Recurrent Early Pregnancy Loss - 7 - Immunologic and Hematologic Causes
Thursday, April 05, 2007
Kenneth F. Trofatter, Jr., MD, PhD
Normal pregnancy is considered by many to be a ‘hypercoagulable state.’ Many of our blood clotting factors are made in the liver and production of these is enhanced by estrogens, levels of which rise 100-1000-fold during pregnancy because of their production by the placenta. Although this would seem to place all pregnant women ‘at risk’ for blood clotting problems, few actually develop such complications (although this is still a major cause of morbidity and mortality for pregnant women). When such complications do arise, however, we have discovered that certain environmental, genetic, and acquired factors, working alone or in concert, may contribute to the imbalance. We have also come to suspect that some of these same factors may play a role in recurrent early pregnancy loss as well as later pregnancy complications such as small (growth restricted) babies, hypertensive disorders of pregnancy (preeclampsia; eclampsia; HELLP syndrome), intrauterine fetal demise, and early delivery, even if a woman has never had a problem related to clotting.
Perhaps the most common environmental influence associated with an increased tendency to ‘clot’ is smoking. I do not want to imply that smoking’s effects on the coagulation system is its sole contribution to pregnancy complications. Tobacco products have the potential to exert multiple deleterious effects on a pregnancy (and highly variable expression of those effects in different individuals). However, I have had several patients over the years that consulted me for repetitive miscarriages, had no other identifiable risk factors, and who only successfully carried a pregnancy after they were finally convinced to discontinue smoking. Although I do not want to dwell on ‘environmental factors’ in this post, certain prescription medications and over-the-counter ‘natural’ herbal preparations may also be culprits that need to be evaluated in the context of recurrent pregnancy loss.
The ‘genetic’ and ‘acquired’ factors have various mechanisms by which they effect the coagulation system, but the upshot is that those abnormalities which shift the balance in the directions of either increasing clot formation or diminishing fibrinolysis (the rate at which blood clots are broken down) have the greatest potential to cause pregnancy complications (although the contributions of these to early pregnancy loss is still highly controversial). Affectionately, these conditions have been termed ‘thrombophilias’ (= clot loving). Included among the common genetic abnormalities associated with an increased tendency to form or retain clots (and without going into detail about the specific mechanisms of action of any!) are gene mutations such as Factor V Leiden, prothrombin gene mutations, antithrombin III deficiency, methylenetetrahydrofolate reductase (MTHFR) deficiency (especially when associated with hyperhomocysteinemia which is also correlated with risk for neural tube and congenital heart defects), and deficiencies in Protein C and Protein S.
With regard to ‘acquired factors’ (perhaps also a misnomer because genetics also plays a role in the development of autoimmune conditions), in my last post we discussed a patient who had recurrent pregnancy losses and a ‘lupus anticoagulant.’ Lupus anticoagulants were named such because of their ability to prolong clotting in certain laboratory assays, but they are actually associated with a greater tendency to form blood clots in humans. They were first detected in patients who had systemic lupus erythematosus, but are now known to occur spontaneously in individuals who do not have lupus and may not cause any problems except difficulty carrying a pregnancy (as was the case with our patient). Lupus anticoagulants are only one of a host of autoantibodies (antibodies directed against ‘self’) classified as antiphospholipid antibodies. Others include anticardiolipin and antiphosphatidylserine antibodies among others.
As demonstrated by my patient with the lupus anticoagulant, the effects of antiphospholipid antibodies on different individuals is highly variable and probably dependent on other components of the person’s own genetic make up. In the most extreme cases, some individuals have severe and life-threatening problems related to these antibodies. Indeed, the triad of recurrent pregnancy losses or poor obstetrical outcomes (related to severe preeclampsia, intrauterine growth restriction; fetal deaths, and preterm delivery), recurrent episodes of venous and arterial thrombosis, and persistence of antiphospholipid antibodies has been termed the “antiphospholipid syndrome (APS).” In individuals with APS, successful pregnancy may not only be difficult to achieve, it could prove deadly, even with aggressive medical management.
In closing today’s post, I would be remiss in not mentioning another characteristic (and when dysfunctional, perhaps, an aberration) of the immune system that may be associated with recurrent early pregnancy loss. In fact, as I have alluded to previously, this may be the barrier which must be overcome to carry any pregnancy and also may be the most common cause of first pregnancy losses and, in some cases, consecutive miscarriages in many women who have no other identifiable ‘risk factors’ before they can successfully carry a pregnancy. It appears to be necessary that the maternal immune system recognizes the fetal tissues as ‘foreign’ (i.e., become ‘immunized’ to them) before it is able to generate a response that will nurture their growth (while maintaining certain boundaries).
It has been proposed (and is indeed the basis for some forms of empiric therapy) that the maternal immune response at times has difficulty properly recognizing the fetal tissues in this way. This may be more likely to occur if the fetal tissues are too similar to the maternal tissues. Indeed, some couples that share multiple ‘transplantation antigens’ seem to have the greatest hurdles to overcome in this regard. The reasons for this are unclear. Our immune system has both humoral (antibody) and cell-mediated components. It has been proposed that failure to elicit ‘blocking antibodies’ might be involved (and in some cases may be) under circumstances of recurrent early pregnancy loss. However, we also know that some women, who have a condition called ‘agammaglobulinemia’ and don’t make measurable levels of certain antibodies, may successfully achieve and carry a pregnancy. My own bias in this regard is that the important actors are components, perhaps, both nonspecific and specific, of the cellular immune system.
Well, we have come a long way in our discussion of factors that contribute to recurrent early pregnancy loss (and there are more we could mention!). But, I plan to conclude this series by devoting two more posts to this subject that will focus on the practical aspects of using the information we have presented to formulate plans for both evaluation and management of this problem. Thanks for hanging in there with me and I hope the thoughts will help those of you who have had their lives affected by this condition…
77 Comments:
At Mon Jun 11, 08:58:00 AM 2007,
yahoo.com said…
i want to know the main causes of miscourrage in pregnancy women and how to prevent it. please help me solve my problem.
At Mon Jun 11, 12:12:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
The main causes of miscarriage, the evaluation of recurrent miscarriage, and treatment recommendations are summarized in my last 3 posts in this series: April 8, April 12, and April 14, 2007. Take a look at these and then if you have anymore questions, or want to tell me about your special situation, feel free to write back to me. Thanks for reading!
At Tue Jun 19, 11:42:00 AM 2007,
I.R. said…
Dr. Trofatter, I have been diagnosed with Recurrent Pregnancy Loss. I've lost three early pregnancies- 6 weeks, 7 weeks, and less 4 1/2 weeks- over the last year. After the third loss, my husband and I went through testing in March 2007 and it's been determined that I have a PAI 1 (4G4G)genetic mutation. When I first went through the testing, I also had a slight deficiency in antithrombin III levels and antinuclear antibodies...but the tests were redone a couple of weeks ago and all came back within normal ranges. I am a healthy 26 year old. I have found a wonderful hematologist that goes above and beyond for me. However, I'd like to know your (obgyn view) perspective of how PAI 1 (specifically) correlates with early first trimester miscarriages. I do see a RE, but find that he is not very knowledgeable about PAI 1 either.... I am having a difficult time finding much information on PAI 1 and miscarriages. It seems that most blood clotting disorders cause second trimester micarriages; however, I feel that scientists and doctors are still building correlations between clotting and early first trimester losses. And, I believe (hope) that we'll see more info regarding these types of losses within the next few years. Thanks for any advice! I.R.
At Wed Jun 20, 06:20:00 PM 2007,
Anonymous said…
Dr. Trofatter, I have had 3 miscarriages in the past year, no baby has grown past 6 weeks. I have tested positive for MTHFR C677T - single mutation w/normal homocysteine levels (6.7). Began taking folgard vitamins (along w/prenatal vitamins) and baby asprin/day. Trying to decide if i should do or see anyone else. Any suggestions would be appreciated.
