Recurrent Pregnancy Losses: There are ALWAYS Causes, but They May Not be Related
Tuesday, December 18, 2007
Kenneth F. Trofatter, Jr., MD, PhD
• 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 (Maternal chromosomes)
Protein C
Protein S
Leiden mutation (R506Q mutation)
MTHFR (C677T and A1298C mutations)
Cardiolipin IgG, IgM, IgA
Factor II (prothrombin) mutation (G20210A mutation)
Lupus anticoagulant
- PTT (LAC) Screen
- Hexagonal phase
- DRVVT
- Phospholipid Neutralization
Glucose and Insulin challenge test
Antithrombin III
- everything came back negative. My husband's karyotype was also normal.
My reproductive endocrinologist 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 aspirin or progesterone) because I was still breastfeeding until 9 weeks of pregnancy. We lost our twins at 15 weeks of pregnancy after recurrent heavy bleeding. In ultrasound examination, there was a hematoma with a maximal size of 4cm. At the end of pregnancy, my amniotic 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 a D&C to remove the placentas. The hematoma was under the membranes (not under the placentas).
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 prednisone next time?
Could the hematoma have been caused by any defects of my uterus (like polyps, poor endomterial lining)? Could it be a result of the previous D&Cs?
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' to date has been completely negative. So, you really may be one of those folks who has just had a streak of unrelated 'bad luck.' Although I am the first to admit, there will always be other causes for which you have not yet been screened that could have contributed to all of your losses. 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. You could have had poor placentation, perhaps secondary to scar tissue from a previous D&C. Another possibility is that one or both of the twins was chromosomally abnormal. And, some women who carry nursing into another pregnancy, have less 'receptive' endometrium or increased uterine contractions (even if they don't feel them) because of the oxytocin 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 contractions 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 major source of risk for a pregnancy either. 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 you did take prednisone with the other pregnancy, though, that also would be reasonable; but I will usually stop that in my own patients (unless they have a known autoimmune condition and need it for that reason) by about 20 weeks. Some doctors stop it by the end of first trimester. One word of caution though. There is recent evidence that steroids may be associated with facial clefting, so that may be another reason to go with heparin instead.
Major defects of the uterine cavity were probably ruled out by the workup (HSG and hysteroscopy) your doctor already did, so mark that one off your list. Those procedures should have detected an endometrial polyp, a submucosal fibroid, or scar tissue from your previous D&Cs. Also, red blood cell isoimmunization is something you have probably already been screened for early in each of your pregnancies and even if you were sensitized, that is VERY unlikely to be associated with the problems you have had.
Could something bad happen again? Sure, but even though you have had a poor obstetrical history to date, the different losses may be the result of different, isolated, and unrelated (and less likely to repeat) causes. Other causes could be sought, but at this point, there is a point of diminishing returns and the risk of many 'red flags' that might still not point to a single cause. Based on what you have shared with us here, my sense is the odds are in your favor that you will successfully carry another baby. Good luck and thank for reading!
Dr T
Labels: recurrent pregnancy loss
46 Comments:
At Wed Dec 19, 06:48:00 PM 2007,
Anonymous said…
I have recently had dna and blood testing for factor V leiden, my father died with a massive bleed in his brain stem and this genetic disorder is very dominant in my family, I tested neg for factor V, but I had 2 mutations in MTHFR, one copy C677t and one copy A1298C, homocysteine was 7.5. My platelets have been around 500 as long as I can remember. I had 3 normal pregnancies and 3 healthy children. I can't have any more, but am concerned about my risk for thrombosis and am seeking help for potential dx and further testing measures. Please help.
At Thu Dec 20, 04:42:00 AM 2007,
twack said…
Hi not sure if this is the right place. I just have a quick question I lost my baby at 19 weeks due to an infection of/in the placenta it had not reached the baby. I was wondering if this infection should have/ could have been deceted before my waters broke at 18 weeks and if so what could have been done to fix it. The reason I need to know is that I am 9 weeks pregnant and scared this is going to happen again.
