic and anthropometric characteristics of primary and secondary RM patients.

Primary RM patients (n = 209) Secondary RM patients (n = 71)

Age Height Weight Parity Age Height Weight Parity
30 ± 5 145.3 ± 14.4 73 ± 12 0.11 ± 0.4 31.6 ± 4.7 140 ± 14.6 69 ± 10.7 0.66 ± 0.99

Values are presented as mean ± SD.

Uterine deformities were seen widespread in women with category with two miscarriages (3%). Autoimmune defects were
3miscarriages (7%) compared to women with two miscarriages higher in women with 3 miscarriages (2.3%) as compared to
(5%). Endocrine defects were more prevalent in women with 3 women with two miscarriages (1.5%). However, genetic disorders,
miscarriages (45.4%) compared to women with two miscarriages obesity and thrombophilic factors were observed only in women
(23.8%). Infections and VD3 deficiency was equally prevalent in both with 3 miscarriages. Additionally, higher proportion of cases was
categories but psychological disorders were found slightly higher in idiopathic in the group with 3 miscarriages (50%) compared to
the category of women with 3 miscarriages (3.5%) compared to the the group with two consecutive miscarriages (34.7%) (Table 7).

6.3. Pregnancy outcome index of RM women

All the women enrolled in the study were pregnant. After the
management of these women the overall rate of live birth was
76% with mean period of gestation equal to 37.78 ± 3.61. Miscar-
riages took place in 68 women. The live birth rate in women with
primary RM was 73.7% (154/209) and those of secondary RM
women was 81.6% (58/71) with almost similar mean period of ges-
tation in both groups. Live birth rate was higher in case of sec-
ondary RM as compared to primary RM (81.6 vs. 73.7). However,
the rate of live birth was almost similar in 2 RM and 3 RM women
Fig. 3. Different types of RM. Illustrates the respective incidence of primary vs. (73.9% vs. 79.7%). The gestational weeks were similar in either
secondary RM among women of reproductive age group. group (Table 8).

Table 5
Comparison between the etiologic factors of primary RM and secondary RM.

Etiology/ causes of RM Sub-causes of RM Primary RM (n = 209) N% Secondary RM (n = 71) N% p value

Uterine abnormalities Bicornuate uterus 2 11/209 (5.2%) 0 5/71 (7%) 0.22
Fibroids/ myometrial fibroids 2 4
Cervical polyps 4 1
Cervical weakness 2 0
Utero-placental insufficiency 1 0
Endocrinological Hypothyroidism (TSH  4.0llU/mL) 59 81/209 (38.7) 25 28/71 0.39
disorders Hyperprolactinemia (Prolactin  17.9 ng/ 2 0 (39.4%)
mL)
Diabetes mellitus 8 3
Polycystic ovarian syndrome 5 0
Single ovarian cysts 7 0
Genetic abnormalities Maternal 1 1/71 (1.4%) 1 1/71 (1.4%) 1.00
Paternal 0 0
Embryonic 0 0
Autoimmune defects Anti phospholipid antibodies (APA) 1 5/209 (2.4%) 0 – 0.06
Anticardiolipin antibodies (ACA) 0 0
Anti thyroid antibodies (ATA) 1 0
Antinuclear antibodies (ANA) 2 0
Lupus anticoagulant (LAC) 1 0
b2 glycoprotein1 0 0
Infections Toxoplasma gonodii 4 10/209 (4.7%) 0 – 0.04
Cytomegalovirus 2 0
Herpes simplex virus 4 0
Rubella 0 0
VD3 deficiency  10 ng/dl 2 9/209 (4.3%) 1 1/71 (1.4%) 0.25
 20 ng/dl 7 0
Psychological disorders Social trauma 6 9/209 (4.3%) 0 – 0.09
Fear related to Pregnancy 3 0
Obesity 25 kg/m2 2 2/209 (0.9%) 0 – 0.42
30 kg/m2 0 0
Thrombophilic factors Protein S deficiency 5 5/209 (2.4%) 0 – 0.34
Protein C deficiency 0 0
Factor V Leiden 0 0
Prothrombin G20210A mutation 0 0
MTFHR mutation 0 0
Idiopathic 78 78/209 34 34/71 (48%)
(37.5%)

Values are presented as mean ± SD and number %.

