Recurrent Early Pregnancy Loss - 10 - Empiric Treatment
Thursday, April 12, 2007
Kenneth F. Trofatter, Jr., MD, PhD
If a woman has regular menstrual cycles and has never had trouble conceiving (and no abnormalities found during the diagnostic evaluation which is more often than not the case), I usually offer the following advice and empiric treatment regimen: discontinue smoking and alcohol and limit caffeine intake; begin a prenatal vitamin daily; start supplemental folic acid 4 mg daily; take a baby aspirin (81 mg) once daily (this antagonizes the ‘platelet side’ of the coagulation system); offer ‘progesterone support’ either in the luteal phase, or as soon as a pregnancy is confirmed and continue this until 10-12 weeks. I will also offer a course of a broad spectrum antibiotic (azithromycin or doxycycline) to BOTH partners early during the first cycle she attempts to conceive. These antibiotics treat organisms such as mycoplasma and ureaplasma (rather than culture for these organisms) among many others.
After conceiving, I ask that she return by about 6 weeks (two weeks after the missed menstrual cycle), perform an ultrasound to confirm an intrauterine pregnancy, repeat the lupus anticoagulant and anticardiolipin antibody screens (even if these were negative between pregnancies), and also screen for circulating complement levels. The complement system (the 'classical pathway') is activated by certain antibodies once they have attached to something ‘foreign’ (forming ‘immune complexes’) and help to destroy that to which the antibodies have attached. If complement levels are low or low normal during pregnancy (normally during pregnancy they increase), this might reflect ‘complement consumption’, the presumption being that the invading trophoblasts may be the targets against which the complement-fixing antibodies are directed. (Another possibility is that the 'alternative complement pathway', that does not require antibodies, is somehow being activated, but I do not want to get into that here and it doesn't change what I do at this point anyway!) I have used this approach (the low complement levels) over the years (although I have never seen a published study to justify it) to guide more aggressive therapy in women with known autoimmune disorders, lupus anticoagulants, or anticardiolipin antibodies, and even those with no other abnormal findings (the rationale being that there are things we still do not know, other factors which have not yet been found or implicated in pregnancy loss and, therefore, are not tested for at this time).
If the studies noted above are all ‘normal’, and the patient has a history of 3 or fewer losses, I recommend that no other therapy be started during this pregnancy. If the patient has had more than 3 losses, has previously failed this initial empiric approach to therapy, has any abnormal immunologic or coagulation studies, or just plain insists because "I want to do everything possible now," I offer to add either heparin (inexpensive) or low-molecular weight heparin (very expensive) therapy (which antagonize the other side of the clotting system), both of which must be given by subcutaneous injection. This regimen has replaced the immunosuppressive steroid (e.g., prednisone) therapy (except in the patient with an overt and active autoimmune disorder) that we used, also emprically, years ago when I first became interested in recurrent early pregnancy loss and it appears to be just as effective (with far fewer side-effects such as gestational diabetes, swelling, and increased risk for infection).
This approach to therapy is the foundation upon which I build for any woman with recurrent early pregnancy loss. In the absence of other specific abnormalities, 'success rates' are extraordinarily high using this approach. Others would argue that success rates in this group of patients are high regardless of what is done. I don't necessarily disagree with that, but I have had patients over the years who had far more than 3 losses who only successfully carried after starting this regimen, and quite frankly, I don't think any of us are smart enough at this time to know who actually needs it and who doesn't! In our next post let’s address what we do if specific abnormalities are found during the diagnostic workup, always keeping in mind that multiple factors may be in play and the 'empiric regimen' (or parts of it) might still be warranted, even after these other factors are addressed…
37 Comments:
At Wed Aug 01, 12:38:00 PM 2007,
Anonymous said…
Thank you for writing so much information on this subject. I just suffered my second miscarriage. The first was at 5 1/2 weeks, and this one was missed at 12 weeks (baby was only 10 weeks). We're waiting on pathology from the baby and are being referred to a geneticist.
At my 8 week appointment, the blood work came back positive (but inconclusive) for an antibody. I haven't been able to get specific information regarding this, but did ask to have a follow up screen. I am Rh + and my husband is Rh -. I'm worried it may be related to APS, but don't know who to ask about getting tested. Should I request a referral to an RE? Thank you for your help.
At Thu Aug 02, 12:43:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
First of all, I am sorry for your losses. I would be curious to know what exactly you have been tested for and the actual results before making a recommendation about whom you should see next. If this was simply a "positive antibody screen" on your prenatal lab panel, counseling will be based on the specific antibody that is present. Those antibodies are directed against blood group antigens and some are not at high risk for causing problems. That antibody screen will not detect antiphospholipid antibodies. Also, wait until you get back a report on the baby. I am assuming they were going to try to do chromosomal studies. Talk to the geneticist and get back to me with any answers/questions you might have. Thanks for reading! Dr T
At Fri Oct 26, 01:05:00 PM 2007,
Nancy said…
I have just had my 8th miscarriage. All early and all "missed". 7 needed to be resolved with d&e's the last one needing 2 separate surgeries.
