Another Late Midtrimester Pregnancy Loss

54 Comments:

• At Fri Aug 17, 09:31:00 PM 2007,  Anonymous said…

  I have been reading the comments on pregancy loss on this website. Sadley, I loss my son at 23 weeks. A month early I found out that there was abnormal umblicial cord flow. I was to follow up the the perinatal doctor within two within to check on his growth and development. I schedule my appointment for the 3rd week. I had a routine with my gyn the day before I was scheduled to see the perinatal doctor. To my horror, my son was dead. Prior to this, I lost my firt at 13 weeks. My gyn has performed several test, including one for lupus. He indicated that if these tests come back negative I will have to to an Reproductive Endocrinologist. As far as I know, I have no family history of pregnacy lost.

   

• At Sat Aug 25, 02:52:00 PM 2007,  Anonymous said…

  I had a full term pregnancy in 2000 but my baby suffered from meconium aspiration and died three days after. In 2003 I had a miscarriage at 26 weeks, the doctors said they were unable to save the baby so he too died. They thought I had an incompetent cervix. So last year when I got pregnant I was sutured but I again suffered a miscariage at 4 months. I have been to a specialist and have now been reffered to a rheumatologist. I would really like to hear your comments and I have a profile of Labarotary tests that were done June 2007 if u need more information.

   

• At Mon Aug 27, 06:13:00 PM 2007,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Anonymous Aug 25: You have had a rough time of it. Things seem to go smoothly or are never easy as far as pregnancy is concerned. Before I can comment, it would be helpful to have the results of any studies you have had done to date to evaluate your difficult OB history. Thanks for reading and feel free to write back with the test results. Dr T

   

• At Thu Sep 06, 11:22:00 PM 2007,  Anonymous said…

  I lost my son at 23 week and a prior one at 13 weeks. In both pregnancies I had develop bacterial vaginosis. I was given flagyl both times. With my first pregancy this infection took place at 5 week (8 weeks later he died). In my second pregnacy the infection start at 15 weeks (8 weeks later he also died). I am wondering if the infections caused fetal demise? I had several tests, including the one for lupus and antiphospholipid antibody syndrome, they all came back negative. I do not know what to do now. My gyn wants to still follow up me if I become pregant again, but I am wondering should I follow up with an reporductive endocriniologist. Tests done on the placenta of my second pregnancy indicated myocardial infarction and infection of the placenta.

   

• At Fri Sep 14, 05:15:00 PM 2007,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Anonymous Sept 6: I think you would be better off seeing a specialist in Maternal-Fetal Medicine rather than Reproductive Endocrinology and Infertility. You do not appear to have trouble getting pregnant, but you have had problems after you conceived. These problems could be related still to an abnormality of your immune system or your blood clotting system, cervical incompetence, or a uterine abnormality that incresaes your risk for an ascending infection from unhealthy bacteria in your vagina. Was the last baby you lost normal in size for 23 weeks or was he small? Did he have any physical abnormalities? Did you have an autopsy done on the baby? Were any bacterial cultures done on the baby or the placenta? Was your cervix open at the time your doctor found the baby was not alive? Did it take you long to deliver? Did you have any bleeding before the baby died? All of these questions, and perhaps others, might help us pin down a diagnosis before you get pregnant again. Thanks for reading and I am sorry for both your losses. Dr T

   

• At Wed Sep 26, 11:16:00 PM 2007,  Anonymous said…

  Dear Dr.T,
  This is to answer your questions from the post on sept. 14. I made my comment on sept. 6
  
  Was the last baby you lost normal in size for 23 weeks or was he small? My baby was very long. However, I did notice that he was 11 ounces at 18 weeks and the same weight at 11 ounces at 23.
  
  Did he have any physical abnormalities? One of his eyes was open and his tongue was sticking out. But other that the he looked very normal.
  
  Did you have an autopsy done on the baby? No, my Gyn did not think that it was necessary.
  
  Were any bacterial cultures done on the baby or the placenta? No, not to my knowledge.
  
  Was your cervix open at the time your doctor found the baby was not alive? He did not mention that it was.
  
  Did it take you long to deliver? It took 8 hours, but the placenta stayed in for an additional 6 hours. I have severe bleeding that clotted (it looked like organs) very bad before I delivered
  
  Did you have any bleeding before the baby died? I have bleeding early in pregnancy around 9 weeks, but I was told that was due to an fibroid on the uterus.
  
  Thanks so much for your response.

   

• At Fri Sep 28, 11:39:00 AM 2007,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Anonymous Sept 26: The FIBROID could be your problem. Fibroids can act as a site for chronic infection and inflammation that can impair implantation and increase your risk for midtrimester losses such as yours. I would definitely suggest seeing a specialist in REI who will evaluate your uterine cavity and remove the fibroid if that is a potential source of your problems. Good luck to you and let me know how things turn out. Dr T

   

• At Fri Oct 19, 03:20:00 AM 2007,  Anonymous said…

  Dear Dr T,
  
  After having a normal pregancy and delivery after 40 weeks of a healthy daughter, I became pregnant six months later. Unfortunately, at 20 weeks I lost my son after almost 5 days of bleeding and stomach aches. During these days my cervix opened. My son lived for a couple of hours ans appeared to be in good condtion. He was of normal size. We choose not to have him examined. 4 months later I was pregnant again. Everything seemed normal until week 17. In this week I had severe head aches and went to the hospital where they cheked my blood pressure which was normal (120/70) but by then my headache was not that bad anymore. As I was given progesteron to prevent miscarriages I thaught this may cause the headache. I normally have a bloodpressure of 100/60 during pregnancy. In week 19 I had some bleeding. I went to the hospital where the GP said that the baby did not have a heartbeat. A few days later I gave birth to my baby that appearantly has died somewhere after week 16 (the last time I saw his/her heartbeat). I did not have a lot of pain but I was also given a medicine that helped my uterus to deliver. At the time the baby was found not living anymore, my cervix was not open.
  The baby had become brown beacause he/she was dead for a longer period, but seemed very normal.
  