2814 S. Ali et al. / Saudi Journal of Biological Sciences 27 (2020) 2809–2817

Table 6
Basic demographic and anthropometric characteristics of patients with two and more than two miscarriage.

Two miscarriages (n = 196) More than two miscarriages (n = 84)

Age Height Weight Parity Age Height Weight Parity
30 ± 5 145.3 ± 14.4 73.4 ± 12 0.53 ± 0.81 30 ± 5.4 146 ± 15.2 70.4 ± 10.4 0.27 ± 0.66

Values are presented as mean ± SD.

Table 7
Comparison between the etiologic factors of women with two miscarriage and women with three or more miscarriages.

Etiology/ causes of RM Sub-causes of RM Two Miscarriages N% Three or more Miscarriages N% p

(n = 196) (n = 84) value
Uterine abnormalities Bicornuate uterus 2 10/196 (5%) 0 6/84 (7%) 0.3
Fibroids/ myometrial fibroids 3 3
Cervical polyps 3 2
Cervical weakness 1 1
Utero-placental insufficiency 1 0
Endocrinological Hypothyroidism (TSH  4.0llU/ 68 89/196 16 20/84 0.3
disorders mL) (45.4%) (23.8%)
Hyperprolactinemia 2 0
(Prolactin  17.9 ng/mL)
Diabetes mellitus 11 0
Polycystic ovarian syndrome 5 0
Single ovarian cysts 3 4
Genetic abnormalities Maternal 0 0 2 2/84 (2.3%) 0.3
Paternal 0 0
Embryonic 0 0
Autoimmune defects Antiphospholipid antibodies 1 3/196 (1.5%) 0 2/84 (2.3%) 0.5
(APA)
Anticardiolipin antibodies (ACA) 0 0
Anti thyroid antibodies (ATA) 0 1
Antinuclear antibodies (ANA) 1 1
Lupus anticoagulant (LAC) 1 0
b2 glycoprotein1 0 0
Infections Toxoplasma gonodii 2 7/196 (3.5%) 2 3/84 (3.5%) 0.3
Cytomegalovirus 1 1
Herpes simplex virus 4 0
Rubella 0 0
VD3 deficiency  10 ng/dl 2 7/196 (3.5%) 1 3/84 (3.5%) 0.3
 20 ng/dl 5 2
Psychological disorders Social trauma 4 6/196 (3%) 2 3/84 (3.5%) 0.3
Fear related to Pregnancy 2 1
Obesity 25 kg/m2 0 0 2 2/84 (2.3%) 0.4
30 kg/m2 0 0
Thrombophilic factors Protein S deficiency 0 0 5 5/84 (5.9%) 0.3
Protein C deficiency 0 0
Factor V Leiden 0 0
Prothrombin G20210A mutation 0 0
MTFHR mutation 0 0
Idiopathic 68 68/196 34 42/84 (50%)
(34.7%)

Values are presented as mean ± SD and number %.

Table 8
Pregnancy outcome index of RM women (Primary vs. secondary and two vs. three or more).

Primary vs. secondary RM Two vs.  three RM

Primary Secondary Two RM  Three RM Total
Pregnancy 209 71 196 84 280/280
Live births 154 (73.6) 58 (81.6) 145 (73.9) 67 (79.7) 212/280 (75.7)
Gestational period 37.31 ± 5.47 38.65 ± 1.51 37.91 ± 3.52 37.27 ± 4.32 37.78 ± 3.61

Values are presented as number (%) or mean ± SD.