I am 44, and have 13 living dc so my doctor is just putting all of this to my age and has never suggested testing...just contraception and dealing with the losses that WILL come.
I am at a loss as to where to start with him and what tests to ask for...
He says my uterus is too scarred to support a pg. I know many women that have had more pg then I and yet they are not having a problem.
I guess I am wondering if it is worth it to push for the testing. And what tests to start with.
At Thu Nov 01, 06:39:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Nancy Oct 26: Let me get this right- you have 13 living children and you have had 8 miscarriages (many with D&C's) and you are 44 years old and want more?????????? Your doctor is correct. The uterus has a limited number of sites to support implantation and between all of your pregnancies, and all of your surgical procedures, there probably aren't many places where a healthy pregnancy could implant. And, if it should, you are at extremely high risk for a placenta previa or a placenta accreta-both of which could be dangerous to you and a baby. Your risk for conceiving a chromosomally abnormal baby is also more than 1 in 10. I do not know any good reproductive endocrinologists who would think it was ethical to help you get pregnant at this point, although I am sure you could find one who 'practices on the fringes' and would be willing to take your money. I will be perfectly frank,why don't you quit thinking about pregnancy and enjoy your children and your grandchildren while you still can; or, consider adoption! Thanks for reading and for writing! Best wishes. Dr T
At Fri Nov 02, 07:51:00 AM 2007,
Anonymous said…
So, should someone with those "statistics" not get tested? What about conditions like MTHFR which can affect her future health? Just not test because she has so many living children already? How is that responsible medicine?
What would you say to me? I have had 19 losses (ranging from "chemical" to blighted ovum, missed miscarriage and ectopic) but only have 3 living children (2 deliveries) and am 32. Is my uterus too scarred despite having only had 2 D&C?
I feel blessed that I've encountered doctors who were willing to test, and sad that the only reason they do so is my lack of a large amount of living children and my age.
For what it's worth, they've never found a reason.
At Mon Nov 05, 05:58:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Nov 2: I am sorry if you thought my response was less than proffessional! I guess I assumed, perhaps falsely, that she would have already been tested for things that would most likely "affect her health" at her age ( e.g., diabetes, hypertension, hyperlipidemia, etc.) that would also be potentially correctable causes of pregnancy loss. One could spend an awful lot of money and could come up with no answers under these circumstances. By history, her losses are most consistent, not with a thrombophilia, but either aneuploidy (resulting from translocation or sporadically) or a genetic condition,for neither of which is there any treatment. The fact remains, that a pregnancy in her, even if it successfully gets beyond the first trimester is fraught with serious risks for both her and a baby with as many pregnancies she has had. So would any pregnancy you might have under the circumstances you describe, and you are not 44 years old. I am curious though, you say your doctors have not come up with any explanations, so does that mean they also have not tried any form of empiric therapy over the years either? To demand an explanation to justify 'treatment' in these settings makes us out to know more than we really do about recurrent pregnancy loss. We are actually quite stupid in this regard! Thanks for you comment. It is actually quite thought-provoking and does remind us of the challenges we still face in caring for women with RPL. Dr T
At Mon Nov 05, 06:15:00 PM 2007,
Sarah Elisabeth said…
Quote:
"To Nancy Oct 26: Let me get this right- you have 13 living children and you have had 8 miscarriages (many with D&C's) and you are 44 years old and want more??????????" end quote.
You're a disgusting individual. I wish your mother had decided she "didn't want more" before she had you.
SHAME ON YOU. You're talking to someone who just had a LIFE DIE INSIDE OF THEM. Perhaps you should consider a course in empathy before you continue using those letters after your name. Bedside manner goes a long way.
I'll be sure to let everyone know that you hold this attitude---BEFORE they come to you with their hopes in your hands. They should know you have a "limit" on how many children you'll help someone conceive. And, that you think some people should just shut up and suffer continuous losses.
Nancy wasn't asking for help to conceive---SHE WAS ASKING FOR HELP TO SUPPORT THE CHILDREN SHE ALREADY CONCEIVED. Just because you think she should stop having kids doesn't mean she deserves your snide attitude. Good to know you think human life is worthless if 13 other lives came before it.