  After my first loss the GP thaught bacterial vaginoses could be reason for the miscarriage (there was a litte increase of granulocytes in my blood). I wonder what could have causes these two miscarriages as this time I have been checked for infections and did not have any.
  
  There is no history of miscarriage in my family, but the mother of my husband has had 5 five miscarriages and 4 normal pregnancies. Is it likely that there could be a geneteric reason? Is it likely that I have a weak cervix? Is this also likely although I have had one normal pregnancy?

   

• At Mon Oct 22, 04:27:00 PM 2007,  Kenneth F. Trofatter, Jr., MD, PhD said…

  T Anonymous Oct 19: First, I am very sorry for your losses. this does not sound like cervical incompetence. These losses are much more likely to have been the result of chromosomal abnormalities, either spontaneous or, perhaps, inherited from the baby's father (e.g., he could be a balanced translocation carrier) in view of his mother's history of multiple miscarriages), or a genetic condition. The latter would be a real possibility if this second child you lost was also a boy. Another possibility is that you have developed an autoimmune condition since the birth of your previous child, or that you have a genetic thrombophilia that did not cause problems until now (but I think that is less likely). I would suggest taking a little time off from pregnancy and have these options explored with your doctor or a specialist with whom he/she is familiar. If you need specific recommendations for a 'workup', please let me know and I would be glad to provide some ideas. I also recommend you have a discussion with a genetic counselor who has an interest in pregnancy loss. Best wishes to you and please let me know what you find out. Thanks for reading. Dr T

   

• At Sat Nov 03, 10:29:00 AM 2007,  Anonymous said…

  Dear Dr T,
  Thank you for the information. May I ask what specifically causes the loss of boys? My last baby was indeed a boy. Meanwhile I have had an appointment with my dr. He told me that as the both losses were so different he could not tell me what might have caused the losses. However, in principle he is willing to do any test needed. He further told me that there were no abnormalities with the baby and that also everything seemed was normal with me. They did not find deviations in my blood or the placenta. It would help me very much if you could inform me how I should take this further.

   

• At Tue Nov 13, 04:26:00 PM 2007,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Anonymous Nov 3: I am not sure if this is applicable to your case or not because your losses do appear to be so different, but repetitive losses of boys can occur if mother's care a bad recessive gene on one of their X chromosomes. If the boy happens to get that particular chromosome (remember, boys get an X-chromosome from Mom and a Y-chromosome from Dad), he doesn't have a second 'good gene to mask the expression of the bad. These are called X-linked disorders, such as hemophilia, and they do most often affect males. Girls can have the same problems if they happen to inherit two X-chromosomes with the same bad genes. Dr T

   

• At Wed Feb 06, 06:57:00 AM 2008,  Anonymous said…

  Dear Dr T,
  After my last miscarriage my Dr examined whether I have trombofilia problems. Me and my partner have also had our chromosomes examined. Both tests were negative, meaning that no deviations/causes for the miscarriages were found. This leaves me with a lot of questions. Why did I have twice a very late miscarriage? Currently I am pregnant again, but I am very afraid that it will happen again. I fear that there is something wrong with me which have caused the miscarriages. How likely is this if I already had have a full term delivery? Could my second miscarriage have been caused by the progesteron injections? Would you advise me to take progesteron injections in this pregnancy (my dr does). Does progesteron has any adverse effects on pregnancies?
  I would be very gratefull if you would like to answer these questions or advise me further on this.
  Kind regards

   

• At Sun Feb 10, 07:02:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Anonymous Feb 6: Answer several questions for me and then I will be in a better position to respond to yours. 1) Did you have the full-term pregnancy and then have the miscarriages? 2) Did you have any complications with that pregnancy or with the delivery? 3) Did you have a vaginal delivery or a cesarean? 4) Have you had any cervical procedures such as LEEP or cervical conization done 5)How "late" were the miscrriages you had? What were the circumstnaces surrounding those miscarriages, ie., did the babies die in utero; did you have premature labor; did you break your bag of waters prematurely; did you have any evidence of 'infection'; did you labor or did your doctors put you into labor; did you receive prigesterone with either of those losses; do you have any medical problems? There are reasons for ALL of these questions and the answers will help me get a better idea as to what happened with your previous losses. Dr T

   

• At Wed Feb 13, 05:17:00 AM 2008,  Anonymous said…

  Here are my answers:
  
  1) Yes, I had a full term pregancy first and had the two miscarriages thereafter.
  
  2) The delivery took very very long (almost 40 hours from the first signs) and eventually I was given medicine to delivery my daughter. I could not have done it by myself probably. I had a bleeding afterwards and was for more then two weeks very weak.
  
  3)It was a vaginal delivery.
  