At Thu Jun 21, 06:51:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Single MTHFR mutations alone with normal homocysteine levels are not often the cause of recurrent miscarriages. So, there may be something else going on. You have now miscarried 3 times, and probably deserve a more thorough workup, but that is really your choice at this point. See my last 3 posts on this subject (Recurrent Early Pregnancy Loss 9, 10, 11) regarding summaries of "Evaluation; Empiric Therapy; and Therapeutic Interventions." These may help you make a decision about which course to pursue next. Do what's right for you. Thanks for reading and best of luck!
At Thu Jun 21, 06:55:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To I.R. from June 19: Fantastic question! Hold the thought and I will devote a whole post or two to the subject in the near future. Thank you so much for reading and 'keep posted.'
At Wed Jul 11, 02:30:00 PM 2007,
Jennifer said…
I really desperately need your advice.
1t started a week ago. I went to the loo, I had just started my period, when i wiped, their was a lump on the tissue.
I called the doctors, and was advised to go and collect a sample pot.
Then within a couple of hours, another 2 larger lumps came out, the 3rd lump was quite big and was hard to get it in the sample pot.
I know it sounds discusting but I could feel these lumps coming down. I didn't know if they were blood clots or a misscarriage.
I took the lumps to show my new doctor.
Before I pulled out the sample, I explained what had happened and he said strait away, "miscarriage" and after he saw the sample, I asked, 'could it be anything els?' and he looked me strait in the eyes and said "you are having a miscarriage".
He sent the sample away.
I went to see him a couple of days later just to make sure the pain i was experiencing was normal, and I was crying a little, because it was a shock.
Then today, he just called me to say, that it probably wasn't a miscarriage, and it probably was just a big bloodclot, as there was no foetus in the sample.
Is it possible that i did have a miscarriage? For about 4 weeks before, my breasts were tender and felt bigger. and I did feel neasous. I have got pain in my stomach right at the bottom, and sometimes its a bit sharp but mostly its crampy. My stomach seems to be sticking out also.
I just can't help thinking the doctor has mis-diagnosed or maybe the foetus came out and I didn't collect it?
I'm almost sure I had a miscarriage, what do you think?
Many many thanks
At Fri Jul 13, 07:38:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Jennifer: I am not sure what is happening with you right now. Did you actually have a pregnancy test done? If you did, and it was positive, you could have had a miscarriage (and missed an early fetus)or you could still have an ectopic (tubal) pregnancy. If the pain and bleeding continue, you need to get back to your doctors office. Sorry I can't be of more help, but there are limits to the internet!!!!!! Thanks for reading and hope things turn out alright for you.
At Mon Sep 17, 07:42:00 PM 2007,
Anonymous said…
Hello,
In 2004, after the stillbirth of my first child at 22 weeks gestation, I was diagnosed with APS. I have a very good reproductive endocrinologist and perinatologist to work with me when I decide to become pregnant again. I know that I will have to follow the twice daily heparin injections. My question is, is a woman on this therapy always forced to have a c-section? I understand that the drugs are stopped 24 hours before the delivery, however I want to know if I can attempt to have a natural childbirth even with APS. Thanks for the advice..
At Tue Sep 18, 07:06:00 PM 2007,
Anonymous said…
Dr Trofatter, I am 29 years old. I have had one successful pregnancy. However 3 miscarriages after that. The first they said it was just a missed abortion (my body showed no signs)Was picked up at 12week ultra sound that fetus died at 8 weeks. The second they said it was considered to be due to an implantation bleed.. (no signs)(fetus died at 7 weeks) And the recent one - last week was inconclusive. My body showed signs - bleeding. (all within 15months). I have been taking half an asprin (150mg) a day for the last 5 months which amazingly stopped my migraines. But I read on one of your posts that you should only take 80mg.. I have also been taking 5mg Folic acid, and just today started taking prenatal multivitamins and minerals... Is there anything else I can try.
Kind Regards. D.D.
At Thu Sep 20, 04:37:00 PM 2007,
Stephanie said…
Dr. Trofatter, I have had 3 early miscarriages. The first one at 12 weeks (baby stopped living at 9 weeks), the second only 4 days after my period was due, and the third at 8 weeks (baby was 6 week size, heartbeat was detected at 7 weeks but small size, no heartbeat at 8 weeks). I have begun testing with a reprod. endocrinologist.
So far ANA was negative, Cardiolipin antibodies IGA, IGG and IGM were all less than 10. Progesterone was 14.6 and 8 days post ovulation and TSH was 2.04. My doctor says this is all normal.
I have not seen the results for the estrogen and FSH but was told they were normal. I am also having genetic testing for my husband and myself along with some other tests.
I feel that this could be immunologic. I have interstitial cystitis and vulvodyna (vulvar vestibulitis). Could either of these be contributing to the miscarriages? My mother has rheumatoid arthritis but I do not.
Would you please let me know your opinion? I hope I have given you enough information.
Thank you
At Fri Sep 21, 09:43:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To DD Sept 18: Before you try anything else, I have a few questions. Was the father of the successful pregnancy the same as the father of any or all the miscarriages? Do you have any known medical problems? Are you taking any other medications? Have you had much of a weight change since your first baby? Is there any family history of genetic problems, birth defects, or chromosomal abnormalities on either side? Have you had any 'work up' to date for your losses and what were the results?
Regards, Dr T
At Fri Sep 21, 01:23:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Stephanie Sept 20: So far so good on the testing! Among othr things, this could still be the result of a chromosomal abnormality (e.g., balanced translocation)of either you or your husband, or a genetic thrombophilia (e.g., Factor V Leiden, prothrombin or MTHFR gene polymorphism, deficiencies of protein C, S or antithrombin III, or an excess of factor VIII). If you are seeing an REI, have they evaluated you for a congenital uterine abnormality or intrauterine fibroid or polyp? Do you have any evidence of hypothyroidism, diabetes, or insulin resistance? Any history consistent with endometriosis/adenomyosis? Most people with a real reason (other than just bad luck) will have something identified by one of these studies. If not, the possibility of an abnormal immunologic response to pregnancy cannot be ruled out and you could be considred for all out 'empiric' therapy! Let me know what you find out from the other studies and thanks for reading! Dr T
At Sun Sep 23, 11:07:00 PM 2007,
Anonymous said…
Dr. Trofatter. Answers to your questions. Yes, it is the same father to the successful pregnancy and the 3 miscarriages.My weight has only varied since the successful pregnancy around 6kg's to date. I currently weigh around 63kg's. As far as I am aware there are no genetic or chromosonal abnormalities, birth defects on either side. I am on no other medications (other than general multi vitamins). I had a spontaneous Numo Thorax just over a year ago but I don't think that would have anything to do with my miscarriages. I have not had any 'work up' to date other than the blood tests done this morning as they would only look into after I had 3 miscarriages. The blood test my husband's had was to check 'karyotype' and mine was the same plus for thyroid, protein etc etc.
Kind Regards DD
At Mon Sep 24, 05:13:00 PM 2007,
Anonymous said…
Dr. Trofatter, I posted a comment on June 20th, I have the MTHFR gene mutation c677t allele, had 3 miscarriages - just wanted to give you an update; i am currently 8 1/2 weeks pregnant again - had an ultrasound at 8 weeks and there was a strong, healthy heartbeat and the baby was right on track! Before pregnancy i was taking prenatal vitamins, fish oil, baby aspirin, and folguard vitamin. Once we knew i was pregnant, began taking prometrium, and dropped the folguard and switched to 4 mcg's of folic acid, also switched from fish oil to Expecta DHA supplement. Hope this may help someone else!