At Tue Nov 06, 11:53:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Sarah Elizabeth: My opening comment could have been left out, but I am sorry, you could not be more wrong about what I was trying to say to her. Pregnancy is a great risk to her and any more children (living and unborn) and there is no denying that fact. And, unless I cannot read at all, she is asking for help to have more pregnancies. I would like to know how a pregnancy that might cost her life is going to help her "support the children she already has." If you read her note, she "required two separate procedures" to recover from her most recent loss. These may well have been necessary because of a placental accreta. My "limit" is not the number of children someone can or should have, it is the risk and benefits related to those decisions. And, in the end, it's the patient who has to make the final choices. Not me. My only pledge is to provide as accurate information as I can and then support them the best way possible, regardless of the decision they make - even if it is contrary to my own opinion. If you think I have no empathy, I want you to consider the hundreds of hours I spend answering (at no charge) the hundreds of comments I get on this site; and, there are very few patients I have had over the past 25+ years who would share your opinion of my "bedside manner." But, you are certainly welcome to your own opinion. Dr T
At Wed Nov 07, 05:15:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Nancy Oct 26: I AM SO SORRY. I could and should have expressed my thoughts in a more sensitive way. My brain tends to jump from A to Z and that can sometimes be an advantage in medicine and at other times we have to remember that all the letters in between are as important. One of the reasons I have such an interest in recurrent pregnancy loss is that my first three children ended in miscarriages and even after grieving and with the knowledge of probable reasons why, I still wonder to this day about what could have been...
Anyway, to answer your question, I would recommend the following in the way of testing if it has not already been done: screening for diabetes, hypothyroidism, hyperlipidemia, hypertension and basic liver and kidney function. Although you are probably at low risk, a general screen for autoimmunity (antinuclear antibodies, ANA) and perhaps antiphospholipid antibodies could be considered. I think the yield on the latter is low, but it might offer an explanation and identify you as a person who should be followed more closely over time for autoimmune disorders. It would help to know what if any studies you have had done to date and also if chromosomal studies were ever done on any of the pregnancies you lost. Your history is more one of having babies with chromosomal abnormalities rather than losses related to chronic disease or 'thrombophilia.' Chromosomal abnormalities can arise de novo and increase with age as the result of increased risk for nondisjunction, or they can result from babies that have unbalanced karyotypes resulting from a parent(s) with balanced translocations. I have posts on each of these subjects over the past year if you are interested. Parents with balanced translocations really do have to just keep trying because unless the translocations involve the same chromosome (which is not good at all, and could not be the cause in your case or you would have no normal children), a proportion of of your eggs (or your husband's sperm if he is the carrier) will result in a chromosomally 'balanced' baby - either completely normal or as a carrier of the same balanced translocation. You could find out if either you or your husband have balanced translocations, but it is expensive. There are still two reasons you might consider having that done: 1) it would provide you with an explanation that you are seeking; 2) if either of you is a carrier, you could then have your children evaluated for the same chromosomal abnormality. Those that had it would then be aware that they are at increased risk for recurrent miscarriage and babies with chromosomal abnormalities themselves.
Despite my lack of tact in my previous response, I am still greatly concerned for you and your risks for a future pregnancy and I did not want you to miss that message. The risks are very real based on what you told me in your comment. Again, I am sorry and I hope this helps...Dr T
At Wed Dec 05, 08:20:00 AM 2007,
daisy said…
I am not sure I am posting on the correct page... but here goes.
On Nov 5th, I suffered a missed miscarriage at 11wks 5days (gestational age=7wk 5d, which required an emergency D&C due to a suspect Molar Pregnancy. This is my 1st pregnancy, I am 36yrs old, regular 28day cycle, period lasts 4 days medium flow, nothing significant to note other than 5 sisters - all very very fertile.
Besides the obvious shock at facing into what I was told at the Early pregnancy clinic, I now want to ensure I understand what the histology report says.
The histology report results presented "no atypical features", but there are things I do not understand.
The clinical details: "Missed abortion @ 10/40. No foetal pole on ultrasound scan. ??Hydropic changes seen on scan."
The Macroscopic report reads: "a bulky amount of haemorrhagic products, 70x40x20mm's. No Membranes seen. No Foetal Tissue seen. Mp 2b SPE".
The Microscopic report reads: Chorionic Villi, inflamed and degenerate decidua, blood and fibrin, in keeping with retained products of conception. No atypical features seen"
Can you tell me in plain english what this means? We desperately want to have a baby and I'm concerned about maximising my success rates given the gynaecological challenges I could face at my age.
thank you for any help.
At Thu Dec 13, 02:31:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Daisy Dec 5: Hi Daisy, sorry for your loss. From what you describe, you had a 'blighted pregnancy' that did not get past the very early stages of embryonic development, although the placental tissues continued to grow for awhile (which is not all unusual) and make pregnancy hormone (hCG) so that your body did not know the baby did not make it. It is very unlikely that you actually had a 'molar pregnancy', although that is what your doctors were concerned about based on the ultrasound. Hydropic degeneration of the placental villi are characteristic of molar pregnancies, but also of pregnancies undergoing spontaneous abortion if it has been awhile from the time the baby was lost to the time of miscarriage or if the baby was chromosomally abnormal. First pregnancies have a high rate of miscarriage for reasons I have detailed in my posts, but at your age, there is also a greater chance that the baby had a chromosomal abnormality. These are not uncommon and most babies with aneuploidy are lost in the first trimester. Your pathology report is not unusual under these circumstances - you had blood clot and the placental tissues were inflamed. The latter does NOT mean you lost this pregnancy as the result of an infection. It simply means that your immune system was reacting to the pregnancy tissues - that might be a good sign and increase your chance for success with a subsequent pregnancy. Hope this helped. Thanks for reading and good luck to you! Dr T
At Mon Jul 28, 01:23:00 PM 2008,
Anonymous said…
Hello Dr T.