  4) I dont know what these are, but before having my daughter and the miscarriage, I have had two abortions (I was too young then). And after the first late miscarriage the doctor cleaned up my uterus as the pregancy product did not leave my uterus competely.
  
  5) The first time the baby was 20weeks and a couple days old, he was born alive and I had premature labor. After this miscarriage the doctor thaught (although I didn't have any infections) that the miscarriage might have been caused by a bacteria (little increase of granulocyts) or cervical incomptence.He was not sure however. I also then had an severe allergic reaction to the antibiotica I was given in the hospital in order to prevent any infections. My bloodpressure was 80/40 and I was in a very bad condition. So maybe this might also have caused the increase of the granulocyts or even the eventual delivery as I did not have a lot of dilation at first, but the situation got worse after I got antibitioca.
  
  The second time I delivered at 19 weeks, the baby probably has died somewhere at 15/16 weeks. I had no labor at all and was given medicine to deliver. Only in this pregancy I was given progesteron (as off week 16)because of the first miscarriage and in order to prevent any cervical incompetence.
  Also this time there were no signs of infections, and to my knowledge I am healthy and do not have medical problems. My age is 35.
  
  In both cases I did not have break of bags/water.
  
  So this leaves me with questions: Why does this happen so late and do I have to live with the knowledge that this kind of things happen without reasons?
  And could the second miscarriage have been caused by the progesteron as the period the baby died was more or less the period I started with the injections? Would you advise me to take these injections also in this pregnancy?
  
  Would you advise me to take extra vitamins, other than folid acid (as I have been pregnant many times in a relatively short period)? Could this circumstance have played a rol (short period in between pregnancies)? I would be grateful for your answers.

   

• At Fri Feb 22, 07:06:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Anonymous Feb 13: I do not think the abortions you had when you were younger contributed in any way to your more recent losses. However, I am worried that the first full term delivery might have. You might have had damage to your cervix from the difficult delivery or from the D&C procedure that had to be done to stop your hemorrhage. I believe in your first loss at 20 weeks, this was the result of cervical incompetence and probably a secondary ascending infection. I am not sure the 'allergic reaction' you report was that or perhaps it was 'septic shock' from the infection. I do not think the antibiotics or your 'reaction' caused you to lose that baby. Your loss at 15-16 weeks might also be the result of infection, or perhaps the baby had a chromosomal abnormality. I do not think the progesterone alone caused you to lose that baby, but some people believe that it can possibly reduce your body's ability to fight off some infections (although that has NOT yet been proven). Before you get pregnant again, I would recommend that you have a sonohysterogram and perhaps a hysteroscopy done to evaluate the uterine cavity for any abnormalities that could be present (fibroids, polyps, scar tissue). I would begin a prenatal vitamin and extra folic acid a month or two before you deecide to try again and then, when you do get pregnant, I would recommend placement of a cerclage at 13-14 weeks (after you have had first trimester screening for aneuploidy done). Your doctors can explain all of these procedures and the reasons for having them done. Best of luck to you and pleae let us know what is found, what you do, and how things turn out! Dr T

   

• At Wed Apr 16, 12:09:00 AM 2008,  Anonymous said…

  Dear Dr T,
  
  I have written earlier (Oct 19, Nov 3 2007 and Febr 6 and 13 2008). Meanwhile I had a third late miscarriage at 18 weeks. The first miscarriage was at week 20, the second at week 19). I already have a daughter and did have no problems with that pregnancy. I have described the detail in my post dated Febr 13. This time the baby died in utero, my cervix was not open and as said earlier we have had had several test, including trombopholia and chromones and they came back negative. So I am guite desperate and want to know what causes these uncommon very late miscarriages. I don't think that cervical weakness is the cause and am starting to believe that there might be something wrong with my uterus or that there is chromosom problem with me or my partner which has not been tested yet, especially because the mother of my partner had 5 miscarriages.
  
  Although I love children and would like to have one more, I am now seriously considering to let go my wish. Could you please inform me what your thoughts are on my situation?

   

• At Sun Apr 20, 05:54:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Anonymous Apr 16: Oh my, I am so sorry again. My only suggestions, if they have not been done already: 1) have a sonohysterogram done before you get pregnant again; 2) get more informations about your partner's mother's problems and medical history; 3) has he had chromosomal studoies done? 4) has he had a semen analysis done 5) You two are not related in any way you know, are you? If all that turns out negative, it could be that the two of you share some 'bad genes' (recessive) that do not affect either of you but in combination create lethal conditions for your babies together. These situations are not that common, often defy diagnosis unless you have a baby who lives with the problem, or there is a family history of the same, and often requires that you just keep trying. Thanks for writing back and best wishes again. Dr T

   

• At Mon May 26, 07:09:00 AM 2008,  Anonymous said…

  Dear Dr T,
  
  Thanks again for your reaction on my message of April 16 2008. In reaction to yoy questions:
  1). Yes, I will have this sonohysterogram in a couple of weeks. I think that this is necessary (although I already have a daughter) as my mother was given medicine (des hormon?) in the seventies in order to prevent a miscarriages when she was pregnant with me.
  2) His family does not have any additional information. My partners mother was pregnant nine times and had five miscarriiages.
  3) yes, chromosome tests were done and nothing was found. The babies' chromosomes were normal as are my partner's and my chromosomes.
  4) is semen analysis necessary in our case? We do not have problems with getting pregnant but with staying pregnant. All the miscarriages were late (after week 16)
  5) We are not related. My partner is Dutch and I am Turkish.
  