7. Discussion order to develop advanced treatments as well as precautionary

approaches. In our prospective cohort study, the incidence of pri-
RM is a multi-factorial disorder with a huge proportion of mary and secondary RM was found to be 73.70% and 26% respec-
patients with unidentified etiology that creates complexity in its tively. A previous study also reported almost the same incidence
management and leads to psychological trauma and frustration of different types of RM in that order (Singh et al., 2017). Our study
in affected couples as well as in physicians. As a result, researches was in accord with the earlier studies that also reported a higher
have been carrying out to find out the unknown etiology of RM in incidence of primary RM (Jivraj et al., 2001, Li et al., 2002, Jaslow
 S. Ali et al. / Saudi Journal of Biological Sciences 27 (2020) 2809–2817 2815

et al., 2010). Conversely, Shapira et al. (2012) reported higher inci- in our study had undergone karyotyping. Their karyotyping reports
dence of secondary RM. We explored that known factors affect 60% were normal except two couples where in each case the maternal
of cases. Endocrinological disorders remained as one of the most chromosome 9 had increased heterochromatin region in the long
widespread abnormalities among the RM patient in our study arm [46 + XX, 9(q h +)]. According to our study, 0.7% couples
and influenced 38.9% cases. Our finding is almost consistent with underwent RM due to maternal chromosomal defects. No paternal
some research studies that reported endocrine disorders in 34.3% chromosomal abnormalities were seen. Conversely, the rate of
(Lee et al., 2016) and 46.6% (Vomstein et al., 2016) RM patients. chromosomal aberrations was reported to be 7.75% among
However, there are researches contrary to our study that reported Kashmiri RM couples. The paternal and maternal chromosomal
the endocrine defects in 4.98% (Le et al., 2018), 6% (Babkeret al., alterations were seen as 2.11% and 5.63% (Zargar et al., 2015). In
2013) and 10% (NICE, 2012) RM cases. A different study reported our study, we found that 25% patients had higher age
endocrine pathology in 13.5% RM cases (Jaslow et al., 2010). Fur- (35 years). The same percentage (25.35%) of advanced age has
ther studies reported that 17–20% RM patients were distressed been reported among RM patients of Kashmiri women population
by endocrinological abnormalities (Ford and Schust, 2009, Jeve (Zargar et al., 2015). The higher age of female partner has been
and Davies, 2014, Singh et al. 2017). reported to serve as an independent risk factor for spontaneous
The replacement of thyroid hormone therapy with levothyrox- pregnancy loss (Risch et al., 1988, Abdalla et al., 1993, Andersen
ine improved the outcome of pregnancy in child bearing women et al., 2000, RCOG Green Top Guideline, 2011, Patki and Chauhan,
affected with subclinical hypothyroidism (Reid et al., 2013, Ke, 2016). Vitamin D3 deficiency was reported in 3.6% RM patients
2014). Polycystic ovarian syndrome (PCOS) as the most frequent in our study. This finding has been supported by the study of
endocrinopathy among women of reproductive age increases the Ghaedi et al., 2016 who reported higher prevalence of vitamin
risk of miscarriage. PCOS management with metformin or regula- D3 deficiency (33.3%) in women with RM. Moreover, in the present
tion of body weight appears to decrease the risk of miscarriages. study reproductive tract infections were found associated with RM
Uterine alterations brought about RM among 5.7% of cases in our and affected 3.6% patients. In our study we reported stress as one
study. However, there are research reports according to which of the factor responsible for RM. Our data is support by Qu et al.
uterine alterations account for 10–15% cases of RM (Ford and (2020) who reported higher prevalence of depression and anxiety
Schust, 2009, Jeve and Davies, 2014). Another study reported the in RM women particularly during early stage of pregnancy.
prevalence of structural uterine abnormalities in 6.6% cases which Another study also reported higher level of depression and anxiety
is almost in consistence with our investigation (Dobson and in RM women compared to women with no history of miscarriage
Jayaprakash, 2018). Uterine alterations have been reportedly (Tavoli et al. 2018). RM remained idiopathic in a large section of
detected in up to 19% of women experiencing RM (Li et al., 2002, women giving rise to a challenging situation that augments emo-