Currently I'm age 33 going to be 34in October. I successfully delivered, vaginally, a healthy 9lb baby boy July 2006 at age 31.
Past history:
Age 28-missed abortion at 10 wks, d&c-no abnormal histology
Age 29-misscarry 6 wks, no histology testing
Age 30-testing for etiology-resulted in Factor V Leiden, heterozygotic, no other abnormalities found.
I achieved pregnancy after HSG and immediately was started on ASA, LMWH 5,000u BID, and Prometrium. I had a normal pregnancy- lots of sonos and bio profiles, none the less, at Age31-vaginal delivery, no complications and then completed 6 wks LMWH therapy.
No personal history of clots.
My paternal grandmother who is + for Factor V had her first clot at age 30 during pregnancy and has had others later in her life. that would make my father + for Factor V. He has horrible varicous veins and due to that, he has always been very vigilant in clot prevention-TEDS, ASA, active lifestyle ect...therefore, he has had no clots to this point.
We are about to embark on our second and final pregnancy. My OB has provided options to me regarding my medical management but I am undecided as he believes all I need to have is prenatal vits., daily asa, and progesterone up to 10 wks. No heparin as it is "not indicated." He repeated it was not indicated the first time and it's not indicated this time. He said the decision was up to me and he would be willing to prescribe the heparin and manage me again that way. However, he would advise against it. I did it the first time because I figured I had nothing to lose. This time, I initially questioned if I could have Lovenox as it would be 1/2 as many injections since my hips took a year to heal up from the soreness, and now I have found information on Arixtra. He his advising against those two drugs as "there could be complications when it come to the delivery and changing over drugs." I under stand there are potential long term side effects from long term anitcoagulation therapy and those are a concern of mine in trying to decide if I'm going to us heparin again or not. Another concern is this could be a second round of heparin (long term effects again)and the fact that I'm really pushing for a pregnancy and delivery before age 35(to decrease chance of downs)I'm so confused as what the best choice would be? Can you advise?
Thanks, CT in KANSAS
At Mon Jul 28, 05:13:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To CT: Whether the heparin "worked" or not the last pregnancy, you ended up with a healthy baby. I guess I am thinking more like you, why argue with success. That is a very low dose of heparin and for the duration of a pregnancy, the risks to you are relatively small. You can use Lovenox as well, but we generally switch folks over to heparin at 36 weeks in anticipation of delivery. There is not a lot of experience with Arixtra (and I have no clue how much it costs), but it seems to have a very good safety profile and works reliably on a fixed dosage regimen. I wrte a post on Arixtra earlier this year if you go back through my archives. Anyway, those are my thoughts - the final choice is yours! Dr T
At Sun Sep 07, 06:52:00 PM 2008,
Anonymous said…
Dear Dr. T - I hope you can offer some advice!
My husband and I have been ttc since June 2007. I have had three chemical pregnancies in a row (July 2007, Apr 08, Aug 08), all of which have been identical in nature (very faint hpt when period due, little to no preg symptoms, highest beta was 130 and m/c at 5-6 weeks). With the last pregnancy I had implantation spotting.
All of the m/c occurred naturally (no d&cs needed). I had 1 miscarriage before my daughter (but had full preg symptoms with that one) and my daughter is healthy and almost 2 yrs old. I stopped breastfeeding when she was 6 months old. Same partner for those pregnancies. We have been seeing an RE since April, they have run all of the standard tests as well as genetic analysis. The only thing that came back abnormal is that I have the prothrombin gene mutation. Both our RE and the prothrombin specialist did not think that this was the cause of my recurrent early miscarriages. The specialist said she would prescribe Fragmin injections if I really wanted them, but did not think they were necessary. I also have a few small uterine fibroids (which I also had when I was preg with my daughter), but the specialist said that because of where they are located and their size they are not concerned. I am told that the lining of my uterus looks normal. I am 35 years old and I am in good health. My cycles are 24-27d (luteal phase 9-11d since I have been charting for 1 year). I was given progesterone suppositories for my last pregnancy but still miscarried. We are ttc again this month and I am taking baby aspirin for the first time this time and will be taking progesterone after ovulation. What do you think is the most likely cause of these early miscarriages?? And what are my chances of having a successful future pregnancy? Could something like Clomid help me?