At Thu Sep 27, 01:11:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To DD Sept 23: Thanks for the answers to some of my questions. Why don't you touch base with me after you get back the results of the laboratory studies (ask your doctor for a copy of the specific tests and the actual results with the 'normal' test ranges for your laboratory). If nothing is found (and, probably, even if something is found except for a chromosomal abnormality such as a balanced translocation in you or your husband), the next step would be to add either Lovenox or heparin to what you are already taking at either empiric prophylactic or at therapeutic levels (depending on your test results). Please stay in touch and thanks again for reading. Dr T
At Thu Sep 27, 01:13:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Sept 24: Thanks for the feedback and BEST OF LUCK with the pregnancy. Let me know how you do! Regards, Dr T
At Thu Sep 27, 01:25:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Sept 17: You do NOT have to have a cesarean delivery just because you have antiphospholipid antibody syndrome. However, many women with APS will end up with one simply because, even with therapy, they are at increased risk for an abnormality of placentation that results in fetal growth restriction, preeclampsia, or decreased placental reserve (with "fetal distress") during uterine contractions. Also, you do NOT need to stop heparin for 24 hours prior to delivery. You can take that until you actually present in labor and, if necessary, the effects of the heparin can be 'reversed' with a drug called protamine sulfate. If your doctor chooses to use 'low-molecular weight heparin' (such as Lovenox), that does need to be stopped at least 24-48 hours prior to delivery because its effects cannot be reversed and that maight increase your risk for bleeding problems. Indeed,many anesthesiologists will not consider an epidural or spinal anesthetic unless you have been off Lovenox for at least 48 hours. In our practice, we generally stop Lovenox at 34-36 weeks and intentionally switch to heparin to avoid risks of bleeding complications and to allow the patients the benefits of regional anesthesia during labor and delivery. Thanks for reading and for a great question. I will feature this query in one of my daily blogs! Best regards, Dr T
At Fri Sep 28, 10:26:00 PM 2007,
Anonymous said…
Hello Dr.,
I had a miscarriage 8 days ago (blighted ovum). The doctor said that according to the ultrasound, everything was cleared out, aside from some tissue which would pass naturally (no D&C required). The bleeding has been significantly lighter, however tonight I passed a very very large blod clot (I'm thinking). It was firm and rubbery (sorry, tmi). It is very large. Is there cause for alarm, as it could be an infection? Thank you very much.
At Wed Oct 03, 06:03:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Sept 28: It was probably just a fibrin clot. If the bleeding slowed down afterwards, you don't have a lot of pain, a malodorus discharge, or a fever, things will probably be just fine. Sorry for your loss. Thank you for reading. Dr T
At Wed Oct 24, 06:37:00 PM 2007,
Anonymous said…
Hello Doctor: I have been diagnonsed with PAI 1 4g/5g. I have had 3 second trimester losses consecutively and am currently 6.5 wks pregnant. I am on lovenox 2x 40 mg, i am 185 lbs. I am currently bleeding, mostly brown but have noticed that I have passed 2 very small clots. Sonograms reveal a strong heartbeat, and no sign of why the bleeding. In the past I had a subchorionic hematoma, but I can't tell if this is also the same fate as that led to a miscarriage. I am very scared, I just moved to a new state and barely know my doctors, and although I feel they are good, I don't know how much experience they have with this. My question is does the lovenox help with a subchorionic hematoma (will it break the clot up?). Or can the clotting be pointing to a miscarriage? I will appreciate your help with this. SL
At Fri Oct 26, 05:40:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To SL Oct 24: Tell you what, I would certainly like t know more about those midtrimester losses. How far along did you get with each one; what kind of complications did you have precedung the losses; did the babies die in utero or did you simply miscarry; did you have any D&Cs; were there any abnormalities of the babies or placentas; etc? With regard to he current pregnancy, if you are having bleeding problems, the Lovenox might be hurting as much as helping. Have your doctors considered reducing the dose for awhile until the bleeding has resolved? Sorry I can't be any more help to you at this point, but I do wish you well. Dr T
At Fri Oct 26, 07:56:00 PM 2007,
Anonymous said…
Dear Doctor:
I just miscarried, 6 weeks, 2 days, and I was wondering if an autopsy of a fetal pole that young is common practice or advisable?
At Fri Oct 26, 08:03:00 PM 2007,
Alice said…
Hi Dr. I sincerely hope you can help me and I thank you ahead of time for reading my long post.
I took misoprostol on my own last week to induce miscarriage. I took 600 mcg sublingually, repeated with another 600 mcg 3 hours later and another 800 mcg 6 hours later. Nothing happened. Two days after I took the medication I started having brown spotting. Five days after taking medication I took it again (this time 400 mcg sublingually, then 600 mcg 3 hours later and another 400 mcg 3 hours later and another 400 mcg 3 hours later).
(Please let me explain real quick my reason for taking this - I heard is possible to cause miscarriage by using misoprostol alone which I already had prescribed to me from a missed miscarriage earlier in the year - This time I got pregnanct I was raped and there are no clinics within 5 hours drive that provide the surgical or medical procedure and I was desperate).
So now I am bleeding mildly (thru a pad about every 4 hours if I left on that long). I am cramping and I have passed 2 small clots. The last one was firm and kind of rubbery (gross I know sorry). What exactly is it that I am passing? What passes during a miscarriage besides the obvious baby?
I was only 4 weeks, at the most, along. How much bleeding/tissue/clots should I expect to pass? Also, I plan on going to ER in a few days for ultrasound to see if the miscarriage has completed. If it has not been completed, will they offer me a D & C? What if the pregnancy is still viable? Should I tell them about the medication I took as I know this medication can cause severe birth defects? Are hospitals/doctors required to help a women out if her baby may have birth defects? Please help me as I am worried I may not completely miscarry this time as well since I am only bleeding mildly. Though I am still having cramps. This is terrible and I wish more doctors would provide this service because there are many desperate women like me that need help and will continue to put their lives in danger because they do not want a baby at this time in their life.
I thank you sincerely for any help or guidance.