El Hachem et al., 2017). The damaging consequences of uterine tional and physical morbidity in affected couples as well as clini-
malformations on pregnancy are well recognized. Research studies cians as a result of the therapeutic dilemma since the
have recommended uterine imaging only in those patients that information about reasons for RM and its accurate management
have undergone two spontaneous consecutive miscarriages since is deficient. Nevertheless, the probability of successful pregnancy
no variations have been observed in the occurrence of uterine among couples with idiopathic RM in future might be 50–70% usu-
abnormality among human females who spontaneously aborted ally depending on the maternal age along with the number of ear-
twice and those who suffered with three or more pregnancy losses. lier pregnancy failures (Lund et al., 2012, Kling et al., 2016). Such
In our study, antiphospholipid antibodies (APLA) including lupus patients should be supported psychologically and reassured of
anticoagulant, anticardiolipin antibodies, antib2 glycoprotein 1 the possibility of successful pregnancy in the future. Clifford
antibodies were reported in 1% cases. Antiphospholipid syndrome et al. (1997) reported the significantly lower rates of miscarriage
(APS) represents a defective autoimmune state characterized by owing to any cause in women attending a specialized clinic during
APLA production, vascular thrombosis or morbid pregnancy early pregnancy as compared to non-attendees. The rate of live
(Miyakis et al., 2006). Conversely, a study reported the prevalence birth was almost similar in each group. Lund et al. (2012) achieved
of APLA in 7.4% cases (Dobson and Jayaprakash, 2018). Another the live birth rate in 66.7% RM affected women in five years after
study reported that 16% of human females affected by RM were their management with progesterone, immunoglobulin, heparin,
diagnosed APLA positive (Noble et al., 2005). One more study steroid or aspirin. Similarly, in Korean RM women the overall rate
reported that 11.29% patients were affected by APLA (Le et al., of live birth reported was 86.8% irrespective of therapeutic regi-
2018). Most of the APLA positive women had merely undergone mens such as intravenous immunoglobulin (IVg), low molecular
early miscarriages and this suggests that all women irrespective weight heparin (LMWH), or low dose aspirin (LDA) (Lee et al.,
of the gestational age of fetal loss ought to be screened for the pres- 2016). In our study, the overall live birth rate achieved was 75.7%
ence of these auto antibodies. The fetal loss rate in female patients after the management of RM patients with single/combined thera-
with APLA is approximately 80%. In the present study, APS inci- peutic regimens such as Levothyroxine, progesterone, folic acid,
dence was less compared to other various studies. In the manage- hCG, LMWH, LDA, VD3, genetic counselling, psychotherapies. Com-
ment of patients with APS, aspirin and heparin has been treatment bined therapy was preferred since many cases had multiple
of choice that leads to successful live births in about 75% of treated defects. The rate of live birth compared between groups (i.e., pri-
women (Kutteh and Hinote, 2014). Among hereditary throm- mary (73.6%) vs. secondary (81.6%) and two miscarriages (73.9%)
bophilias, prothrombin G20210A (3%) and Factor V Leiden (8%) vs. three or more (79.7) was almost similar. However, secondary
mutations are most frequent in Caucasian population (Poter and RM cases seem to have better pregnancy outcome index that needs
Scott, 2005, Jaslow et al., 2010). Antithrombin III deficiency has to be evaluated further with larger studies.
been found in 1.5% RM cases, while protein S deficiency and pro-
tein c deficiency in 3.5% and 1.1% cases respectively (Jaslow
et al., 2010). In the present study none of the RM women was seen 8. Conclusion
affected by prothrombin G20210A, Factor V Leiden and MTFHR
mutations, however, protein S deficiency was found in 1.8% cases. In conclusion, the major factor of RM was endocrionopathy.
In a previous study, Factor V Leiden G1691A and prothrombin However, the association of VD3 deficiency, psychological disor-
G20210A mutations also were found not associated with RM in ders, obesity, protein-S deficiency and increased heterochromatin
Kashmiri women population (Shafia et al., 2017). Only 20% couples region in long arm of maternal chromosome 9 with RM was
2816 S. Ali et al. / Saudi Journal of Biological Sciences 27 (2020) 2809–2817