At Tue Sep 23, 07:45:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sept 7: It appears you are having 'implantation' problems. The most likely causes fopr this are hormonal abnormalities (sometimes subtle), fetal chromosomal abnormalities, and abnormalities of the uterus. What sorts of studies have you had done to look for any of these? Have any of the pregnancies provided sufficient tissue to have chromosomal studies done on them? One of the REI experts with whom I work feels very strongly that subclnical endometriosis contributes very commonly to recurrent early pregnancy loss. He recommends a 3-4 month course of Lupron followed by ovulation induction and/or another form of assisted reproductive technology. Talk with your doctors about these options. Best wishes! Dr T
At Sat Oct 04, 11:01:00 AM 2008,
Anonymous said…
Hi Dr. T:
I'm hoping you can provide some thoughts about my situation. I'm a 37 year old who has one son, but 4 other pregnancy losses. Initially we had trouble conceiving. We had an extensive w/u at that time and a reason was not found. Ultimately I got pregnant for the first time with IUI, but that was an early loss followed by a D and C. Chromosomes were normal. Then we went through IVF and I carried my son to term. Since then, I seem to have no trouble getting pregnant naturally, but first I had a fetal death at 23 weeks, which the autopsy says was due to an abruption (though my OB is skeptical; I had no clinical symptoms and he wonders if the bleeding was "after the fact" as it was clear our baby had died at least a week or more before it was diagnosed). Anyway, chromosomes and everything were normal. Now, I've had 2 more losses, at 8 weeks and 10 weeks, both followed by D and C's (the second was just yesterday). The chromosomes were normal with the first, and of course we don't have results back yet on the second. In my most recent pregnancy, we used intravaginal progesterone starting at day 14 of my cycle. I should mention I've had a normal HSG and blood work including TSH, antithrombin III, Protein C and S (that whole panel), cardiolipins, PTT...but all that testing was done a few years ago.
So our plan is to go back and consult with our Reproductive Endocrinologist, but I'd also like your opinion. Would you repeat all the workup? Would you consider supporting the pregnancy just like we did with our son after IVF, the the IM progesterone, baby Asa (and maybe heparin, too)? Can you think of any other reason why we might have been successful with IVF but not anything else? After 3 apparently uncomplicated D and C's, what are my odds of significant scarring? By the way, I have nice, normal cycles with predictable ovulation.
At Tue Oct 07, 06:22:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 4: I would probably repeat a few of the lab studies: TSH, free T4, antiphospholipid antibodies, and lupus anticoagulant and include anti-beta-2 glycoprotein-1 in that mix. Repeating a hysteroscopy is probably warranted at this point as well. I would also suggest empiric therapy with prophylactic doses of heparin or lovenox starting in midluteal phase and consider going back to IVF. That could probably be discontinued once you have gotten through midtrimester. Just a few suggestions...let me know what your doctor thinks! Dr T
At Thu Oct 23, 07:03:00 PM 2008,
Anonymous said…
Hi,
I would appreciate your advice. I gave birth to a healthy girl at the age of 38. Since then, I have had a miscarriage at 7 weeks and last year lost our son at 20+ weeks. I have been told that my age (now 41), obesity (5'-6" and 220 lbs), high blood pressure (which is controlled with Labetalol) as well as possible incompentant cervix may have contributed to our son's early delivery and subsequent death. The autopsy indicated that he had some IUGR but was otherwise genetically normal and all organs etc were formed appropriately. I had severe early bleeding with that pregnancy at 8 weeks. I am now pregnant again with twins (naturally) and am currently at 9 weeks. For the past two weeks I have encountered several bleedings with one severe incident. Ultrasound has indicated a "bleed" that is small. I have been given instructions to take one 81 mg ASA daily in order to prevent clotting and damaging the "connection to the uterus" (this is what I understand). I am extremely anxious as to the outcome of this pregnancy and my husband and I desperately pray and hope for it's success. Do you have any suggestions for us that I could share with our doctor? Any would be greatly appreciated. Thank you.
Dee
At Wed Oct 29, 05:50:00 AM 2008,
Anonymous said…
I am 30 years old and have one daughter. I am a type 1 diabetic (which is under control)on a insulin pump. My hubby and I have been trying to concieve for the last year but to na avail. I have had 3 miscarriages in the last two years and for the last 4 months have been having chemical pregnancies. My doctor has put me on Eltroxin (thyroid), Glucophage (to increase insulin absorbtion)and Folic Acid, But nothing seems to help keep the pregnancy. What can I do?? I want to have my second child before I am 32.
At Wed Oct 29, 06:24:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Dee: Even the aspirin might be risky now that you have had some bleeding - but I will not second guess your doctors on that one. I wish I knew more about the events surrounding the loss of your son. Was the cervix changed prematurely? Was there any evidence of infection of the baby or the placenta? All I can recommend at this time is that you consider having first trimester screening done for aneuploidy and then consider a cerclage placement at 13-14 weeks. I usually recommend waiting at lest two weeks after you have had any bleeding before placing the cerclage because the bleeding increases the risk of infection and that might have also contributed to the loss of your son. An alternative would be to begin serial transvaginal ultrasounds of the cervix at about 16 weeks and then only place a cerclage if there was cervical shortening/funneling. Best wishes and let us know how things turm out. Dr T
At Fri Oct 31, 05:07:00 AM 2008,
Anonymous said…
Dr T - I am "Anonymous" from Sept 7th...thank you for your advice...I never got a chance to look into it because the next cycle that we tried (with taking baby aspirin the entire cycle as the only difference) worked! I am currently 9 weeks pregnant and a strong heartbeat has been heard. This one definitely implanted well (I always suspected this was my problem) - I got a + home preg test at only 10 DPO...and my beta hcg at 12 DPO was already 315!