At Thu Nov 01, 06:25:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Alice Oct 26: Alice, physicians should never even treat themselves! If you were raped, you should have gone to an emergency room for possible evaluation. The routine in most is to evaluate and treat you for possible sexually transmitted infections and to offer the "morning after" pills. That would have been much more sensible than taking misoprostol. Although that might work, it also might not and if you have an ectopic pregnancy, it won't help at all. The ER could have also recommended various support services. I suggest you either find a doctor, go to the local health department, or find a clinic that provides counseling and abortion services if you do not want to take the chance of carrying this pregnancy. That would make more sense and cost a whole lot less than going to the ER. You ABSOLUTELY should tell them about the medication you took and about the circumstances surrounding the conception. I am going to hold off answering your other questions at this time. Don't be afraid to ask for help. It's out there and it's much better than me trying to give you guidance online! Good luck to you. Dr T
At Thu Nov 01, 06:30:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Oct 26: If this was your first miscarriage, I usually don't recommend anything be done other than routine evaluation of the 'products of conception' - usually this is mostly placental tissues. If you miscarry again, you might consider sending the same 'products of conception' to a laboratory that can do chromosomal studies on the placental tissues. But, I warn you in advance, that is expensive and many insurance carriers will not cover that expense. Sorry for your loss, thanks for reading and best of luck in the future... Dr T
At Thu Nov 01, 07:11:00 PM 2007,
Anonymous said…
Hi Dr. It's SL from Oct 24: Thank you so much for answering me. I just had a fourth miscarriage at 7 weeks. The first miscarriage I had a slow water leak, then one day a dull side pain and was told my baby died in utero at 15 weeks. Autopsy results were: "fragments of acutely inflamed decidua and endometrial glands; a degenerating villus is identified and blood clot and fragmented, inflamed second trimester placenta." The second I had IVF after trying for 3 yrs, I had bleeding from 6 weeks til I miscarried at 14 weeks. I was under the care of an RE who said I had PCOS, was on progesterone 2x per day however, I had a subchorionic hematoma that became worse; I broke my water and miscarried. The third was IUFD, discovered at a routine appt. I was on progesterone for through week 10 but no bleeding or pain. Autopsy results: "uterus, endometrium: inmature chorionic villi with sclerosis"; placenta: chorionic villi were gross ly identified from section of fetal skin, muscle and placenta. cultures failed to yield any metaphase cells for analysis. For this last miscarriage, the doctors did not adjust my medication which I thought was too much in the first place, but the difference was that this happened in the first trimester. The first and third miscarriages I had a D & C, the second I ended up having a hysteroscopy because of retained products. This last one no D&C as it looks like everything has been expelled. I am releasing a lot of clots and though it happened a week ago, I am bleeding a lot. Thanks again and sorry for the long email, I am looking for answers and am desperate. SL
At Mon Nov 05, 06:12:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To SL Nov 1: I am sory for your loss. Thanks for the medical history, I still do not have all the pieces to your puzzle. I know you are concerned that you were on too much medicine, but that's just what it might take in your case. Were you on metformin? Did they do ovulation induction? Have you tried Femera? What kind of evaluation of your coagulation system have you had to date? Anyway, stay in touch and sooner or later I might come up with some good ideas for your evaluation and care! Dr T
At Wed Nov 07, 06:45:00 PM 2007,
Anonymous said…
Hi Dr.: I was on metformin last year for about two months after my second miscarriage--I got pregnant again soon after. I have not used it again. In the beginning of my infertility treatment, I was on Clomid for about 4 months, then went for the IVF. After using Clomid and having a hysteroscopy my periods became more normal, and I became more "fertile" so my RE never put me back on Metformin nor did I need Clomid. The last two pregnancies though the doctors said I had late ovulation because the LMP and sonograms were always inconsistent. I have never tried Femera. The only evaluation I have had in regards to coagulation has been the initial test that detected the PAI 4g/5g. I have not been referred to any other specialists though as I write I am considering seeing a hematologist. I appreciate anything you can suggest. Thanks a million. SL
At Tue Nov 13, 04:55:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To SL Nov 7: If you "ovulate late" and responded to metformin, you might benefit by being on it for several months before conception and then continuing during the first 9-12 weeks of a pregnancy. The underlying metabolic defects do not go away with just a short course of therapy. Femara is VERY effective at ovulation induction and might be a good drug for you to try. I don't know whether it is better for you to see a hematologist, a maternal-fetal medicine specialist or an REI who has a special interetst in early pregnancy loss. But, I think you would benefit from someone who pulls out all stops in helping you to get and stay pregnant. Stay in touch and again, good luck! Dr T
At Tue Nov 20, 12:48:00 PM 2007,
Amber said…
I have Factor V (hetero) and had one normal pregnancy without knowing that I had it. This pregnancy the doctors started me on Lovenox. My original doctor said that I would be switched from Lovenox at 36 weeks and induced at about 38 weeks. Because I am military, I don't really have the luxury of seeing the same doctor because of duty station changes, etc. At my most recent appointment, the doctor I spoke with said they weren't going to change me to heparin until 38 weeks and that they would not induce early. My son was 3 weeks early, so if this pregnancy chances to follow suit, shouldn't they change me to the heparin at 36 weeks like my original doctor advised? And is being induced 2 weeks early normal? I tend to believe my orginal doctor because the other one changes his mind constantly about even the littlest things. Thank you
At Sat Nov 24, 11:06:00 AM 2007,
Anonymous said…
Dr. Trofatter,
I was just diagnosed w/ 2 copies of MTHFR C677T
mutation (homozygous positive). I am 38 yrs old, have a healthy 2 yr. old boy and have had 3 miscarriages this year, all pregnancies w/ the same father. we are meeting w/ a genetic counselor next week. I am having several tests done and have gotten this result so far. I miscarried at 8 wks, 11 wks, and 5 wks. NO testing was done prior to the 3rd miscarriage. I have gotten pregnant each time I have tried though my dr. is still going to test my estradial and FSH. Do you think this is neccessary?
Here is my question- I have done a ton of research and have a basic grasp of the blood disorder but am wondering what actually stops the baby from surviving? Is it always that there is a defect b/c of the lack of folate and vitamins B getting to the fetus? Or is it that there is blood clotting and the baby isn't getting what it needs? I also want to know and I know the geneticist will tell us more once she has mine and my husbands results but should we NOT try for another? THis year has been gut wrenching and I selfishly want another child, not just for me but for my son. I always wanted more than one child but is it too risky??? I am on Vitamin b12, B6, 5 mg of folic acid and 81 mg of baby aspirin. I 'm assuming I will get my Homocysteine levels checked before i get the green light to conceive? I don't want to wait much longer b/c i am 39 in March. Thank you for any and all info. regarding these questions.
At Mon Nov 26, 06:58:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Amber Nov 20: Sorry for the delay in responding but I just got your comment in my mailbox today. I need to havethe answer to one VERY important question, before I can answer any of yours properly. What led to you finding out that you were a factor V Leiden heterozygote? Those test usually don't get done for any routine basis! Anyway, personally, I would switch you to heparin at 36 weeks, especially if you delivered early before (and why was that delivery early? - another important question!). The reason for switching you is to decrease your risk of anesthetic complications (bleeding at the site of an epidural or spinal). Most anesthesiologists would prefer that Lovenox be out of your system for 48-72 hours before you need one of those procedures done. Heparin can be reversed easily with protamine sulfate, whereas Lovenox cannot be reliably. Let me know the answers and I will see if I have any other thoughts. Thanks for reading! Dr T
At Tue Nov 27, 12:36:00 PM 2007,
amber said…
I found out because my grandmother has had clots her entire life, and was finally tested a couple years ago. She had clots after all of her pregnancies. She tested positive, hetero. My uncle had a pulmonary embolism in 91, and so he tested as well, and was positive. My mother has had some minor clots, and tested positive for it too and told me about it. She said it was genetic, so, I requested to be tested because I had been on birth control and I have heard that hormonal birth control can add to the risk. I haven't had any problems with clotting thus far, it probably helps that I am military and usually fairly active. This was after my first child though, I didn't know about it with him. My son was early naturally and I didnt have any complications with him thankfully.
At Thu Nov 29, 11:05:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Amber Nov 27: Thanks for your answers. I figured there was more to the story! My first answer stands. Based on your family history and your previous early delivery, I would switch you to heparin at 36 weeks. However, if the baby was growing well, had normal fluid, normal NST,and normal Doppler flow studies, and you were not having any complications yourself, I would not deliver you before 39 weeks unless I first documented fetal lung maturity with an amniocentesis. Then I would place you on Lovenox, starting 12-24 hours after delivery, until at least 6 weeks postpartum and then keep you on one baby aspirin (81 mg) per day for the rest of your life! Good luck my friend and let us know how things turn out! Dr T
At Thu Nov 29, 05:16:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Nov 24: You were homozygous for C677T when you had your first child and you did just fine. To answer your questions, these polymorphisms may put you at slightly greater risk for clotting problems, particularly if you have other risk factors, but I don't think they are a big cause of recurrent early pregnancy loss, especially once you have been started on supplemental folic acid. That probably also reduces the risk of neural tube defects and congenital heart disease as well. But, I would wager that your primary problems are 'age-relaated.' Fertility drops with age for reasons that are not completely understoods. Part of the contribution may be the increased risk for having a chromosomally abnormal fetus; part may be other medical problems such as diabetes, obesity, thyroid disease, hypercholesterolemia, and hypertension; part is simply that your body's ability to hormonally support an early pregnancy might not quite be what it was when you had your son. Ovulation induction and progestrone support may be all that you need, but I would suggest you find a Reproductive Endocrinologist (if you haven't already) since he/she will be in the best position to move you through thorough evaluation and treatment, even if that ends up being just empiric. Good luck to you! Thanks for reading. Dr T
At Thu Nov 29, 08:03:00 PM 2007,
Anonymous said…
Baby asprin-does it really prevent miscarriage? I've had people swear by the stuff.
Also, after a miscarriage, how long should one wait before requesting fertility meds? We've been ttc now for over two years, and we had a miscarriage in September.
Thanks for your help! This site is amazing.