  We have had pretty much all tests done, but nothing has been found. Do you have any idea what have caused these miscarriages and am I right that in the case we carry bad genes the chance that a miscarriage occurs should only be 25 percent?

   

• At Tue May 27, 06:51:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous May 26: No, if they are all late losses, he probably does not need a semenanalysis done. You might have answered this before, but were the babies you lost boys or girls? Have you been tried on any empiric therapy with heparin or low-molecular weight heparin? Do you have any unusual dietary habits, including herbal medications? Let us know what you find out with the sonohysterogram and I will think about this some more. Thank you for writing and I am so sorry for all the trouble you have had. Dr T

   

• At Wed Jun 18, 02:27:00 AM 2008,  Anonymous said…

  Dear Dr T,
  
  In reaction to your message of May 26 and in addition to my previous messages, please find below my answers:
  
  -I had the sonohysterogram done and nothing was found (my uterus had a normal shape).
  -the last baby was a girl (so twice a boy and one girl)
  -the miscarriages occured between 18-20 weeks and all relevant tests have been done, nothing was found. I did not try heparin in my pregnancies. Would you advise to do so if I decide to try again?
  -I have no unusual dietary habits (I do not smoke and have a normal weight). I have been pregnant four times in 3 years. Could this be relevant? Could it be a lack of vitamines?
  -there is no family history of diseases. The only thing that might be relevant are the five miscarriages of the mother of my partner.
  -I am wondering whether I have a hormonal problems (right levels?) as the miscarriages more or less occured in the same period (after week 16 when the placenta should make progesteron itself)
  -How likely is it that my partner and I both carry bad (recessive) genes if we both do not have any heredital disease in the family?
  -I am Turkish. Should I be examined for beta thalassemy?
  
  Thanks in advance for your reaction

   

• At Sat Jun 21, 06:15:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous June 16: You have the most intriguing problem, but I still cannot venture a guess as to what the actual cause is. Recurrent midtrimester pregnancy losses are very unusual. If anything, this is most likely the result of an autosomal recessive genetic disorder wherein both you and your partner carry the same bad genes or have a combination of abnormalities that is not tolerated by the babies. I think you should find an expert in medical genetics and carefully review the history and family history on both sides of the famil. Wish I could be more help, but please let me know if you find out anything helpful along the way. Kind regards, Dr T

   

• At Mon Jun 30, 11:06:00 AM 2008,  Anonymous said…

  Dear Dr. T.
  
  I have some questions for you. I really do hope you could spare a moment and read my history. Thank you so much
  
  I have been though egg donation programmes because of age (my eggs were too old).I am 48 and Danish.
  
  In 2005 I got pregnant but lost my little baby boy in 17th week of pregnancy. He died in my uterus.(found out with a regular ultrasound) . They found clottings in the placenta and found out, I have this disorder (Prothrombin mutation) but they could not say, if this was the reason, or if the clottings came, because he had been dead for a week. A year later 2006 I got pregnant again (donor eggs), but again it was a baby boy who just died in my uterus, when I was in my 25th week of pregnancy. I could not feel him move so I was at the Hospital to do an ultrasound, and he was dead 1 day before) This time they could not find any reason, said it was unexplained (I took blood thinner this time, like Lovenox LMWH). Then again I got pregnant last April 2007 - with twins – but unfortunately I start bleeding in September when I was 21 weeks and 6 days pregnant, came to the Hospital, and they find me totally open without any contractions. The boys (yes it was boys again) were doing just fine and I was lying in bed at the Hospital for 2 weeks before they decide, that I had to give birth to the boys because of my
  health. While lying there fully open in these two weeks, I got an infection
  and they couldn't stop it, even though I got 2 kinds of antibiotic The amniofluid of twin number 2 was infected but they couldn't tell, if it was because of this I start bleeding or if the infection came after, because I have been open so long.
  Sadly they both dies of immaturity, twin 1, when he was 11 days and twin 2 just two month ago, because of very bad lungs. We had him for 7 month and 9 days. There were no abnormalities in any of the babies. And they were all normal size of their age. In my second loss (baby boy lost in 25th week they did a autopsy and did not find anything.
  Now I am sitting here thinking about what went wrong. Why did I loose? Is it because my body reject either baby boys or just pregnancies and what can I do about it? I have 3 healthy boys from an former marriage and have no problems in pregnancy or delivery – now I just really want a child with my new husband. I get easily pregnant (also with donor eggs) and I just can't understand why this happen.... In Denmark where I come from they don't treat women older that 40 in public Hospitals, and the most of the private clinic here don't know so much about testing and treatment for immune disorders (if this should be the problem). There is only one hospital where they do immunology treatment, so I am really helpless and need some advice. Can I take some medicine if we decide to take another try? If not I really would like to do some test of my blood - but which tests should I take? I have done this Trombophilia panel (that’s where they found the Factor II mutation) Hope you can give me some advice. Thank you so much.