At Thu Dec 20, 04:54:00 AM 2007,
twack said…
Hi sorry not sure if this is how to post a question. I lost my baby in April 2007 at 19 weeks and have recently found out that is was due to an infection of/in the placenta the infection had not reached my baby. But at 18 weeks my waters broke the hospital did not pick up the infection until the autopsy. I have recently found out that I am 9 weeks pregnant and am really scared that it is going to happen again is there anyway that they can pick up an infection of/in the placenta?
Thanks
Twack
At Thu Dec 20, 10:58:00 AM 2007,
Anonymous said…
Hi, my wife just miscarried our 7 week old baby. Her levels were about 2,000 during that time. The doctors said that her levels were pretty low when we did the pregnancy test two weeks ago. My question is, could we have been able to prevent this miscarriage if they placed her on progesterone supplements early on in the pregnancy? Could there have been anything we could have done to prevent this miscarriage?
At Thu Dec 20, 03:35:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Twack Dec 20: Women who rupture membranes early are at risk for that happening again for reasons that are not always clear. For example, in your own case, we do not know whether the infection caused the membranes to rupture, or if you developed the infection because you had ruptured your membranes for a week before the actual delivery. Did you have any bleeding or another precipitating event when you ruptured the membranes? Regardless, your doctors should follow you very carefully for any evidence of vaginal or urinary tract infection and treat those aggressively in view of the other loss. We would also recommend serial ultrasound exams to see if you have a weak (incomptent) cervix. By the way, between pregnancies did you have any evaluation of your uterine cavity by hysteroscopy or a sonohysterogram to see if you, yourself, might have a congenital (Mullerian) abnormality of the uterus? These can be associated with cervical incompetence because they are 'midline' defects. Do you have any other medical problems? Good luck to you and please let us know how things turn out! Dr T
At Thu Dec 20, 03:43:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Dec 19: Hi there. I have more questions than answers at this point. Do you have any medical problems that are currently being treated? Has that high platelet count ever been evaluated. If not, perhaps you should see a good hematologist who could also counsel you regarding your thrombosis risks and continue your work-up. Some folks who smoke have high platelets, so if you do, it is time to quit with your family history and high level of concern. After you have been more fully evaluated, if no other risk factors are found, regular supplementation with folic acid, B vitamins, and a baby aspirin each day will certainly reduce your risks givem the combination of laboratory abnormalities you have noted. Good luck to you and let us know what happens with regard to your work-up and the recommendations for traetment!
Dr T
At Fri Dec 21, 06:00:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Dec 20: Progesterone probably wouuld not have helped at this point. If you have had other children, the most likely reason for the miscarriage is that the baby is chromsomally abnormal. most of those babies are lost in first trimester. If this was a first pregnancy, or if your wife has any other medical problems, there may be other explanations - usually hormonal or endocrinologic in nature. I am sorry for your loss, but this is one situation in which you should not kick yourselves for having done anything 'wrong.' Miscarriage is always sad - wondering what was, what could have been, and what could we have done different, but if there are no underlying medical conditions to have contributed to the miscarriage, then the odds are you will be successful in the future. My thoughts and best wishes are with you. Thanks for reading! Dr T
At Wed Dec 26, 08:12:00 PM 2007,
Anonymous said…
Dear Dr. Trofatter,
I have a question about RPL. My situation is a bit unique in that I have had successful uncomplicated pregnancies but have recently suffered two losses this year one at 11 weeks with no testing done due to it being my first loss. We had a well established pregnancy with good fetal heart tones until week 11 when the baby's heartbeat stopped. The other was a well established pregnancy followed closely by my OBGYN from the beginning due to our prior loss. All testing normal until week 7 when we had some bleeding and a subchorionic hemmorhage was seen. We were told there was nothing to do and were put on pelvic rest with weekly scans to check the baby. Everything progressed well with the baby including a normal first trimester screening and NT. We saw a 3 vessel cord, 4 chambered heart, bladder, spine, normal brain/ventricles, normal biparietal diameter and crl. When we went back one week later at 13 weeks the baby had died. We were told 13 weeks was the magic number to be safe and for us it didn't work out that way. Karyotype of the baby is pending. My husband and I do not have any children together but we both have healthy children from each of our first marriages. The doctor says that since we have children we don't need to undergo karyotyping ourselves. I had no infections, normal first trimester screen, baby growing well weekly. Is this just bad luck or can there be an underlying medical cause for this in me even though I've carried babies to term without complications in the past. Or is there something between the two of us that could make this happen? We have been successful conceiving on our first cycle of trying both times. Our OBGYN wants to do the prophylactic progesterone and baby aspirin. Please advise if you think there is something that may be the cause, especially perplexing for our OBGYN since we both have healthy children. We're both 38 years old. Please offer any advice, we're getting desparate and heartbroken after our unexplained losses. Thank you.