At Sun Dec 02, 08:58:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Nov 29: Thanks for your comment and for the positive feedback! I think that low-dose aspirin does improve outcomes in selected patients, but I don't think we are ready to put it in prenatal vitamins yet! I am more concerned that it took you over two years to conceive the pregnancy you recently lost. That might be reason alone to seek out a specialist in Reproductive Endocrinology and Infertility. Other factors may need to be addressed to give you your best shot at a successful pregnancy outcome. By the way, was this your very first pregnancy? Thanks for reading and good luck to you! Dr T
At Wed Dec 05, 08:35:00 AM 2007,
Margaret said…
Have 3 healthy children, then had 3 missed - miscarriages ranging between 8 weeks and 16 weeks. Had no pain or bleeding. Have had 3 d c prodeedures. Was dignosed with antiphosolipid antibodies that only seem to appear when pregnant. am on 75mg nuseals aspirin daily and was on innopro injections for last pregnancy which i miscarried at 8 wks,gyn advises one more go with empire. Am 38 and 68kg.wondering if risk of deformities due to lack of nutrients getting to fetus high?Any encouraging words. V scared
At Thu Dec 06, 11:58:00 AM 2007,
JS said…
Dear doctor Trofatter, Could you please tell me your opinion on this.
I had two missed abortions (first trimester losses) both pregnancies terminated with D&Cs. My OB did all these tests:
HSG
hysteroscopy
Karyotype
Protein C
Protein S
Leiden mutation (R506Q mutation)
MTHFR (C677T and A1298C mutations)
Cardiolipin IgG, IgM, IgA
Factor II mutation (G20210A mutation)
Lupus anticoag
- PTT (LAC) Screen
- Hexagonal phase
- DRVVT
- Phospholipid Neutraliz.
Glucose and Insulin challenging test
Antitrombin III
- everything came back negative. My husband's karyotype was OK too.
My RE recommended to take baby aspirin and 600mg of progesterone. So I did and had a successful pregnancy then - full term, healthy baby born in 2006. I just had to be induced due to high blood pressure at 39 weeks.
The thing is that we just had another pregnancy loss - twins at 15 weeks. I didn't take any drugs during this pregnancy (no BA, nor progesterone) because I was still breastfeeding until 9 weeks of pregnancy. We lost our twins at 15 weeks of pregnancy after recurrent heavy bleedings. In ultrasound examination, there was a hematoma with a maximal size of 4cm (then it was 2 cm) At the end of pregnancy, my amnionic fluid suddenly broke which caused subsequent contractions and miscarriage. In previous exams, no placental separation was seen and the placentas actually did never separate. I had to have D&C to remove the placentas. The hematoma wasn't subchorial (I don't know how to call a hematoma which isn't under the placenta)
So we've had three losses, all tests came back negative and I'm really scared and have tons of questions.
Should I take the baby aspirin, progesterone and/or prednison next time?
Could have the hematoma be caused by any defects of my uterus (like polyps, poor lining)? Could it be a result of previous D&Cs, subsequent pregnancies, or so?
Could it be due to a sensibilisation towards a rare blood antigen (such as Kidd or Kell antigen groups)?
And the most important question:
What's the chance of happening this again? All doctors we've consulted think that there is no reason for our losses and that it was "just" bad luck. Do you agree? It seems like too much of bad luck... :( Should we keep looking for possible causes of our losses?
My husband and I are 30 years old with no chronic conditions.
I'm so sorry for such a long post. It's so hard to find a doctor who is an expert in this though and I really need to get answers to at least some of my questions to stay hopeful and to be able to try again...
Thank you very much in advance. This site is great!
Take care,
JS
At Fri Dec 14, 12:05:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Hi JS: I am sorry for your recent loss, but you have several VERY good things going for you. Despite your losses, you HAVE carried a baby to term and your 'work-up' was completely negative. So, you really may just be one of those folks who has just had a streak of 'bad luck.' But, let me make a few other comments. With regard to the twins, that loss was probably the result of the bleeding. What caused the bleeding is uncertain, but some women who carry nursing into another pregnancy, have increased uterine contractions (even if they don't feel them) because of the oxytocin (Pitocin) released from their brains when they nurse. This isn't a problem for all women, but you may be more sensitive than others and that might have caused an abnormality of placentation that then led to the bleeding. The bleeding by itself is not necessarily the problem, but most women who continue to bleed, eventually develop an ascending infection (blood changes the pH of the vagina and is a fertile culture medium for pathogenic bacteria to overgrow). Ascending infection potentiates the placental problems, usually leading to even more bleeding, and eventually results in rupture of the membranes as happened with your twins.
With regard to next pregnancy, even though we don't know whether or not the aspirin and progesterone were the reason you carried your other baby to term, they certainly aren't a amjor source of risk for a pregnancy. So, I would go back to that regimen. Rather than prednisone, if something else is needed, I would suggest heparin or low-molecular weight heparin. If did you use prednisone with the other pregnancy, though, that also would be reasonable.
Major defects of the uterine caity were probably ruled out by the workup (HSG and hysteroscopy) your doctor already did, so mark that one off your list. Also, red blood cell isoimmunization is something you have already been screened for and is VERY unlikely to be associated with the problems you have had, even if you were isoimmunized.
Could something bad happen again? Sure, but odds are in your favor that you will successfully carry another baby. Good luck and thank for reading! Dr T
At Fri Dec 14, 12:20:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Margaret Dec 5: Things don't get any easier with age, do they!?! Margaret, I probably have more questions for you than you had for me. Was the father of your liveborns the same as the father of the babies you lost? Did any of those losses have chromosomal studies done? Do you have any medical problems? What work-up other than the antiphospholipid antibodies have you had done? Are your periods still regular and how often? When after you conceived did you start the heparin therapy? If you get back with some of thhose answers, maybe I can offer a few suggestions. Dr T
P.S. It's normal to be "scared: under these circumstances...
At Fri Dec 21, 05:03:00 AM 2007,
Margaret said…
hi again. to answer your questions. Yes same dad. Chromosomal studies done and all normal.No medical problems except Homocysteine 14.taking h factors to combat this? unsure about this as not by conventional doctor.Lupus tests unequivocal in between all pregnancies and only take asprin no other work up. very interested in this as thought that i could do nothing before becoming pregnant as unoquivocal results.Periods regular every 22 days. Ovulate on day 8 or 9. Previous heparin started at 5 weeks. would appreciate any more suggestions. thanks dr
At Thu Jan 17, 11:38:00 AM 2008,
Anonymous said…
Hi Dr. Trofatter, I have APS and have had one live birth and 2 m/c (both at 8 weeks). The second m/c was sent out for genetic testing and there was a triploid (49 chromosomes or extra set of chromosomes), so had nothing to do with APS. I often wonder about the first m/c though. I was diagnosed after the first m/c. I am 12 weeks pregnant now and was advised that I need a cerclage. I am currently on 40 mg of Lovenox and a baby aspirin. I am literally terrified regarding the spinal because of known paralysis. Can you please talk me down from the ledge and shed some positive light on the subject? Much appreciated, C
At Mon Jan 21, 04:36:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Jan 17: I am not sure where to start with you! First of all, on what basis were you told that you have APS - what clinical events or what laboratory tests (be specific with the results if you have them) led to the diagnosis? The baby you lost with the triploidy (69 chromosomes) had NOTHING to do with APS or with your other miscarriage. Why do yur doctors think you need a cerclage. And, are you afraid of "paralysis" from the spinal or from complications to a spinal because you are on Lovenox. If you were not on the Lovenox, I would not worry about the spinal. they are very safe. However, most anesthesiologist will NOT perform a spinal or epidural anesthesia in women on Lovenox unless they have been off it for 48-72 hours. But if you REALLY need a cerclage, and you REALLY need to be anticoagulated, and your doctors are afraid to take you off the Lovenox, then a general anesthetic is very safe at this point in pregnancy. I am curious to hear your responses, so thanks for reading and please get back to me! Dr T
At Wed Feb 06, 03:31:00 PM 2008,
Anne said…
I have had in this order:
1- Healthy pregnancy/baby born(10/03/1998)
2- Miscarriage @ 7 wks (07/1999)
3- Pregnancy w/ preeclampsia (healthy baby born @ 32 wks (05/26/2000)/ blood transfusion for me)
4- Healthy pregnancy/baby born (01/14/07)
5- Miscarriage @ 8.5 wks (1/17/08)-two days after normal healthy ultrasound.