   

• At Fri Jul 04, 08:28:00 AM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous June 30: I am so sorry for all the troubles you have had. At your age, even if you are healthy, there may be other factors contributing to your losses. My only suggestions would be to continue with the medical therapy you have used in the past (the lovenox and any other medications your doctors have recommended). Have thyroid studies and diabetic screening done before you conceive again. Consider having a cerclage placed around the cervix at about 13-14 weeks during the next pregnancy. Avoid sexual intercourse from 16 weeks on. Have your doctors looked inside your uterus by hysteroscopy to see if you have any abnormalities in there that might be increasing your risk for bleeding or infection? Good luck and thank you for reading. Dr T

   

• At Sat Jul 05, 03:16:00 AM 2008,  Anonymous said…

  Dear Dr. T.
  
  Thank you so much for your answer above. I have been through diabetic screening, this is included in a normal test during pregnancy, and it came back negative. For 2 years ago I had my thyroid examined and it came back as this:
  TSH (5,3)
  T3 (1,14)
  T4 (103)
  T4 free (117)
  
  I asked the doctor for the TSH which I thought was a little elevated, but she said that in Denmark they don’t treat this if T3, T4 and t4free is in normal range. I did read though on foreign websites, that it should be under 2 when getting pregnant – is this correct? And could this number be the reason for my losses??Thanks again.

   

• At Sat Jul 12, 07:44:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous July 5: Thyroid disorders are probably more commonly associated with recurrent early pregnancy loss than has been previously recognized. They also are very common in women as they age. If that last thyroid screen was done two years ago, it should probably be repeated. How many miscarriages have you had and what other evaluation have you had to this point? Dr T

   

• At Mon Jul 14, 04:45:00 AM 2008,  Anonymous said…

  Thank you so much for your answer above. I have had 3 miscarriages. 1.in 17th week, 2.In 25th week and 3.was a preterm birth in 24th week - the last one was a twin pregnancy . I have this Prothrombin mutation and take Low Molecular Weigh Heparin during pregnancy plus baby aspirin,Progesterone, and Predisone (5mg) the first 14 weeks of pregnancy… I only have had a evalution of thrombofilia panel where they found this prothrombin disorder. And now my foreign clinic will have me tested for immunologic disordes such as : all antiphospholipids antibodies, anti-beta-2 glycoprotein, anti-zona, anti-sperm, anti-ovarian antibodies, NK (natural killers) cells - about 2 types. IgG, IgA, IgM. It is their standard test panel. Should there be any other tests for me to be done? Thank you so much Dr. T. for all your help. I am so sad having lost these 3 pregnancies and can’t understand why?

   

• At Mon Jul 14, 04:52:00 AM 2008,  Anonymous said…

  Dear Dr T,
  I have written to you earlier, and need your helpfull advice one again. After a normal pregnancy, I have had three late midterm miscarriages. The first time I gave birth to a boy at week 20, after bleedings and contractions. This boy seemed normal and died soon after birth. The second (boy) and third (girl) babies were born at week 19 and 18. They died in utero. Only the second baby was small for gestation, but he has probably died for a couple of weeks. I have had all tests done (including chromosome test for the third baby) but all tests were negative. My uterus has been checked and seemed normal. I recently went to another doctor for a second opinion and this doctor believes that my problem could be a combination of autoimmune and bloot clottings problems. She advised me (if I decide to go for another pregnancy) to take heparin and (depending on the outcome of a second test for lupus anticoagulant) aspirin. She also advised me to take clincadamycine to fight bacterial vaginose which she thinks has probably played a role in my first loss at week 20. I tend to agree with her advice, but would like to know what your thoughts are. Thanks very much in advance.

   

• At Tue Jul 15, 10:56:00 AM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous July 14: I am so sorry. It sounds like you are in good hands though and both the evlautaion and treatement are appropriate. I am somewhat concerned that you might have an incompetent cervix because of your loss of the twins at 24 weeks. Make sure your doctors follow the cervical length very carefully with another pregnancy. By the way, do you have diabetes or evidence of insulin resistance as is often found in polycystic ovary syndrome? If so, you might also benfit by treatment with metformin. Best wishes! Dr T

   

• At Tue Jul 15, 11:00:00 AM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous July 14: I still think there is a chance you also have an incompetent cervix that sets you up for the bleeding, infection, and pregnancy losses. Your doctors might want to consider a cervical cerclage at 13 weeks. I frequently will place women in your situation on a different antibiotic - metronidazole 500 mg - starting at 13-14 weeks and continuing two or three times per day throughout the midtrimester. It has fewed side-effects that clindamycin and is very unlikely to cause the growth of resistant bacteria and yeast. Good luck and kind regards. Dr T

   

• At Sun Aug 10, 08:14:00 AM 2008,  Anonymous said…

  Dear Dr. T. You answered me the 15th July:
  "To anonymous July 14: I am so sorry. It sounds like you are in good hands though and both the evlautaion and treatement are appropriate. I am somewhat concerned that you might have an incompetent cervix because of your loss of the twins at 24 weeks. Make sure your doctors follow the cervical length very carefully with another pregnancy. By the way, do you have diabetes or evidence of insulin resistance as is often found in polycystic ovary syndrome? If so, you might also benfit by treatment with metformin. Best wishes! Dr T"
  
  I am the one, who has lost 2 pregnancies i 17th and 15th week both boys died in my womb and 1 preterm pregnancy in 24th , twins, which also died later) – have prothrombin gene mutation and do Lovenox when pregnant. I have now got the results from the immulogic blood tests It has been done in a Czech republic clinic so I can not translate “smes” in the two lines lowest. The clinic said I should take Lovenox again, if I get pregnant plus doing IVIG? Is IVIG necessary when it is APA?What does these numbers shows????
  