reported for the first in this population. In our study 40% patients El Hachem, H., Crepaux, V., May-Panloup, P., Descamps, P., Legendre, G., Bouet, P.E.,
2017. Recurrent pregnancy loss: current perspectives. Int. J. wom. Heal. 9, 331.
represent a heterogeneous group experiencing idiopathic RM.
https://doi.org/10.2147/IJWH.S100817.
The overall live birth rate achieved was 75.7% with highest preg- Ford, H.B., Schust, D.J., 2009. Recurrent pregnancy loss: etiology, diagnosis and
nancy outcome in secondary RM patients after the management. therapy. Rev. Obstet. Gynecol. 2, 76–83.
The reproductive outcome in women with idiopathic RM may be Fritz, M.A., Speroff, L., 2012. Clinical Gynecologic Endocrinology and Infertility,
Eighth ed. Lippincott Williams & Wilkins.
very much improved via effective and productive psychiatric ther- Ghaebi, M., Nouri, M., Ghasemzadeh, A., Farzadi, L., Jadidi-Niaragh, F., Ahmadi, M.,
apy, antenatal counseling, psychosomatic support, tender care love Yousefi, M., 2017. Immune regulatory network in successful pregnancy and
and reassurance of live births in subsequent pregnancies. Further- reproductive failures. Biomed. Pharmacother. 88, 61–73. https://doi.org/
10.1016/j.biopha.2017.01.016.
more, exhaustive well structured researches are necessitated in Grimstad, F., Krieg, S., 2016. Immunogenetic contributions to recurrent pregnancy
etiology, reproductive immunology and medicine for the manage- loss. J. Assist. Reprod. Genet. 33, 833–847. https://doi.org/10.1007/s10815-016-
ment of this disorder. 0720-6, https://doi: 10.1097/01.grf.0000211959.53498.a4.
Ghaedi, N., Forouhari, S., Zolghadri, J., Sayadi, M., Nematollahi, A., Khademi, K., 2016.
Vitamin D deficiency and recurrent pregnancy loss in Iranian women. Glob. Adv.
Acknowledgements Res. J. Medic. Med. Sc. 5 (6), 194–198.
Jaslow, C.R., Carney, J.L., Kutteh, W.H., 2010. Diagnostic factors identified in 102
women with two versus three or more recurrent pregnancy losses. Fertil. Steril.
This research work has not been presented at any scientific meet- 93, 1234–1243. https://doi.org/10.1016/j.fertnstert.2009.01.166.
ing previously. We are indebted to the Department of Obstetrics Jeve, Y.B., Davies, W., 2014. Evidence-based management of recurrent
and Gynecology and Department of Biochemistry, Government miscarriages. J. Hum. Reprod. Sci. 7, 159–169. https://doi.org/10.4103/0974-
1208.142475.
Medical College (GMC-Srinagar), for their collaboration that made
Jivraj, S., Anstie, B., Cheong, Y.C., Fairlie, F.M., Laird, S.M., Li, T.C., 2001. Obstetric and
the work possible. The authors are also thankful to all patients who neonatal outcome in women with a history of recurrent miscarriage: a cohort
participated in this study. Special thanks are due to Centre of study. Hum. Reprod. 16, 102–106. https://doi.org/10.1093/humrep/16.1.102.
Research for Development, University of Kashmir, Srinagar, J&K, Ke, R.W., 2014. Endocrine basis for recurrent pregnancy loss. Obstet. Gynecol. Clin.
North. Am. 41, 103–112. https://doi.org/10.1016/j.ogc.2013.10.003.
India. The authors would like to extend their sincere appreciation Kling, C., Magez, J., Hedderich, J., von Otte, S., Kabelitz, D., 2016. Two-year outcome