Jennifer
At Mon Jan 07, 08:03:00 PM 2008,
Anonymous said…
Dear Dr Trofatter, I have a question regarding the results of blood tests run after having 2 miscarriages in the last 6 months. My ob history is one birth in 2006 after a trouble free pregnancy. Since then I have had a missed miscarriage in June and again in October 2007, both pregnancies ended at 6 weeks and resulted in D&C’s. My doctor referred me to an Ob/Gyn who ran some basic blood tests. The tests run were; LFTS, EUC, VT, BIO, RUBS, SYPS, TSH, FBC, FIB, TT, PT, APTT. The only test that has come back abnormal is a Fibrinogen level of 1.8 g/L. My doctor is not concerned by this result, I have not heard from my Ob/Gyn who was only going to contact me if there was a problem. Is this fibrinogen level ok, or do I need to request further testing? I am 33 and I have regular pain free periods,and no family history of blood clotting problems.
At Thu Jan 17, 08:42:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Jan 7: I am not familiar with your lab nomenclature, so I am not sure what the EUC, BIO, or VT tests were. There are many possibilities here. It could simply have been that both losses were the result of babies that were chromosomally abnormal. It also could be that you or your husband has a balanced chromosomal translocation that puts you at greater risk for conceiving a baby with an unbalanced amount of chromosomal material (and things just worked out fine the first time, which happens about a third of the time in those situations). Yu could have an intrauterins fibroid or polyp that is preventing implantation. I am not particularly concerned by the fibrinogen level at this time. I would suggest starting a baby aspirin and extra folic acid prior to conceiving again and if things don't work out the next time, having a much more thorough evaluation than you have had to date before attempting another pregnancy. If you do miscarry again, see if your doctors can send some of the tissue for chromsomal analysis as well. Hope things turn out better the next time. The odds are in your favor since you previously had a successful pregnancy! Thanks for writing. Dr T
At Thu Jan 17, 11:09:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Dec 26: It appears that yours was another one of those comments that did not get to my mailbox in a timely fashion, so I apologize in the delay to respond. It appeasr you do not have an 'infertility' problem so much as a successful implantation problem. Certainly, at your age, you are at a greater risk for conceiving a baby with a chromosomal abnormality and most of these are lost at some point in first trimester. So, it will be interetsing and informative to have the results of the fetal karyotype. If that is a trisomy, then it is likely to be the result simply of your age and the solution is to try again. If there is evidence of an unbalanced translocation, then either you or your spouse might be a balanced translocation carrier, but the solution there is again to simply try again. If the baby ws chromosomally normal, then it may just be that immune system is having trouble figuring out how to carry a baby with different genetic characteristics than that resulting from your previous partner. Of course there are many other possibilities, but in a woman who has successfully carried a baby before, these are the most likely. Why don't you try the aspirin and progesterone and see if that works. There are other options for empiric therapy, but that is very safe and may be all you need. If the baby was chromosomally abnormal. You probably don't even need that. Best of luck to you and thanks for reading (and your patience)! Dr T
At Sat Jan 19, 02:46:00 PM 2008,
ONE OUT OF SIX said…
Dr. T - what are your thoughts on starting lovenox prior to implantation - either right before, or right after ovulation? And is your opinion the same in regard to a natural cycle as opposed to an OI cycle in which ovulation is then triggered with HCG? Also - does patient already being on a daily baby aspirin have an impact one way or the other?
It has been suggested to me that being on both baby aspirin and lovenox (40mg/once a day) could actually inhibit implantation by causing a bleed at implantation site.