At Fri Dec 12, 08:06:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 29: Sorry for my delayed response, but I JUST received your comment from Healthline today. First a question - is your current partner the father of your first child? If not, have either one of you had chromosomal studies done or did you have chromosomal studies done on any of the pregnancies you miscarried? Regardless, with your history of recurrent early pregnancy loss and your diabetes, I would strongly suggest you see a specialist in Reproductive Endocrinology and Infertility to get an efficient and comprehensive evaluation, and perhaps, medical management that might improve your prospects for a successful pregnancy. regards and thanks for reading! Dr T
At Fri Jan 09, 01:44:00 PM 2009,
Midwest Girl said…
I would love your opinion on my history. Keep in mind I am currently pregnant with my 7th pregnancy (no living children). We just found out 2 days ago.
-Started trying to conceive Aug 05
-Compound Hetero MTHFR, and I carry an inverted chromosome 10
-Inverted 10 is a normal familial variant and shouldn't affect anything according to 2 genetic counselors, 2 perinatologists, and 1 RE
History:
10/05-chemical
2/06-D&C at 8 weeks, baby measured 5w6d, girl with double trisomy and my benign inverted 10
07/07/07- stillborn son at 37 wks, 46,XY-Normal Male Karyotype...the placenta had "40% massive pervillous fibrin deposition" indicating clotting. We found out I am compound hetero MTHFR due to this. I was on baby aspirin through 14 weeks with this pregnancy due to RE telling me to take it as a precaution. However, I was told to stop it after 14weeks by the OB and I did. I was also on progesterone as a precaution for the first time this pregnancy.
11/07-chemical
3/08-D&C at 10 weeks, baby measured 9w1d, girl with Turner Syndrome (Monosomy X), full karyotype unknown
7/08-D&C at 10 weeks, baby measured 8w6d, 46,XX-Normal Female Karyotype
I am now pregnant again and currently on 1 baby aspirin/day, lovenox, and folgard (extra folic acid for the MTHFR). I was on all of these medications for the last 3 pregnancies that I lost as well. So they haven't exactly helped.
Any thoughts? I'm desperate to keep this one. I have not had a HSG or any of those other FSH, thyroid, etc tests ever. If I lose this one what is my next step? Should I push for those tests?
At Fri Jan 09, 02:07:00 PM 2009,
Anonymous said…
Dr T, I was wondering if you would share with me your thoughts of taking baby aspirin even though my clotting tests all came back normal, just to be sure. I ask this because clotting increases in pregnancy and I would like to be proactive. I'd rather be safe than sorry. I would like to do anything if it will only possibly help as long as it doesn't do any harm. Can baby aspirin harm a fetus?
At Sat Feb 14, 07:34:00 PM 2009,
Michele said…
I have been very grateful to read the information on your site as it feels so familar. I have one healthy 4 year old girl through a very uneventful pregnancy followed by 2 miscarriages (9wks & 6 wks). After the 2nd miscarriage, my OB at the time suggested baby aspirin the next time I became pregnant. (Lupus anticoagulant, anticardiolipin antibody, Factor V,& TSH tests all came back negative). Wanting to do everything to prevent another loss, I also visted an RE who ran many of the same tests again as well as chromosome studies. When no problems were detected, he offered progesterone support and when I asked about the baby aspirin, it was given the okay. I am currently 20 wks pregnant. I am no longer on the progesterone but still taking the baby aspirin. I am wondering what your recommendation is as to how long I should continue to take the baby aspirin? My current OB (not the one who originally recommended the baby aspirin) has said to stop taking it. When I first asked at my 10 week appointment she said that I could stop taking it any time since it was just "vodoo" anyway. At that time I contacted my RE's office to get their recommendation since my OB didn't believe in it anyway, I wanted a second opinion. I was told by the nurse there that I could continue taking it until 36 weeks. So, I have continued to take the it. But, I am bothered by the fact that I am not on the same page as my OB and now that I am at 20 weeks I am considering weaning off the baby aspirin as I wonder if it is really helping.. Is there any harm it taking it? I would be greatful for any light you could shed on the situation. I want to protect my child, but I don't want to unnecessarily expose her to medication either...
Thanks in advance!