to the Researchers Supporting Project Number (RSP-2020/19), King after recurrent first trimester miscarriages: prognostic value of the past
Saud University, Riyadh, Saudi Arabia. obstetric history. Arc. Gynecol. Obstet. 293, 1113–1123. https://doi.org/
10.1007/s00404-015-4001-x.
Kolte, A.M., Bernardi, L.A., Christiansen, O.B., Quenby, S., Farquharson, R.G., Goddijn,
Author contribution M., Stephenson, M.D., 2015. Terminology for pregnancy loss prior to viability: a
consensus statement from the ESHRE early pregnancy special interest group.
Hum. Reprod. 30, 495–498. https://doi.org/10.1093/humrep/deu299.
SA collected patient details, samples, performed experiments Kruger, T.F., Botha, M.H., 2007. Clinical Gynaecology, Third ed. Juta and Company
and wrote the paper and developed tables. SM provided laboratory Ltd, Cape Town, South Africa.
Kutteh, W.H., Hinote, C.D., 2014. Antiphospholipid antibody syndrome. Obstet.
facilities and helped in experimentation. MNA, HAE, FAA helped in
Gynecol. Clin. North. Am. 41, 113–132. https://doi.org/10.1016/j.
writing the manuscript and prepared figures. ST provided blood ogc.2013.10.004.
samples and helped in performing laboratory tests and SA also per- Le, T.A.D., Nguyen, D.A., Ta, T.V., Hoang, V.M., 2018. Analysis of the cause of
formed statistical analyses of the data. MNA, HAE, FAA helped in recurrent pregnancy loss in Vietnam: A cross-sectional study. Heal. Care Wom.
Int. 39, 463–471. https://doi.org/10.1080/07399332.2017.1391264.
project administration and funding acquisition. All authors Lee, G.S., Park, J.C., Rhee, J.H., Kim, J.I., 2016a. Etiologic characteristics and index
reviewed the manuscript. pregnancy outcomes of recurrent pregnancy losses in Korean women. Obstet.
Gynecol. Sci. 59, 379–387. https://doi.org/10.5468/ogs.2016.59.5.379.
Lee, S.K., Kim, J.Y., Han, A.R., Hur, S.E., Kim, C.J., Kim, T.H., Cho, B.R., Han, J.W., Han, S.
G., Na, B.J., Kwak-Kim, J., 2016b. Intravenous immunoglobulin G improves
Declaration of Competing Interest pregnancy outcome in women with recurrent pregnancy losses with cellular
immune abnormalities. Am. J. Reprod. Immunol. 75, 59–68. https://doi.org/
The authors declare no competing interests. 10.1111/aji.12442.
Li, T.C., Makris, M., Tomsu, M., 2002. Recurrent miscarriage: aetiology, management
and prognosis. Hum. Reprod. Update. 8, 463–481. https://doi.org/10.1093/
humupd/8.5.463.
References Lund, M., Kamper-Jørgensen, M., Nielsen, H.S., Lidegaard, Ø., Andersen, A.M.N.,
Christiansen, O.B., 2012. Prognosis for live birth in women with recurrent
miscarriage: what is the best measure of success?. Obstet. Gynecol. 119, 37–43.
Abdalla, H.I., Burton, G., Kirkland, A., Johnson, M.R., Leonard, T., Brooks, A.A., Studd, J.
https://doi.org/10.1097/AOG.0b013e31823c0413.
W., 1993. Pregnancy: age, pregnancy and miscarriage: uterine versus ovarian
Myakis, S., Lockshin, M.D., Atsumi, T., 2006. International consensus statement on
factors. Hum. Reprod. 8, 1512–1517. https://doi.org/10.1093/oxfordjournals.
an update of the classification criteria for definite antiphospholipid syndrome. J.
humrep.a138289.
Thromb. Haemost. 4, 295–306.
Ali, S., Majid, S., Ali, M.N., Taing, S., 2020. Evaluation of T cell cytokines and their role
National Institute for Health and Care Excellence, 2012. Ectopic pregnancy and