Others have said this is not the case at all - and in fact the opposite is true - healthier blood flow to uterus will assist with implantation (that may have been prevented in the past by diagnosed clotting disorders - homo MTHFR C677T and hetero Factor V.)
Last question - can you move to Pittsburgh, PA so I can become a patient? ;-)
Thanks for your insight.
At Sun Jan 20, 07:25:00 PM 2008,
kellio924 said…
Dear Dr. Trofatter:
I recently had a missed miscarriage discovered at 22 weeks (baby measured at 16 weeks)and I just have a couple of questions for you. This was my first pregnancy. My first trimester screening blood work came back terrible, hcg 1.92, papp-a 0.12, amnio came back fine, so we knew we were possibly dealing with something placental. The pathology report stated that the baby had a very long cord with some strictures and nothing extremely telling on the placenta (but since the baby had died 6 weeks prior, I'm not sure how much that would have told anyways.). Autoimmune and clotting work up came back normal. Is the long cord with strictures something we need to watch for next time, or is it more likely just a stroke of bad luck? Would empiric treatment with aspirin be a good thing?
At Wed Jan 23, 06:24:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To kellio Jan 20: Judging from that first trimester screen, I would have bet on a chromosomal abnormality myself. There is a small chance the baby had a chromosomal mosaicism and the only cells that grew in culture were the normal ones and not the chromosomally abnormal ones. There is also a possibility the baby had a normal number of chromosomes, but still had a genetic or syndromic problem (espeically with the possibility of an abnormal cord). With regard to the aspirin, personally, I don't think it would hurt, but it may not help either. Tell your doctor if you decide you are going to take it. I am sorry for your loss and hope things go better the next time. Thanks for reading. Dr T
At Fri Jan 25, 10:53:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To One out of Six: Flattery will get you an answer EVERYTIME! Personally, I rarely will start lovenox or heparin before midway through the luteal phase after ovulation (about day 20-21) unless you have documented antiphospholipid syndrome or another condition that requires chronic anticoagulation. The reasons for that are it may increase bleeding from the ovarian ovulatory site (and, personally, I have taken to young women who were not on lovenox to the O.R. in the past month with bellies full of blood from that very thing) and I sincerely doubt it does much good until implantation has actually taken place. With all that said and done, on prophylactic doses of lovenox such as you are taking, it probably would not hurt or put you at much risk. With regard to recurrent early pregnancy loss, however, the anticoagulation properties of lovenox may be LESS important than their roles in improving trophoblast invasion and migration! This may be especially true under those circumstances in which 'thrombophilic antibodies' such as lupus anticoagulants, antiphospholipid antibodies, and anti-beta2-glycoprotein-1 antibodies are present. These can bind to the trophoblasts in association with beta2-glycoprotein-1 and impair both trophoblast invasion and migration that are necessary for early pregnancy success. Interestingly, heparin and lovenox can reverse the effects of these antibodies by blocking their binding to beta2-glycoprotein-1. OOOPS, sorry for the lecture. Anyway, I will put your question and my answer into a full post on this subject soon, so, thanks for reading, for the excellent questions, and best of luck! Dr T
At Tue Jan 29, 01:20:00 AM 2008,
Anonymous said…
I am 6wks4dys pregnant. I had several preg symptoms before my period was due. After taking a pregnacy test (+), about 4 days later notice that my symptoms started to diminish. Then they would come and go. I m/c in Oct. 2007. I have no symptoms of m/c bleeding, cramps, backpain etc.. should I bee concern about a missed miscarriage ? I have a dr. appt later this week .
At Tue Jan 29, 04:21:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Jan 29: It's hard to say. In some women, losing the early symptoms of pregnancy is relatde to the loss of a pregnancy and in others it is not. When you see your doctor later this week. they should be able to tell whether or not the baby is alive at this point by ultrasound (if you really are 7 weeks). Best of luck to you and thanks for reading. Dr T
At Thu Jan 31, 05:12:00 PM 2008,
Anonymous said…
I posted a comment on jan 29th regarding diminishing pregnancy symptoms. I was able to see my doctor that day. I had an u/s and the baby measured 6wks3dys with a heartbeat. I also had blood work done. my doctor's office called today and said that the dr want me to start taking prometrium. My progesteron level was 17.3; she wants my prog level to be around 25. While reading the information that is giving by the pharmacy, It says not to take while pregnant. should I be concerned ???