  Kardiolipin IgG - 14,0,
  Kardiolipin IgM - 7,3,
  Kardiolipin +B2GPI IgG - 2,1,
  Fosfatidylserin + B2GPI IgG - 1,8,
  Fosfatidylinositol + B2GPI IgG. - 1,2,
  "Smes" fosfolipidu + B2GPI IgG 2,2
  "Smes" fosfolipidu + B2GPI IgG 2,6
  ...I really need your advice. Thank you so much . Kind regards P.

   

• At Sun Aug 10, 11:42:00 AM 2008,  Anonymous said…

  My patient, 40 g3 p0, is 35 weeks into her present pregnancy. She has been taking Lovenox, folic acid, ASA 81 mg daily. Her pregnancy has been uneventful and serial ULSO indicate normal development of fetus. Chromosome studies on amniotic fluid were normal. How should anticoagulation drugs be handled at delivery? C-section is planned.
  
  Thanks

   

• At Mon Aug 11, 10:08:00 AM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous Aug 10: We usually convert to heparin at 36 weeks because that can be readily reversed if necessary by protamine sulfate if the patient shows up unexpectedly before her planned delivery. Then we simply withold any morning dose of heparin she would have received on the day of surgery and resume the lovenox 12 to 24 hours following the surgery. If she needs long-term anticoagulation, we convert to heparin while she is on lovenox following delivery. Thanks for asking! Dr T

   

• At Tue Aug 12, 09:07:00 AM 2008,  Anonymous said…

  Dear Dr. T. You answered me the 15th July:
  "To anonymous July 14: I am so sorry. It sounds like you are in good hands though and both the evlautaion and treatement are appropriate. I am somewhat concerned that you might have an incompetent cervix because of your loss of the twins at 24 weeks. Make sure your doctors follow the cervical length very carefully with another pregnancy. By the way, do you have diabetes or evidence of insulin resistance as is often found in polycystic ovary syndrome? If so, you might also benfit by treatment with metformin. Best wishes! Dr T"
  
  I am the one, who has lost 2 pregnancies i 17th and 15th week both boys died in my womb and 1 preterm pregnancy in 24th , twins, which also died later) – have prothrombin gene mutation and do Lovenox when pregnant. I have now got the results from the immulogic blood tests It has been done in a Czech republic clinic so I can not translate “smes” in the two lines lowest. The clinic said I should take Lovenox again, if I get pregnant plus doing IVIG? Is IVIG necessary when it is APA?What does these numbers shows????
  
  Kardiolipin IgG - 14,0,
  Kardiolipin IgM - 7,3,
  Kardiolipin +B2GPI IgG - 2,1,
  Fosfatidylserin + B2GPI IgG - 1,8,
  Fosfatidylinositol + B2GPI IgG. - 1,2,
  "Smes" fosfolipidu + B2GPI IgG 2,2
  "Smes" fosfolipidu + B2GPI IgG 2,6
  ...I really need your advice. Thank you so much . Kind regards P.

   

• At Tue Aug 12, 07:30:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To P: Can you get the "normal" results for those studies from the laboratory that performed them? Maybe then I can help. Dr T

   

• At Wed Aug 13, 03:12:00 AM 2008,  Anonymous said…

  Dear Dr. T.
  
  Here are all results from the Czech republic – also the “normal one”. Some of the words “smes” and “kys” are Czech words which I can not translate. Hope you can help. I appreciate your help very much. Thank you so much. Best regards P.
  
  Cardiolipin IgG 14,0
  Cardiolipin IgA 7,5
  Cardiolipin IgM 7,3
  Beta-2-glycoprotein IgG 5,0
  Beta-2-glycoprotein IgA 5,0
  Beta-2-glycoprotein IgM 5,0
  Beta-2-glycoprotein (B2GPI) IgG 0,5
  Cardiolipin +B2GPI IgG 2,1
  Fosfatidylserin + B2GPI IgG 1,8
  Fosfatidylinositol + B2GPI IgG. 1,2
  kys fofatidova – B2GPI 0,9
  Smes fosfolipidu + B2GPI IgG 2,2Smes fosfolipidu + B2GPIgG 2,6
  beta-2-glycoprotein(B2PGI)IgM 0,5
  Cardiolipin + B2GPI IgM 0,8
  Fosfatidylinolsitol + B2GPI IgM 0,7
  kys fosfatidova + B2GPI IgM 0,8
  smes fosfolipidu + B2GPI 0,7
  smes fosfolipidu + B2GPI 0,7
  Ovarium Ig hemagl.[1:8] negative
  Spermie Ig hemagl. (1:8)negative Zona pellucida Ig hemagl.(1:8)negative

   

• At Sat Aug 16, 05:09:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To P: In reviewing your results, I am not sure the IVIG is going to be much benefit. Rather than using the IVIG, you might ask you doctors to simply place you on aspirin (81 mg per day), a theraputic (higher) dose of Lovenox, and prednisone (low dose 5 mg per day). I would still follow your cervix length very carefully during the pregnancy because of your high risk of cervial incompetence (weakness). Good luck! Dr T

   