At Sun Mar 08, 06:19:00 PM 2009,
Anonymous said…
Dr. Trofatter,
I am a 40 year old woman with a history of 3 first trimester pregancy losses. The first was discovered at 10 wks when no heatbeat could be detected. Fetus only measured 8 wks. Fetal heartbeat was observed at about 6.5 wks. The second ended in natural miscarriage at 10 wks 3 days after about a week of spotting. Heartbeat was never seen/heard. The third time, no fetus or heatbeat were visible by ultrasound at 8 wks. Just a sac and egg sac. Fetal pole had been seen at 6 wks. My doctor put me on baby aspirin and progestrone for the third pregancy which I started at 6 wks. These 3 losses all occurred within the last 15 months. My husband and I do not have any problems getting pregnant. I do not have any previous children.
In your post you mention you would start you empiric treatment with any woman. Even a woman of advanced maternal age such as myself? I have now been referred to a fertility specialist and feel they are "pushing" IVF with PGD because I do not have much time left. They reason the PGD will allow testing for chromosomal abnormalities which is the most likely cause of my miscarriages and IVF will provide a greater choice of eggs. I haven't actually had any tests done by them yet. Is IVF with PGD the correct route to go based on my age if all the tests come back normal or should we try one more time with your plan?
At Mon Mar 09, 07:54:00 PM 2009,
Anonymous said…
I'm 32 my husband is 34. I have a 14 year old from a previous marriage. I'm remarried now. Aug 07 chemical, April 08 blighted ovum, June 08 chemical...My primary did a C-peptide, tsh, hiv..so thought maybe i was insulin resistant. Those came back fine...tsh 2.60. I got pregnant again in July 08 blighted ovum d&c, my losses all stopped developing or it seems i would spot brown around 5 weeks. My ob/gyn did a tsh, ana, protein s, protein c, antiphospholipid antibodies, Factor V Leiden, karyotype, they all came back fine except the tsh 13.00 so then we did a another test i believe an tpo, it came back for having antibodies. So, i'm told i have hashimoto hypothyroidism. So, we got my tsh level in range levothyroxine 1.73, i'm pregnant again March 08 and now it looks like this is a blighted ovum. This will be 5 early losses in a year and a half. I never really thought it was thyroid related since i managed to have 3 losses without an abnormal tsh, then after my 4th my tsh became abnormal. I feel like giving up but i just can't. What do you recommend for me? My cycles vary from 28-34 days and i usually ovulate cycle day 14-19. Should i just give up my dream?
At Mon Mar 16, 07:12:00 AM 2009,
Traci said…
Hi Dr. T,
I've had 4 early losses (1 chemical, 1 ectopic, 1 D&C, 1 blighted ovum...1 of them was quadruplets that all had different issues) a few years ago (we decided that we wanted to be parents more than pregnant so we stopped TTC & adopted but now we want our DD to have a sibling & don't want to adopt again). I had unexplained bleeding & clotting w/ all pregnancies but RPL testing came back normal. I'm about to be 35, am overweight (5'3" & 210 lbs), & have PCOS.
We would like to TTC again (w/ RE help since I don't ovulate on my own--Follistim was the only medication that worked for me). We never did any Empiric Treatment b/c at the time we didn't realize this was an option, our old RE (we've moved so would see a different one) never suggested this treatment & pretty much said we could keep trying until a pregnancy worked.
Would IVF help? Is Empiric Treatment &/or IVF something we should try & is there any hope for us to have normal pregnancy?
At Wed Mar 25, 08:21:00 PM 2009,
Kristina Marie said…
Hello, I just fell upon this post and find it very intriguing. I'm in the process of suffering my second loss. My husband and I have one beautiful six year old daughter together. We started trying to concieve Summer of 2008. After three 50 mg Clomid cycles (I have PCOS) I had a great pregnancy up until 16 wks where we loss the heartbeat with no s/s of miscarriage. Since my D&C we tried again, we found out we were pregnant in February and lost this baby just recently at 9 wks. I've been tested for IR and my insulin came back a bit high so I started metformin ER at 500 mg/day. I took OTC prenatals the whole time. I've never have had any tests come back positive for hypothyroidism though I've been tested many times. I'm just at my witts end. We will be doing repeat loss testing soon. Would chromosomal issues still be a concern considering we have a healthy daughter together? Thank you!
At Thu Jul 02, 12:32:00 PM 2009,
Tiffany said…
Update to my 3/8/09 posting
I am the anonymous 40 year old woman who originally posted on 3/8/09. Since then my husband and I have had all the testing completed including karyotyping for both of us. All tests came back normal except my FSH level was 11.4 and I had a slightly elevated Prolactin level. I started taking 1.25 mg Bromocriptine daily 2 months ago. I just had the Prolactin level retested and it came back in the mid range of normal. The Dr. recommends we keep taking it until we get pregnant again.
We have TTC using the empiric treatment for the last 2 months with no success. We have decided to try one more month and then persue the IVF with PDG route although the costs involved and possbility of multiple births are very scary to us.
Do you think that in view of my age we should stop trying by ourselves now and go the IVF route if we are really serious about having children or do we have some more time to keep trying?