At Fri Feb 01, 12:17:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous jan 31: TAKE THE MEDICATION...Dr T
At Mon Feb 04, 09:26:00 AM 2008,
Anonymous said…
hi
i had a miscarriage some time in feb. of last year. i was never given a D&C but was given cydotec (i think thats the name of the drug) instead to pass the baby out. after going thru that i went for my check up in may i was given the depo-provera shot as a form of contraceptive (took only once)ever since then i didnt have any period until 2 months ago. my question is will it cause a problem for me to get pregnant again? i have been trying but there is no luck.need your true advice
At Tue Feb 12, 04:44:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anaonymous Feb 4: You were given Cytotec (misoprostol) which is a prostaglandin compound that is very effective at causing a "medical D&C" (and also effective at iducing labor). When it works, I actually prefer using it rather than doing a D&C. The Depo-Provera is labelled to prevent pregnancy for 3-4 months, but I know many women who did not ovulate for 8 months or longer after a single. The bottomline is, however, if you were having regular periods before the pregnancy, you will probably resume having them again sometime soon, IF you don't get pregnant first! Neither the Cytotec or the Depo-Provera should affect a pregnancy once you begin ovulating again regularly. Dr T
At Sun Feb 24, 06:26:00 AM 2008,
Anonymous said…
During my 10 week ultra sound (Feb 21st) the technition notice a black around outside of the uterus. Said that the black area could be either blood or mucus. Should I be concerned? She said that everything looks fine concerning the baby. Heartbeat 181 baby was moving around quite a bit. I have had very few symptoms of pregnancy (tender nipples)and is currently taking promethium. I have had 1 miscarriage (Oct 2007) and currently am 38 years old.
At Mon Feb 25, 02:03:00 AM 2008,
Anonymous said…
I had an ultrasound Feb 21(10wks) baby heart beat 176. The tech said that there was either a pool of blood or mucas located outside of my uterus. He told me not to worry about it. I am currently taking progesteron. Does progesteron stop bleeding and if it does , do the blood remain in the body? Should I be alarmed. next appt. is in 2 week.
At Wed Feb 27, 06:27:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Feb 24/25: You probably had what some term a 'subchorionic hemorrhage'. If you are not having any bleeding at this point, I would not worry about it. It is diagnosed more often than it is a real problem. The progesterone helps the placenta develop early in pregnancy, but the placenta usually makes enough progesterone on its own by this point that the medication can be stopped soon. Good luck and let us know how things turn out. By the way, why were you placed on the progesterone to begin with? The previous miscarriage? Dr T
At Thu Feb 28, 04:56:00 PM 2008,
Anonymous said…
Dr. T. This is anonymous feb.24/25. In response to your question regarding why I was prescribed progesteron? I had a miscarriage in Oct 2007 and my progesteron level measured 17.3 at my 6wk checkup in Feb. 2008. My doctor has taken me off progesteron. She says that my placenta should take over. Question? I have had only one lab work done and that was at 6wks (heartbeat 167?) went for u/s @8wks baby fine heartbeat and 10wks.
Ask dr. why level were not being taken she said that since the u/s show the baby growing lab work is not needed ? is this the norm ?
At Mon Jun 23, 09:16:00 AM 2008,
amyBaby said…
hi there i had a surgical miscarriege at 12wks and lsdt week a letter came back saying that the pregnancy tissue has shown a slight abnormailty
could u tell me what u think that could be as ive been think ing the worst and my partner and i want nothing more than to start a family together
thanks
amy
At Thu Jun 26, 09:50:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Amy June 23: The most likely abnormality is that the placental tissue showed some evidence of "hydropic degeneration." This is not at all unusual in early pregnancy losses, especially if a chromosomal abnormality was present, however, it can also be difficult to differentiate from a condition called "molar pregnancy." A molar pregnancy puts you at increased risk for developing choriocarcinoma and that usually requires more follow-up and delaying another pregnancy. Your doctor will review the pathology results with you and make further recommendations for your care. Good luck to you and thanks for reading. Dr T
At Mon Jun 30, 10:27:00 AM 2008,
Anonymous said…
Dr. Trofatter:
I am just amazed there is a doctor like you out there! Thank you for answering ALL these questions with such compassion and diligence.