• At Wed Aug 20, 04:58:00 AM 2008,  Anonymous said…

  Dear dr. T. You answered me the 16. july following:
  To P: In reviewing your results, I am not sure the IVIG is going to be much benefit. Rather than using the IVIG, you might ask you doctors to simply place you on aspirin (81 mg per day), a theraputic (higher) dose of Lovenox, and prednisone (low dose 5 mg per day). I would still follow your cervix length very carefully during the pregnancy because of your high risk of cervial incompetence (weakness). Good luck! Dr T
  
  I have a few questions for you. In pregnancy I take Lovenox 45ml once a day in whole pregnancy. Would it be better to take it twice and a higher dose all together? And about Prednisone 5 mg: shall I take this the whole pregnancy or only in the 1. trimester? The 3 times I have lost was in 17th week, 25th week and preterm birth (twins) in 24th week. I have Prothrombin Gene mutation and now this APA condition.. Thanks a lot for your advice. Best regards P.

   

• At Fri Aug 22, 05:12:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To P: How much do you weigh - I ask that because would help me make a recommendation regarding the Lovenox. I would start with a low-dose of the prednisone (5mg once or twice per day). In you case, I am not sure I would stop it during a successful pegnancy in view of your past history and medical findings. You are a tough one! Years ago I used even higher doses of prednisone in early pregnancy, and then tried to decereas the dose in the 20-24 week range. Still wish you the best. I know it has been very difficult. Dr T

   

• At Mon Aug 25, 05:43:00 AM 2008,  Anonymous said…

  Dear Dr. T.
  
  About your answer on the 22. August:
  To P: How much do you weigh - I ask that because would help me make a recommendation regarding the Lovenox. I would start with a low-dose of the prednisone (5mg once or twice per day). In you case, I am not sure I would stop it during a successful pegnancy in view of your past history and medical findings. You are a tough one! Years ago I used even higher doses of prednisone in early pregnancy, and then tried to decereas the dose in the 20-24 week range. Still wish you the best. I know it has been very difficult. Dr T
  
  Thank you for your kind words. About how much Lovenox I should take. My weigh is 96 kilo. About Prednisone I have heard this could cause preterm birth, but maybe because of a much higher dose? Could you please confirm all the medicine I should take:
  
  Babyaspirin (81 mg) : For how long?
  Prednisone: 5 mg: One or twice a day??? The whole pregnancy??
  Lovenox: How much? And will this be onece or twice a day??
  
  Thank you so much for all your advice.
  best regards P.

   

• At Mon Aug 25, 06:20:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To P: There is no "right answer", but given your history, I would suggest Lovenox 60 mg twice daily; prednisone 5 mg twice daily; and the aspirin 81 mg daily. I would try stopping the prednisone between 20-24 weeks and that should minimize your risk for preterm delivery and gestational diabetes. Good luck! Dr T

   

• At Fri Aug 29, 03:57:00 PM 2008,  Anonymous said…

  I have written earlier, and need your helpfull advice once again. After a normal pregnancy and delivery with a healthy daughter, I have had three late midterm miscarriages (18, 19 and 20 weeks). I have had a very difficult time with this as no reason could be found. I have had all tests done and they came back negative. As I had some doubts whether some tests were done correctly I asked for a second opinion. Three test were done again and now the test for hyperhomocystenemia came back positive. My vit B12 level seems to be ok, but I am still waiting for the results of the vit B6 test. My question is whether I have good chances for a succesful pregnancy if I start to take high doses of folid acid or should I take extra medicines, such as baby aspirine or heparine? How are my chances, due to my history of pregnancy losses?
  I again would appreciate your help.

   

• At Mon Sep 01, 01:20:00 AM 2008,  Anonymous said…

  Dear Dr. T. Thanks a lot for your advice. You answer me this Monday 25th of August:
  To P: There is no "right answer", but given your history, I would suggest Lovenox 60 mg twice daily; prednisone 5 mg twice daily; and the aspirin 81 mg daily. I would try stopping the prednisone between 20-24 weeks and that should minimize your risk for preterm delivery and gestational diabetes. Good luck! Dr T
  
  I have decided to follow your recomandations. But now I am bit confused. Somebody (one who has immunlogical disorders herself and late pregnancy loss too) told me that I have not been tested for all immunological test. She said I should be tested for:
  
  Leukocyte Antibody Detection Assay(LAD test)
  Antinuclear antibodies (ANA)
  Anti-thyroid antibodies (ATA)
  Natural Killer Cell Assay full panel
  
  It is a bit confusing if I have not been tested for all the "things"
  
  What do you think. Is this relevant for late losses??Sorry to bother you again. Thanks a lot in advance.Best regards P.

   

• At Tue Sep 02, 05:12:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To P: At this point, I do not think further testing is going to change your treatment. We can ALWAYS find another test to perform, but there is a point of diminishing returns (not to mention the expense)! Take care and best of luck to you. Dr T

   

• At Tue Sep 02, 06:04:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous Aug 29: Correct me if I am wrong. Did you miscarry those babies or did they die in utero? I thought it was the latter. If you do have hyperhomocysteinemia with that history, I suppose I would recommend high dose folic acid, B-complex vitamins, a baby aspirin and even ADD heparin or Lovenox. What does your doctor want to do? Dr T

   

• At Mon Sep 08, 01:38:00 PM 2008,  Anonymous said…

  Dear Dr T,
  I miscarried the first time, when a baby boy was born at 20 weeks, and the second and third time the babies died in utero. Due to this, I understand that I might also have another problem than only the hyperhomocystenemia. So I also need to be examined for cervical weakness, and perhaps need to have antibiotics in the first weeks of the pregnacies. Is my assumption correct

   

• At Wed Sep 17, 09:32:00 PM 2008,  Anonymous said…

  I had an early miscarriage around 8weeks in 2006.Second time we tried this year in january,we ended up losing it again around the same time line.
  