I am 29 years old and all these have been with same husband. With the last 2, blood tests revealed "antibodies"; Dr. did not really explain them to me. Is it possible that "antibodies" could have caused this recent miscarriage but not interfered with the previous pregnancy? When they first noticed the antibodies they told me it was likely a result of the blood transfusion. If it is possible, is there any way for me to have another successful pregnancy? We would really love to have a fourth child, I do not want to have another miscarriage and would appreciate any advice.
At Thu Feb 07, 05:56:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anne Wed Feb 6: You need to find out specifically what the "antibodies" are. If they are related to transfusin, they may (or may not) make a pregnancy more difficult, but they should not cause miscarriages and prevent you from having another baby. Most of the time when you have successful pregnancies interspersed with miscarriages, the miscariages are the result of either chromosomal or genetic abnormalities over which you have no control. They are upsetting, but it is nature's way of, perhaps, sparing you greater heartache down the line. Thanks for reading. Dr T
At Sat Mar 15, 07:25:00 PM 2008,
Anonymous said…
Hi there, Wow... I think it's great that you take the time to answer all of our questions... Thankyou! My question is actually for my friend, she started bleeding at 10 wks pregnant, just a little bit, and then nothing for two days. After this she passed several large clots and bright red blood with non-painful contractions, but no sign of baby, sack or placenta. It has been 3 days since this happened, and she has felt great... no more cramping & very minimal bleeding. So my question is, can she still have a viable pregnancy after this, or at 10 weeks is the baby still to small that she could have missed it while passing the clots?
At Fri Mar 21, 06:59:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Mar 15: She really needs to have an ultrasound done. If the baby had stopped growing earlier in the pregnancy, she might have miscarried everything without seeing much more than clot. And, on other occasions, bleeding such as you describe has no identifiable cause and the pregnancy progresses just fine. Thanks for reading and sorry I can't be more help from afar! Dr T
At Mon Mar 24, 01:25:00 PM 2008,
Anonymous said…
Since June 2005 I had 2 miscarriages both in the 6 week (Dec 2005 and August 20006). In April 2007 I started to see a fertility doctor. I tried to get pregnant with timed intercourse but it didn't work. In this period, twice my menstruation didn't arrive until week 6 (I used to have regular 4 week period, though when I was on my 20's it wasn't very regular). I am now 40, my husband 51 (none of us had children before). We decided to go with an IVF procedure. I took birth control pills for 2 weeks then Gonal F, Menopur and Ganirelix. They extracted 17 eggs though at the end only 2 of them were viable (graded 5B and 4B). The doctor decided to implant both embyros. That was March 11th. March 20th my pregnancy test was possitive with a hcg level of 23. I have been on progesterone since March 6th. Today the hcg level was again 23, so it looks like I am going to have another miscarriage. All the tests carried so far were OK (hysteroscopy, immune / thrombophilia, clomiphene citrate challengement test, karyotypes, complex semen analysis) the only issus being high probability for diminished ovarian reserve and mild decrease in normal morphology for sperms.
Anything I can do until Thursday to increase hcg levels? Shall I take baby pills?
Any ideas of what goes wrong?
Thanks in advance for a promt response!
At Mon Mar 24, 01:44:00 PM 2008,
Anonymous said…
I am 40, my husband 51 and none of us had children. I have been trying getting pregnant since June 2005. I had two miscarriages in Dec 2005 and August 2006. In April 2007 we started to visit a fertility doctor. All the test carried out were ok (hysteroscopy, kariotydes, thyroid,We tried a couple of times timed intercourse but it did not work, semen analysis) except for a diminished ovarian reserve and mild decrease of sperm morphology.
In February 2008 we decided to undertake a IVF procedure. I was given birth control pills for 2 wks then put on Gonal F, Menopur and Ganirelix. 17 eggs were retrieved on March 6th. However, the progress of the embryos was not that good and at the end only 2 graded 5B and 4B were transferred. I started progesterone on March 6th. On March 20th the pregnancy test was positive, with hcg level of 23. However today, March 24th the hcg level was again 23. The doctor wants to check again on Thu March 27th.
But given my history chances are very low. Is there anything I could do to avoid another miscarriage? What if I start taking baby aspirins? Any ideas of what could be the reason for my miscarriages?
Thanks a lot for a quick response, though I am afraid I am not very hopeful…
At Wed Mar 26, 07:38:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Mar 24: That is a VERY low hCG level so the prospects for success are not good. And, there is nothing you can do at this point to improve your situation with the current pregnancy. It sounds like you have good doctors and I am sure they will tell you that about all they can do to help is to try to reverse the diminished hormonal reserves related to age and give you enough hormonal support in early pregnancy to get you to the point where the placenta is able to take over those functions without depending on you (or the medications). Age is not a friend to us when it comes to reproduction and in some folks, it is a real enemy even sooner than later. Good luck to you and sorry I cannot offer more concrete advice. Dr T
At Wed May 07, 12:28:00 AM 2008,
Anonymous said…
Can you please give me some advice re: IVF treatment? I am American but am living in Sydney Australia. I have tried 4 attempts at IVF with the same result. The blastocyst attaches and there is a low HcG level but it never continues on to a pregnancy. There appears to be nothing wrong with the embryo but it just never seems to implant properly. All I have been given is Crinone gel and 1 shot of pregnyl 2 days after the blastocyst is transferred. This last attempt I had 2 transferred and still it was unsuccessful. I have PCOS and have exhausted all other fertility treatments. I have 4 frozen blastocysts remaining but I don't want to continue making the same mistake, if there is actually some medication I can take to help or a test I can have that will determine why I can't maintain a pregnancy, could you advise me? I have taken Metformin previously but with no result and bad side effects. Is my dr. doing all she can to help me?
At Fri May 09, 07:33:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 7: The REI physicians with whom I work seem to think that a major cause of unexplained early pregnancy loss (even in women with PCOS) is unsuspected endometriosis. That have used letrazole (an aromatase inhibitor) very successfully in their patients. I am not an REI physician, but it is something else to consider. Another option is to return to the metformin for 3-4 months and adding low molecular weight heparin (at a prophylactic level) to your therapeutic regimen around the time of embryo transfer. Sorry I cannot be of more help, but best wishes to you! Dr T
At Mon May 19, 01:43:00 PM 2008,
Anonymous said…
Hello Dr. T, So happy to find your blog! I am 44 and my husband and I have an egg donor. I had two embryos transferred in March (Day 5 Blastocyst). I had very high HCG levels which initially had my doctor believing I had twins. I had bleeding and clotting week 5 and then extreme bleeding and clotting week 7. Had the D/C with the test on the tissue not resulting with any chromo problems. We have two frozen embryos and plan to transfer them in July08. My fertility doctor has ordered over 20 test and has me seeing a hematologist to consult with us on the blood test in 3 weeks. My question is what more test can we do? What other specialist should we consult? I have NO history of ANY medical problems, I'm in the best shape of my life! My hematologist and Fertility doctor think it could just be "Bad Luck". But are doing all the test they think might determine some unanswered question. Any added insight would be wonderful! Thanks!!
At Thu May 22, 07:10:00 PM 2008,
Anonymous said…
What causes subchorionic hematomas? Can APS be a factor? I have had two first-trimester losses (9 weeks and 11 weeks); in both cases there was a strong fetal heartbeat but also a large hematoma, which it seems might have caused the miscarriages. My OB will be doing tests on me--I'm not sure what tests she plans--and I am wondering whether APS could be something that would explain my losses. (She has been vague about causes of subchorionic hematomas.)