Now, my situation. I'll be 34 in a few months, and we just lost 2 babies in the last year. I carried my first pregnancy to term and delivered a beautiful baby boy who died suddenly 2 months later of undiagnoised PPH (found at autopsy). We waited 3 normal cycles and got pregnant again with our first try about 5-6 months after the previous delivery (vaginal, no complications). I miscarried this second pregnancy at 12-13 weeks (sac measured 8 weeks) naturally at home.
The only problems I had during the first pregnancy was an abnormal pap caused by HPV, and GBS in the last trimester. My question is, could my miscarriage have been caused by either HPV or GBS? Did I not wait long enough after the last pregnancy to get pregnant again? What are your thoughts of depression/stress and any link to miscarriages? And lastly, considering my age (34), is it better to wait longer for my body to "recover and replenish" before trying again, or to race against the clock and try again after another 3 normal cycles?
I am still hopeful but so scared to lose any more babies!
Thank you in advance for sharing your insights and taking the time to care!
J
At Fri Jul 04, 08:13:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To J: First, I m sorry for your losses. The two are probably completely unrelated. Now, on to your questions: It is unlikely that either GBS or HPV caused your miscarriage - that was much mor likely to be the result of a random chromosomal abnormality; the time you waited was probably just fine if you had resumption of normal menstrual cycles; depression and stress can contribute to poor pregnancy outcome related to horrmonal imbalances and other factors we do not understand; why don't you continue to take your prenatal vitamins, some extra folic acid, and then get pregnant again whenever you feel you are ready. It is normal to be anxious about another loss, but your chances for this are probably low because of the high likelihood these were due to unrelated factors. Best of luck and thanks for the kind comments. Dr T
At Mon Jul 28, 09:24:00 AM 2008,
amylynn said…
I have had 6 consecutive m/c between 6-8weeks gestation in the last three years. I am currently seeing an RE at Duke. I have been tested for the full panel of RPL blood tests and come back normal, normal for karyotype also. Two of my pregnancies were karyotyped and were normal (one male, one female). I had a septum resection in November, and have since had two more miscarriages both at 7 weeks gestation. I was on progesterone for the last three pregnancies, although my levels were within the normal range. I was also taking baby aspirin during the 4th and 6th pregnancies where we saw a fetal hr at 7 weeks. My RE is out of explanations and is now reccomending trying heparin and baby aspirin when we try again. I am taking 6 months off from trying to conceive as it has been emotionally draining. Are there some blood tests that we may have missed for clotting factors? Are we headed in the right direction by looking at heparin? Thank you for your help and assistance.
At Mon Jul 28, 03:57:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To amylynn: There are several approaches you can take: 1) simply take the time off and then try again starting heparin in mid-luteal phase; 2) do the same thing as in 1, but do so with a 'stimulated' cycle (ovulation induction) even though you do not appear to have ovulatory dysfucntion; 3) take lupron for the next 3-4 months before attempting conception again and then go with 1 or 2; 4) after 6 months off (with or without lupron), consider stimulated cucles with IUI or IVF. Your REI doctor can probably explain my rational for all of these! Best of luck. Dr T
At Wed Aug 20, 12:43:00 PM 2008,
AshleyElin said…
To Dr. T,
I have had 3 consecutive miscarriages since June '07, most current being July 22 of this year. I am beyond frustrated because it is hard leaving having a child within the hands of my doctor, when I am not so sure he is caring or concerning enough to see me through a full term pregnancy. I have always seen his nurse practitioner for all my pregnancies except for this last one, I met him on my second appt for the first time, which of course was the downfall of the third pregnancy. He had no idea of my second miscarriage, which is super frustrating since that should have been in my chart. I can't help but feel maybe things would have turned out differently had he of known. I was told once I get a positive again (for this last pregnancy) to come in by the nurse practitioner and they would get me started on progesterone. Well, he ultimately turned it down. Would he have if he had known that this was my third pregnancy? All I have been doing since miscarrying is taking blood tests to follow my levels back down to negative after taking mistoprostol to complete the miscarraige on July 18th. I have not spoken to my doctor since! I have a consultation on Sept. 10th to hopefully discuss the game plan for tests. My husband's karyotype has already been done and he is normal. Can you give me a list of things that I can be tested for so that I can discuss it with my doctor? I want to make sure everything can be done possible. Thank You!