in recurrent miscarriage. Int. Immunopharmacol. 82,. https://doi.org/10.1016/j.
miscarriage: diagnosis and initial management in early pregnancy of ectopic
intimp.2020.106347 e106347.
pregnancy and miscarriage. Clin. Guideline. 154.
Andersen, A.M.N., Wohlfahrt, J., Christens, P., Olsen, J., Melbye, M., 2000. Maternal
Noble, L.S., Kutteh, W.H., Lashey, N., Franklin, R.D., Herrada, J., 2005.
age and fetal loss: population based register linkage study. Bio. Med. J. 320,
Antiphospholipid antibodies associated with recurrent pregnancy loss:
1708–1712. https://doi.org/10.1136/bmj.320.7251.1708.
prospective, multicenter, controlled pilot study comparing treatment with
Arias-Sosa, L.A., Acosta, I.D., Lucena-Quevedo, E., Moreno-Ortiz, H., Esteban-Pérez,
low-molecular-weight heparin versus unfractionated heparin. Fertil. Steril. 83,
C., Forero-Castro, M., 2018. Genetic and epigenetic variations associated with
684–690. https://doi.org/10.1016/j.fertnstert.2004.11.002.
idiopathic recurrent pregnancy loss. J. Assist. Reprod. Genet. 35, 355–366.
Patki, A., Chauhan, N., 2016. An epidemiology study to determine the prevalence and
https://doi.org/10.1007/s10815-017-1108-y.
risk factors associated with recurrent spontaneous miscarriage in India. J. Obstet.
Babker, A.M., Elzaki, S.G., Dafallah, S.E., 2013. An observational study of causes of
Gynecol. India. 66, 310–315. https://doi.org/10.1007/s13224-015-0682-0.
recurrent spontaneous abortion among Sudanese women. Int. J. Sci. Res. 4,
Porter, T.F., Scott, J.R., 2005. Evidence-based care of recurrent miscarriage. Best
1435–1438.
Pract. Res. Clin. Obstet. Gynaecol. 19, 85–101. https://doi.org/10.1016/j.
Branch, D.W., Gibson, M., Silver, R.M., 2010. Clinical practice. Recurrent miscarriage.
bpobgyn.2004.11.005.
N. Engl. J. Med. 363, 1740–1747. https://doi.org/10.1056/NEJMcp1005330.
Practice Committee of American Society for Reproductive Medicine, 2013.
Clifford, K., Rai, R., Regan, L., 1997. Future pregnancy outcome in unexplained
Definitions of infertility and recurrent pregnancy loss: a committee opinion.
recurrent first trimester miscarriages. Hum. Reprod. 12, 387–389. https://doi.
Fertil. Steril. 99, 63. https://doi.org/10.1016/j.fertnstert.2012.09.023.
org/10.1093/humrep/12.2.387.
Practice Committee of the American Society for Reproductive Medicine, 2012.
D’Ippolito, S., Ticconi, C., Tersigni, C., Garofalo, S., Martino, C., Lanzone, A., Scambia,
Evaluation and treatment of recurrent pregnancy loss: a committee
G., Di Simone, N., 2020. The pathogenic role of autoantibodies in recurrent
opinion. Fertil. Steril. 98, 1103–1111. https://doi.org/10.1016/j.
pregnancy loss. Am. J. Reprod. Immunol. 83,. https://doi.org/10.1111/aji.13200
fertnstert.2012.06.048.
e13200.
Practice Committee of the American Society for Reproductive Medicine, 2008.
Dobson, S.J., Jayaprakasan, K.M., 2018. Aetiology of recurrent miscarriage and the role
Definitions of infertility and recurrent pregnancy loss. Fertil. Sertil. 89, 1603.
of adjuvant treatment in its management: a retrospective cohort review. J. Obstet.
https://doi.org/10.1016/j.fertnstert.2008.03.002.
Gynaecol. 38, 967–974. https://doi.org/10.1080/01443615.2018.1424811.
 S. Ali et al. / Saudi Journal of Biological Sciences 27 (2020) 2809–2817 2817