My first pregnancy, two years ago, was uneventful; my daughter was full-term and healthy. All pregnancies have been with the same man. I am about 5 kg heavier than when I conceived my daughter (having a toddler makes it harder to get to the gym!), but still within a healthy weight range for my height, and otherwise no changes in my health (which is excellent).
Thanks so much for any advice or information you're able to give! It's wonderful that you answer questions in this way.
At Sun May 25, 04:14:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 19: First of all, I am sorry for your loss, Do you have any living children? What has been the primary cause of your "infertility?" Tell you what, when you get back the results of those "20 tests", let me know what they are and I will tell you what I think! Thanks for reading. Dr T
At Sun May 25, 04:25:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 22: First, thanks for the kind comments. Lots of things can cause subchorionic hematomas, but the significant ones are probably the consequence of an abnormality of placentation that might be related to a fetal chromosomal abnormality, a genetic or acquired thrombophilia, local inflammation secondary to a submucosal fibroid or polyp, or even endometriosis. The best thing you have going for you is that you have previously carried a child. I would suggest a basic thrombophilia evaluation, including antiphopholipid antibodies and lupus anticoagulant, and also consider having a sonohysterogram (and possibly hysteroscopy) done to evaluate the uterine cavity for abnormalities. Although it may be hard, you might consider trying to lose the 5 kg as well. Sometimes slight increases in weight can dramatically affect pregnancy success secondary, perhaps, to hyperlipidemia and inflammation or insulin resistance. Have your doctor explain the latter to you. Best wishes and please let us know what you find out! Dr T
At Tue Jun 03, 08:48:00 AM 2008,
Anonymous said…
Dr. Trofatter - i posted on 8/24/07 and 6/20/07 - i gave birth to a beautiful, healthy 9 lb 7 oz boy 6 weeks ago! I was diagnosed w/MTHFR C677t single mutation. I took baby asprin and LOTS of folic acid! Just wanted to give you an update and let others know that there is hope!
At Tue Jun 03, 07:11:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous June 3: Congratulations! Have fun with the baby :) Dr T
At Mon Sep 15, 07:22:00 PM 2008,
mariahk said…
I just had my 5th miscarriage. My husband and I have been through the whole fertility clinic, and that just ended in a blighted ovum. I have been told I have antiphospholipid antibodies, antinuclear antibodies, and MTHFR....this last pregnancy I was put on Lovenox injections 2xday, and was on folgard along with my prenatal. After we miscarried, my OB told me I would probably never be able to carry a baby again. When I came home and decided to do my own research, however, I was a little upset at what I found. According to my research, I should be on prednisone before I ovulate until pregnancy is achieved, baby aspirin AND heperin injections before I concieve, and the folgard. Is this right? Has the problem been that I haven't found a doctor who knows how to treat my situation? We do have one daughter. Right before we conceived her I was on prednisone for an outbreak of red, raised bumps all over my legs. I am starting to think this wasn't a coincidence. Any information you can give us would be extremely appreciated. We just wanted to give our daughter a sibling and this has turned into a nightmare.
At Tue Sep 23, 06:56:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To mariahk: There really is not a standard treatment regimen. You may be one of those individuals who would benefit from both low-dose prednisone and lovenox eeven prior to conception, and your past experience may not have been a "coincidence." Tell your doctor what you have told me, what you would like to try and why and if he/she will not go along with that, then find a doctor who will. Dr T
At Thu Oct 23, 01:52:00 PM 2008,
Anonymous said…
I am just going through our 15th loss. I have APA Syndrome, Anti-cardiolipin IgG, Anti-TPO, Antithyroglobulin antibody
Hypothyroid, PCOS, Hetero MTHFR Mutation, & Endometriosis. With this last pregnancy I was on metformin 1500mg, dexamethasone, lovenox 30mg bid, folgard, baby ASA, prenatal, synthroid 88mg, and had an IVIG infusion down at 4 weeks pregnant as soon as we found out I was pregnant. We saw a heart beat at 6w4d of 119bpm. Today at 7w5d no heartbeat. I feel like there is a problem with the placental growth as all of the losses occur at this time. I beleive I am on every known drug for immune problem losses, is there anything else we can try????
At Mon Oct 27, 02:23:00 PM 2008,
Trisha said…
Dr. T,
I have been in contact with you on your 'chromosomal causes' board and have learned so much from your writings and answers.
I wrote to you before about my recurrent loss (3 m/c and 1 chemical) following one easy pregnancy and delivery of my son (now 3). We know the second miscarriage was an abnormality (partial molar) but do not have any information on the other two.
I have undergone extensive testing since the most recent miscarriage and have found the following:
positive for ATAs (level was 500-ish, I believe)
positive for MTHFR gene mutation (not sure hetero or homo)
borderline positive for ANA (existent but titers below 1:40)
carry an endometriosis gene from my mother, but asymptomatic
I'm wondering how you would treat me. My RE has prescribed the following:
one baby aspirin daily
synthroid 50 daily
4mg folic acid daily
plus prenatals
Once pregnancy is achieved, I am to begin Lovenox once daily, and IVig infusions.
I am worried that beginning the Lovenox and IVig after I concieve will be too late. I don't know if I have the guts to try again without having the treatment prior to conception. RE says he would only do IVig prior if I had tested positive for NK cells, which I didn't.
Thank you for your opinion. I value it greatly.
-T
At Wed Oct 29, 06:17:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 23: I presume you and your husband have had chromosmal testing done - have you had that done on any of the conceptuses? Have you had a hysteroscopy done? I think the next step in your case might be first 3-6 months of Lupron therapy followed by ovulation induction and IVF using all of the same medications, but moving the lovenox into more of a therapeutic range (60-80 mg twice daily) and starting that in midluteal phase. Good luck! Dr T
At Tue Dec 02, 01:48:00 AM 2008,
Anonymous said…
Hi, I have had 2 miscarriages in recent months-pregnancy confirmed by several early tests in both cases and bleeding in and around period due date in both cases. I was on clomid 50mgs for the first one and was taking a break from clomid for the second one. My gynacologist has incresed my clomid this cycle to 100mgs but i'm wondering if i do get pregnant this time-what tests if any would i need to ensure another miscarriage isn't iminent? my gynacologist doesn't seem too concerned.
thanks
At Wed Dec 17, 05:28:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Trisha Oct 27: I am sorry I have not gotten back in touch with you sooner but the 'blogger' has had some technical difficulties and I just received your comment in my mailbox this week. I think the approach by your doctor is certainly reasonable, but I am not sure the IVIg offers any real benefit over the Lovenox and other components of the treatment cocktail you are getting. Anyway, I hope you get this response and that your pregnancy is going well. Please let us know how things turn out. Regards, Dr T
At Sat Dec 20, 02:13:00 PM 2008,
Christopher said…
Dr. Trofatter, I have a question for you. I have suffered 5 miscarriages. I had 2 boys, both normal pregnancies. Then, I lost a baby at 19 weeks due to a cystic hygroma. When I became pregnant again, and lost it at 14 weeks (another missed ab) then my ob did all of the normal miscarriage testing. Everything came up normal. I went on to have 2 more children, on progesterone and baby aspirin. Then I had another miscarriage, lost at 12 weeks another missed ab. I became pregnant again and delivered healthy twin boys at 34 weeks, I was on baby aspirin and extra folic acid, in addition to my prenatals. I became pregnant accidentally this past spring, and the baby developed normally until 12 weeks when there was no heartbeat. I tried again 6 months later and the same exact thing happened, no heartbeat at 11 weeks, but the baby measured 11 weeks. With many of these losses, I had a sub chorionic bleed detected. I also had one with my 3rd and 4th liveborn babies. The doctors are stumped. My ob is doing another round of thrombophilia testing. What would you recommend when I become pregnant again?
At Mon Dec 29, 10:38:00 AM 2008,
Anonymous said…
i have been told that i have a form of lupus that has caused my miscarriages in the past. i currently am on blood thinners for a year now, and will probaly be on these meds for the rest of my life can you help me understand this diagnosis?