At Fri Aug 22, 10:15:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To AshleyElin: I wrote a whole series of posts on recurrent pregnancy loss in March and April of 2007. Go back in my archives and read those and then let me know if you have any questions. Regards, and sorry for your losses. Dr T
At Mon Dec 22, 03:58:00 PM 2008,
Teresa said…
i have 2 children after my daughter was born i got on the deop provera shot. went off of it back in 2006 got pregnant in march of 20027 lost the baby that same month got pregnant again in october 2007 lost the baby in november went back on the shot in december 2007. my husband and i want to have another baby. what are my chances of carrying a baby to term after being on the depo-provera shot? and is there anything i can do to maybe help me to carry another baby to term. plus i am RH Negative if that can help anything?
At Mon Jul 13, 05:37:00 AM 2009,
Anonymous said…
Hi my name is amy and I am currently 14 weeks pregnant with #3. I have been diagnosed at 8.5wks with a Subchorionic Hemorage however It was found during a dating ultrasound(no bleeding to this date). I have great concern for this pregnancy since I have been told there are many risks with this type of blood clot. Another ultrasound at 12 weeks determined the clot is still there at 3cm. Is this very common? What are the chances I will carry full term? Should I be avoiding anything in order to help the pregnacy continue along? thank you!
amy
At Wed Jul 29, 06:46:00 PM 2009,
Anonymous said…
Dear Dr T,
Thank you for all of your answers to our many questions!
I am soon to be 34 (married to the father to all of my pregnancies). My first pregnancy gave us a healthy girl who is 2 1/2. No problems other than ended in a c-section- failure to progress.
My second pregnancy ended in a missed miscarriage at 13 weeks (9 months ago). I had a D&C. (no work up on baby).
My third pregnancy also ended in a missed miscarriage at 13-ish weeks (I found out at our 16 week appt) which was 3 months ago. Work up done on baby came back normal on chrom. test.
Husband's Karyotype is normal.
My tests include:
Thyroid profile
Prolactin
Anti-Cardiolipin Ab
Anti-Nuclear Ab
Lupus Anti-Coagulant
Prenatal Karyotyping
Cystic Fibrosis Screen
Methylenetrahdrofolate Reductase
Protein S
Protein C (Deficiency Profile)
Anti-thrombin III
Homocystine
Leiden Co-factor V
Heparin Anti-XA
Prothombin 20210 A Mutation
Factor VII
HSG
All came back NORMAL.
Husband and I are planning on taking an anti-biotic for two weeks before we ttc again.
Are we missing something? Are there any other tests to take? Any medication suggestions for next time besides baby aspirin and progesterone considering that my miscarriage happen at the same week?
Thank you,
Nicole
At Mon Aug 03, 06:24:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
Amy,
The best thing you have going for you is that you have had NO bleeding and the baby has continued to grow and develop normally. With each passing day, your risks of a major complication from the "subchorionic hemorrhage" (if that is indeed what it is) diminish. Hang in there and let us know how things turn out.
Regards,
Dr T
At Mon Aug 03, 06:38:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
Nicole July 29: Do you have very regular and 'normal' menstrual cycles? Did you have any trouble conceiving? Do you have much pain with your periods? Were both of the babies you lost at 13 weeks 13 weeks size at the time they died? Do we know the babies genders?
The loss of pregnancies at the end of first trimester is actually fairly unusual in the absence of a chromosomal abnormality which appears to not be the case. There is the possibility that you and your husband are both heterozygous carriers of common autosomal recessive mutations that result in babies with a lethal "inborn error of metabolism." If that were the case, you would have a 1 in 4 chance (25%) of losing a baby with each conception (or a 3 in 4 chance of a successful outcome). You might want to talk with a Genetic Counselor about these sorts of conditions.