  This time around i was refered to a reproductive endocrinologist and they ran all these tests and came up with 3 blood disorders:
  
  1)METHFR Mutation C677T and Mutation A1298C-Heterozygous for which i was prescribed 4mg of folic acid
  2)FVL
  3)PAI-1 and
  4)I am also a PCOS (insuline resist.)But hardly any of the other characteristics,as i am very regular with my period,have no excesive hair anywhere,and not overweigh except the weight that i put on when i am pregnant.
  
  I never had any clotting issue or previous family history with clotting or reproductive challenges so needless to say i was surprised and all my family too who started getting tested after this diagnosis.
  
  The new approach for my next attempt is keep takin the folic acid 4mg a day,METFORMIN 500mg 3 pills a day,my regular prenatal pill....and the endocrinologist suggested CLOMID+IUI.After this procedure (48 hrs) i am suppossed to start daily shots of ARIXTRA the whole pregnancy.
  
  I am under the impression that this is all helping with ovulation/fertilization/the clotting issues assuming that it is the clotting my main concern but i think the PAI-1 is not being addressed and there is no way of knowing what is causing my losses really:It could be the FVL or the PAI-1 interfering with implantation or cell division etc.
  
  Is there anything else to be done to address more up front the PAI-1 or all these dosages will be taking care of it?
  
  Thanks in advance,Carito

   

• At Thu Sep 18, 01:46:00 AM 2008,  Anonymous said…

  I had one miscarriage (baby was born alive) and two times the babies died in utero. My doctor does not believe that the hyperhomocystenie is the sole reason. She still thinks that other factors have also played a role (autoimmune and other blot clotting problems). As my vitamine levels are at a normal level she thinks that it will have no added value to start with vitamine therapie before conceiving. Instead she wants to wait until the first positive pregnancy test and then start with extra folid acid and vitamine B6, heparin injections, two weekly test of the cervix, and antibiotics somewhere in week 13. Nevertheless, I have already started to take extra vitamines B and started with a diet (no meat, only some fish and a lot of vegetables and fruit). Do you agree with my doctors advice and the steps that I have taken?

   

• At Tue Sep 23, 11:18:00 AM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous Sept 8: I am sorry, but I still do not have a good understanding as to why you lost those pregnancies. Cervical incompetence usually does noy lead to death of the baby before delivery unless it is accompanied by an ascending infection. I am still worried that you could have an abnormality inside the uterus, an autoimmune condition that has not been diagnosed, or a genetic condition that might have caused the loss of your babies. If one of the concerns is that you have cervical incompetence, then an early cerclage at about 13 weeks and perhaps antibiotics (I use metronidazole) prophylactically on a daily basis might be warranted. I wish I knew more about what actually might have caused your losses. Dr T

   

• At Tue Sep 23, 11:21:00 AM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Carito: It sounds as if you are in very good hands and it is hard to say which of those factors is contributing to the losses. A simple baby aspirin (81 mg per day) should help cover any concerns related to the PAI-1 polymorphism. I am curious as to why your doctor chose Arixtra over heparin or Lovenox? Best wishes to you and thanks for sharing your story! Dr T

   

• At Tue Sep 23, 11:23:00 AM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous Sept 18: I prefer to start the extra folic acid BEFORE conception and the heparin in mid-luteal phase or as soon as a pregnancy is confirmed (usually around the expected time for your menses). Good luck the next time around! Dr T

   

• At Mon Oct 06, 11:23:00 AM 2008,  kevtoglo said…

  i lost my baby boy at 24weeks 5days .i went for a routine scan on the 29th of sept 2008 and was told that there was no heartbeat . four days later i was induced to bring out the baby and was told that all the tests carried out revealed nothing was wrong with me.they requested for my permission to perform an autopsy which i gave and am now awaiting the results

   

• At Tue Oct 07, 04:18:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To kevtoglo: I am so sorry for your loss. Please let us know what they find out from the autopsy. I hope they can give you some answers. Kind regards, Dr T

   

• At Thu Oct 23, 11:59:00 PM 2008,  gg said…

  Dr., This is deepak from India. My wife had 2 miscarriages at 5months and 7 months respectively. The reasons were best known to doctors in the first case and there is a sudden increase in BP (upto 150) in second. Now, she is 11 weeks pregnant and when tested for CARDIOLIPIN IgM, the value is 45.0 Is there any risk for her or the baby? What do you suggest? URGENT REPLY is awaited.

   

• At Sat Nov 22, 05:16:00 PM 2008,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To deepak Oct 25: I apologize for the delay in my response, but I just got your comment after a month's delay. Anticardiolipin antibodies can be associated with abnormalities of placentation, poor fetal growth, pregnancy losses, pregnancy-induced hypertensive disorders, maternal blood-clotting problems, and early delivery among others. Please let me know what did your doctors decided to do, diagnostically and therapeutically, in response to the anticardiolipin antibodies and your wife's previous obstetrical history? Best wishes to you both. Dr T

   

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