At Fri Jan 23, 05:40:00 PM 2009,
Anonymous said…
Dr. Trofatter,
I have also been diagnosed with Recurrent Pregnancy Loss. I had one perfectly healthy pregnancy (now 2 years old) and then a miscarriage at 18 weeks. After that I have had 3 miscarriages, all between 7 and 8 weeks, all after seeing a heartbeat. All withing a year. All have the same father (my husband.) My Dr. ran all the tests he could on my baby and myself after my first miscarriage (at 18 weeks) but the tests showed no reason to miscarry. I have been tested for all the most common causes of miscarriage (diabetes, lupus, clotting disorders etc) and I don't have any of them. I have also been tested for more rare clotting disorders, and my husband and I have been through genetic testing, all came back normal. I have tried progesterone, baby aspirin, increasing my vitamin E...all with same result. I don't know what my next step should be. My OB said he is at a loss. I have seen a reproductive endocronoligist and he suggested having the fetus I just miscarried genetically tested to see if there is a genetic problem there, but my OB indicated when that test is done he rarely sees it give any answers. I currently am taking Prevacid (for Barretts esophagus) which I was not taking with my first (successful) pregnancy. I have been told by many Dr.'s that this shouldn't cause any problems. Is that true? I am also taking prenatal vitamins. I am just wondering if you have any suggestions on what my next step should be? I have heard some women who experience Recurrent Miscarriage after a successful pregnancy have taken Estrogen and have had successful pregnancies. Is estrogen a good option? Any other suggestions? Please let me know if you need any other information in order to offer suggestions. Thank you in advance for any help you can offer.
At Fri Jan 23, 05:53:00 PM 2009,
Anonymous said…
Sorry, I just submitted the "anonymous" blog a few minutes ago (I have had one successful pregnancy and 4 m/c) I forgot to mention I also had a sonohystergram (sp?) that showed everything was normal too.
Thanks!
At Sun Jan 25, 02:53:00 PM 2009,
Anonymous said…
Dear Dr T,
I have had 3 late miscarriages and one early. I have had a lot of tests done, but these all were negative. I only have been diagnosed with elevated hyperhomocysteine levels. My vitamine levels were normal and even good, and not low. Does this mean that i am positive for MTFHR? Could this alone could have caused the late miscarriages? I'm asking this, because I understand that elevated level of HHC is not related to late miscarriages. Am I correct? Thanks in advance for your advice!
At Tue Feb 17, 12:53:00 PM 2009,
Anonymous said…
Dr. Trofatter, i have had 5 miscarriages in the last year and a half. I have been diagnosed with anticardiolipin syndrome and have taken 40 mg. lovenox for the last 3 pregnancies. Each implants and begins to grow, but by about 6 weeks growth stops. We have never seen a heartbeat. My OB says that i have VERY high levels of the cardiolipin antibodies. I'm wondering if tests should be done to make sure the 40 mg. of Lovenox is an adequate dose to prevent miscarriage. Most other factors have been ruled out, although i have been on progesterone for 2 of the pregnancies. I have a healthy 8 year old son from a prior marriage. Thanks for any advise.
At Fri Feb 20, 01:39:00 PM 2009,
Jody said…
Dr. Trofatter--I am 34. I had my first miscarriage at 24 11wks but died at 6wks 5dys...baby was tested and nothing found..got pregnant right away the next cycle after 6wks waiting and gave birth to son..no complications other than he tried to come at 30wks and was put on bedrest and meds to hold off delivery to 36wks. Had 2nd miscarriage at 8wks..blighted ovum and D&C...got pregnat again right away after 6wks waiting and had normal pregnancy other than bleeding for unknown reason at 11wks and once again son tried to come at 30wks and put on bedrest til 36wks. Both my sons gave birth naturally with no drugs. Then when youngest was 2 years old we tried for baby number 3 and couldn't get pregnant for a year...finally got pregnant and lost after tube dye test and miscarried at 6wks...got pregnant right away and had an ectopic losing my right tube.
I am now remarried again and new husband and I had miscarriage last year...sent for testing and resulted in trisomy most common for all miscarriages. We had a whole genetic workup, all the usual testing for IVF...and my antiphoslipids did show something on one test and a week or so later nothing showed. I do have a family history of autoimmune disorder...mom with Multiple sclerosis and aunt with lupus. I have had some symptoms of APS though through the years...light head, migraines, numbing on one side etc. went to neurologist for that years ago and nothing showed on testing ruled stress. Just got pregnant again in January and started off normal, felt pregnant, levels were normal hcg and progesterone showed 11. At 7 weeks pregnat went for ultrasound showed 6wks2dy pole and returned 8 days later with no fetal heartbeat again. Scheduled for D&C as I never bleed other than my 1st miscarriage but it had died weeks before I realized I had lost it and my 3rd miscarriage which happened at home. Others never bled didn't know til ultrasound. I also bruise a lot and get little red dots in places as if a little blot vessel popped or something. My obgyn referred me to a fertility specialist to look over my test from the original IVF place and the new place while I was still pregnant said if I got a heartbeat i needed to be put on heparin and they wished they had seen the reports done before I got pregnant again. More blood should have been run regarding the APS. What is your opinion of what could be going on. At first we thought it was just bad luck but 6 miscarriages seems a lot. we do know that one was chromosome but out of 8 times pregnant I'm bound to have a "normal" miscarriage as I knwo it is 25% for anybody. Now it is two husbands and I still miscarry so I feel it is something with me. Is it possible I have APS or have bad eggs etc. Should we keep trying or what approach should we take. I always have that hope because I have two children already. Thank you so much,
Jody Perrin-Walters
At Tue Mar 03, 02:16:00 PM 2009,
Anonymous said…
HI, i am a 25yr old female trying to have a baby. I have tried several times and have concieved 3 times all ending in early miscarriage. my doctor now has me on prenatal vitemins and baby asprin..doctor says when i get positie on hpt to contact her and she is going to start me on blood thinners while i am pregnant to help get a sticky baby. she said i carry a blood clotting gene factor v leinden r506q. my question is if i carry the gene does that mean that my blood is clotting for sure and that is why i miscarried and how good is blood thinners while pregnant? please help
At Tue Jun 16, 10:25:00 PM 2009,
Anonymous said…
Dear Dr. Trofatter, I am 28 years old and we (my husband and I) have a beautiful 2 1/2 year old girl. I had a perfectly normal pregnancy with her, except for a lot of morning sickness the entire time I was pg with her, and she was born at 9 lbs. I had an early miscarriage this past August, and again a few weeks ago. We are not sure exactly how far along I was during the summer, but I should have been about 9 weeks this time. However, the baby didn't grow past 6 weeks, had a very week heartbeat, and a large yolk sac. finally, the heart stopped beating and I had a D&E.
My dr. performed several tests, because this was the second miscarriage, and I was just told today that I have a MTHFR single mutation. My dr. has suggested I take prescription prenatals, an addt'l 3 mg of folic acid, a baby aspirin, 25 mg of B-6, and 250 micrograms B-12. My two questions are: 1)Will this help my chances of having another succesful healthy pregnancy? 2)Are there any long term problems that I need to be aware of because of this mutation?
Thank you for any help/insight you can shed on this issue for me.
Sincerely,
KE
At Thu Jun 18, 04:58:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous June 16: I have MANY posts addressing MTHFR mutations scattered over the years I have written this blog. Use the search engine to dig some of those out. The bottomline is that a single MTHFR mutation alone is VERY unlikely to have caused your early miscarriages (chromosomal abnormalities lead the list of causes). However, the medical regimen your doctor has suggested would most likely overcome any effect of an MTHFR mutation (polymorphism) and is unlikely to hurt. However,when you do have a successful pregnancy, you will also not know if the medication was the reason or simply 'chance'. Best of luck and thanks for reading.
Dr T
Post a Comment
<< Home