Qu, J., Weng, X., Gao, L.L., 2020. Anxiety, depression and social support in Chinese Silver, R.M., Branch, D.W., Goldenberg, R., Iams, J.D., Klebanoff, M.A., 2011.
pregnant women with a history of recurrent miscarriage: a prospective study. Nomenclature for pregnancy outcomes: time for a change. Obstet. Gynecol.
1–19. https://doi.org/10.21203/rs.3.rs-32650/v1. 118, 1402–1408. https://doi.org/10.1097/AOG.0b013e3182392977.
RCOG Green Top Guideline, 2011. The investigation and treatment of couples with Silver, R.M., Warren, J.E., 2006. Preconception counseling for women with
recurrent first-trimester and second-trimester miscarriage. RCOG Green Top thrombophilia. Clin. Obstet. Gynecol. 49, 906–919.
Guideline. 17, 1–17. Singh, A., Kujur, A., Rathore, K., 2017. An evaluation of recurrent pregnancy loss. Int.
Reid, S.M., Middleton, P., Cossich, M.C., Crowther, C.A., Bain, E., 2013. Interventions J. Reprod. Contracept. Obstet. Gynecol. 6, 1332–1335. https://doi.org/10.18203/
for clinical and subclinical hypothyroidism pre-pregnancy and during 2320-1770.ijrcog2017138.
pregnancy. Coch. Datab. Syst. Rev. 5, CD007752. https://doi.org/10.1002/ Stephenson, M., Kutteh, W., 2007. Evaluation and management of recurrent early
14651858.CD007752.pub3. pregnancy loss. Clin. Obstet. Gynecol. 50, 132–145. https://doi.org/10.1097/
Risch, H.A., WEISS, N.S., Aileen Clarke, E., MILLER, A.B., 1988. Risk factors for GRF.0b013e31802f1c28.
spontaneous abortion and its recurrence. Am. J. Epidemiol. 128, 420-430. Tavoli, Z., Mohammadi, M., Tavoli, A., Moini, A., Effatpanah, M., Khedmat, L.,
https://doi.org/10.1093/oxfordjournals.aje.a114982. Montazeri, A., 2018. Quality of life and psychological distress in women with
Rull, K., Nagirnaja, L., Laan, M., 2012. Genetics of recurrent miscarriage: challenges, recurrent miscarriage: a comparative study. Heal. Qual. Life Outcomes. 16, 150.
current knowledge, future directions. Front. Genet. 3, 34. https://doi.org/ https://doi.org/10.1186/s12955-018-0982-z.
10.3389/fgene.2012.00034. Vomstein, K., Kuon, R., Müller, F., Goeggl, T., Strowitzki, T., Toth, B., 2016. Evaluation
Shafia, S., Zargar, M.H., Ahmad, R., Khan, N., 2017. Association assessment of of risk factors in a large cohort of patients with recurrent miscarriage. Geburt.
thrombophilic gene mutations in Kashmiri women with recurrent miscarriages. Frauenheil. 76, 254. https://doi.org/10.1055/s-0036-1593085.
World J. Pharm. Res. 6, 1334–1344. Zargar, M.H., Malla, T.M., Dar, F.A., 2015. Occurrence of chromosomal alterations in
Shapira, E., Ratzon, R., Shoham-Vardi, I., Serjienko, R., Mazor, M., Bashiri, A., 2012. recurrent spontaneous abortion couples: a case-only study from Kashmir, North
Primary vs. secondary recurrent pregnancy loss–epidemiological India. J. Genet. Syndr. Gene Therap. 6, 1. https://doi.org/10.4172/2157-
characteristics, etiology, and next pregnancy outcome. J. Perinat. Med. 40, 7412.1000274.
389–396. https://doi.org/10.1515/jpm-2011-0315.