Invisible But Impactful: How Autoimmune Disorders Are Fuelling India's Rising Miscarriage Burden

The silent shift in India's reproductive landscape is now characterized by a clinical paradox that sees many women apparently in good health succumbing to recurrent miscarriages. The Indian healthcare system treats miscarriages through its established process which begins with screening for chromosomal abnormalities and hormonal imbalances and ends with an examination of the patient's lifestyle. Autoimmune diseases, which were previously considered rare medical conditions, have now come to the fore to become a major factor in the rising trend of miscarriages in India.

The Biological Conflict: Immunological Truce vs. Threat

The main problem in this process is the inability of the immune system to identify and accept the semi-allogeneic nature of the pregnancy. The maternal immune system maintains a complex immunological truce during normal pregnancy which enables a father-derived genetic foetus to undergo normal development. The autoimmune patients fail to reach even the first stage of the immunological truce according to their condition. The immune system treats the pregnancy as a biological threat which it proceeds to defend itself against.

SLE (Systemic Lupus Erythematosus) and APS (Antiphospholipid Syndrome) act as the most significant disruptors of the immune system in this case. APS, also known as sticky blood syndrome, produces antibodies that target proteins found on the surface of blood cells and blood vessel walls. The formation of small blood clots in the vessels results in a complete halt of vital nutrients and oxygen supply to the foetus which ultimately causes its death during early or mid-term pregnancy.

Sociocultural Factors and Delayed Diagnosis

It is seen that Indian woman may have a genetic predisposition to autoimmune markers; however, sociocultural factors may result in delayed diagnoses. A first or even second miscarriage may be brushed off as bad luck or the result of physical activity by many. The window for immunological tests may thus be missed. When the patient is finally brought to a specialist for recurrent pregnancy loss (RPL), the emotional and physical condition may be severe. Moreover, the increasing conception age in urban India and the environmental factors may be triggering subclinical autoimmune activity that may have otherwise remained latent in the body.

Diagnostic Challenges and Specialized Testing

Diagnostic challenges are a major hindrance in controlling this problem. Many autoimmune markers are very sensitive and require specific testing, which may not always be readily available outside Tier 1 cities. For example, Antinuclear Antibody (ANA) testing, as well as a full spectrum of thrombophilia testing, is necessary to obtain a full picture. However, such testing is rarely included in a standard prenatal panel. There is also a new concern about thyroid autoantibodies. Even if a pregnant woman's thyroid stimulating hormone (TSH) levels are within the normal range, if she has thyroid peroxidase (TPO) antibodies, she can be at increased risk of placental separation and miscarriage.

Pathways to Treatment and Multidisciplinary Care

When doctors diagnose a patient at the right time, treatment becomes their only source of hope. The treatment of women with antiphospholipid syndrome (APS) who use low-molecular-weight heparin (LMWH) and low-dose aspirin has brought about better pregnancy results. Doctors need to treat severe cases which show overactive Natural Killer (NK) cells and lupus through the combined use of corticosteroids and IVIG (intravenous immunoglobulin) therapy to reduce maternal immune system activity. This requires a multidisciplinary approach, and there needs to be close collaboration between obstetricians, rheumatologists, and haematologists to ensure both maternal and foetal viability.

Destigmatizing Loss and Prioritizing Pre-conception Care

Miscarriage needs to be destigmatized and viewed from a clinical perspective that emphasizes the need for comprehensive workups even after a single miscarriage in the presence of other risk factors. Autoimmune tests need to be a part of pre-conception counselling to avoid thousands of families having to go through the trauma of recurrent miscarriages. The aim is to look towards a future where a patient diagnosed with an autoimmune condition is not given lost hope in the form of infertility but a condition that needs to be managed towards healthy motherhood. The numbers may be increasing, but with specialized care, the invisible can become visible and the impactful can become manageable.

(By Dr Deepika Alva, Consultant- Obstetrician and Gynecologist, Motherhood Hospitals, HRBR Layout, Bengaluru)

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