At Fri Jul 03, 09:15:00 PM 2009,
Anonymous said…
Hello Dr Kenneth,
FIrst of all, many thanks for the time you spare to answer the queries. I just stumbled upon this forum. I have had 6 miscarriages in the last seven years. Before this I had one MTP. So in total been preg 7 times. I have had a battery of tests including karyotype of myself and my husband, all the tests are normal. I recently had livovist test done and it was normal too. They found a very small fibroid but said it was not dangerous at all. The uterous lining is normal.
I have fallen pregnant again and am 5 wks at the moment.My gyno said that every test she has done is normal, so there is no medication that is necessary. I then got second opinion from another gyno who has prescribed 100 mg Aspirin , Fragmin 5000 IU and folate once daily. Is there anything else that could be done to save this pregnancy. I do not have any children at the monent and am 32yrs old. My partner is 37yrs.
At Tue Jul 07, 03:42:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
Tiffany: At your age, it is time to pull out all stops. I wish you the best!
Dr T
At Tue Jul 07, 04:14:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 3: I can not argue with your doctor's though process, but he/she assumes that we have at our fingertips all the answers regarding recurrent early pregnancy loss and we clearly do NOT. If the empiric therapy you describe fails, I would either try again and use it as soon as a pregnancy is suspected or I would consider a 6-month course of empiric therapy for endometriosis, followed by ovulation induction and the current regimen you have been prescribed. Another option would be IVF. If you wait too much longer, your chance of fertility will decrease even further. Best wishes!
Dr T
At Fri Jul 24, 04:45:00 AM 2009,
Anonymous said…
I am glad I found this site.
Me and my husband have been trying to conceive for a year. It was discovered that he has a very low sperm count so we did ivf+icsi in April and one embryo took. Everything was going great. My betas were excellent and the baby had a good heartbeat at 6w5d. When we went for our next u/s at 8w6d there was no heartrate and the baby was measuring behind. I had a d&c since I was showing no signs of miscarrying. I just got the results back - 46XX. I understand that this is inconclusive, but feel in my heart that the baby was a girl and it didn't have any chromosome problems - I was 30 when we did the ivf. I am about to start on another ivf cycle and afraid that I may have a clotting or immune problem that will keep killing any baby I have. I am wondering if going on baby asprin and extra folic acid would be a good idea (I have been on prenatals for a year but heard this isn't always enough)?
At Wed Jul 29, 12:04:00 PM 2009,
Dorthy said…
Dear Dr.Trofatter,
Your post about RPL and treatments was extremely informative. Sadly, my husband and I are going through our second miscarriage in 5 months. I am at a loss for words and so worried about never having children. My question is what do you think the chances are of us carrying a baby to term and if there is any chance of uterine scarring due to 1 D&C even though nothing showed up on the sono test?
Here is more info about me and the testing done to date.
Age: Me-31 & husband is 33
Pregnancy History: First trimester abortion 8 years ago(D&C). Miscarriage at 6.5 weeks in March 2009 (Just 1 day after heart beat was detected) and Miscarriage at 8 weeks (fetus measured 6 weeks 3 days). We had an early scan but the measurement was 1 week behind and heart beat was only 84bpm. The follow up scan showed the baby had died. I was also on progesterone this time around but looks like it didn`t help.
I had my Day 3 FSH at 5.9 and Antral Follice Count was 22 back in April. I had a sonohystogram after the first M/C and my uterus looked perfect.
I am also RH- and had a rogham shot with each pregnancy.
I would appreciate any advise you can give and if we should pursue further testing at this time or simply try again.
At Thu Sep 03, 09:11:00 AM 2009,
Dorthy said…
Hi Dr.T.
I hope you can help me as I just received the news that I have a Protein C deficiency. My levels came back at 0.19 and the normal range is 0.57-1.5. I have suffered 2 miscarriages in the past 6 months and it has been a very difficult time for me. All other test results are normal including SHG, etc
At Fri Sep 25, 11:48:00 AM 2009,
Aaron and Heather said…
I am a 28 year old mother of two. I had my tubes tied after the premature birth of my son, at the age of 22. My husband and I started saving for a reversal and had it done 16 months ago. We started trying to conceive in September of 2008. To our surprise we found out on Nov 7 that we were expecting. Due to the Tubal reversal, betas tend to be ordered and monitored at a very early stage. Sluggish betas and constant bleeding were followed by a miscarriage on Dec. 1st. My next pregnancy in March started the same...betas of 7...18...28...then gone. The third 10...13....34...My VA doctor followed that with a d&c and diagnostic laproscopy. My tubes and uterus looked fine, and he removed two small submucousal fibroids. We were told to again started trying. I found out on Monday that I am again expecting..My beta on Tues was only 9....and today...3 days later is only 19. So my doubling time is at 66 hours. They have run so many tests, and an endometrial biopsy...to no success. There seems to be no reason for all of this. Four losses in ten months seems surreal..Im honestly searching for answers...any ideas?
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