Also, despite the fact that you have been screened for MANY of the major conditions that are more commonly associated to a greater or lesser degree with recurrent pregnancy loss and other pregnancy complications, you must understand that that list of "tests" is far from complete - there are obviously MANY things we do not know about pregnancy loss.
In my mind, rather than subjecting yourself to a series of endless and more expensive tests, you might be a good candidate for a trial of empiric therapy with heparin or low-molecular weight heparin - I would start you at 'prophylactic doses' as soon as a pregnancy was confirmed. Thank you for writing and best wishes!
Dr T
At Mon Aug 03, 07:44:00 PM 2009,
Anonymous said…
Dr T (This is Nicole: July 29),
To answer your questions:
Yes, I've always had regular and 'normal' menstrual cycles. They are about 4 days long and occur 28-30 days apart. It took us a year to conceive our 2 1/2 year old girl. (coincidentally I got pregnant as soon as I quit my caffeine addiction). The next pregnancy only took 2 or 3 months and the last pregnancy I only had one cycle after my D&C and we got pregnant right away. I have very mild cramping with my periods. The first m/c I found out at 13 weeks (no heartbeat detected. I had no spotting or cramping) and the baby measured 12-13 weeks. The second m/c I found out at 16 weeks (again no heartbeat detected. I also had no spotting or cramping) and the baby measured about 13 weeks. I do not know the gender of the first miscarriage because they did no testing. I do know that the second miscarriage was a boy.
One other question, I am seeing a high risk OB. Should I see a genetic counselor in addition to this doctor?
Thank you again for your help!
Nicole (July 29)
At Tue Aug 04, 11:23:00 AM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
Nicole: Based on what you have told me, my previous comments stand. My only thought would be that if you successfully carried a girl and at least one of the babies you lost was a boy, from a genetics perspective, there is also the possibility that you carry an X-linked recessive trait that would then only likely affect male children. I think it might be a good idea to have a chat with a Genetic Counselor. If you are working with a specialist in Maternal-Fetal Medicine, she/he can refer you to whomever they use on a regular basis. Again, best of luck!
Dr T
At Sun Sep 20, 03:36:00 PM 2009,
Anonymous said…
Dr. T. I recently had a miscarriage at 16 weeks. I was induced and delivered 2 weeks ago. This was a donor egg (24 year old). The umbilical cord had an apparent stricture near the fetal insertion. The baby was phenotypically normal. I will receive a thrombophilia and antibody work up in 2 weeks. Assuming this workup is normal, what are the chances or recurrent umbilical cord stricture in a subsequent pregnancy?
At Sat Sep 26, 10:10:00 PM 2009,
Anonymous said…
Dear doctor Trofatter, THANK YOU VERY MUCH for your blog. What you're doing is really amazing. Thank you so much for your reply you wrote almost two years ago. It was very encouraging and also I printed it out for my new doctor then. I have a 7 months old baby now! I was taking aspirin and an hematologist saw me every months during my pregnancy. All tests for blood clothing disorders were done repeatedly and were always negative. Still I think there might be something. My sister had two missed m/c in a row, also all test came back negative, but now on baby aspirin she's having a healthy pregnancy (touch wood!)Thanks again! You're such a wonderful doctor. Best wishes. JS
At Tue Sep 29, 03:51:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sep 20 It is very unlikely that this will recur unless the donor or your partner has a family history of a genetic problem that might increase the risk for recurrence. Best wishes and sorry for your loss.
Dr T
At Tue Sep 29, 03:52:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To JS: Thank you for the update and the kind comments. I wish your sister the best with her pregnancy as well.
Dr T
At Sun Oct 11, 07:14:00 AM 2009,
Dariela said…
Dr T,
You have been so informative on all your posts. I wish you were my doctor. I'm hoping you can help with my situation. I'm 29 and I have always been very healthy. I eat healthy, have never smoked, rarely had a drink and never did any drugs. I don't even drink coffee. My cycles have always been regular and lasted between 28-31 days. We started trying last year. We got pregnant 3 months later. I had no bleeding or anything abnormal until I woke up one morning and lost my baby at 5 1/2 wks. No testing was done as it was my first loss. Then we tried again with the second period and got pregnant again. This time I insisted on hcg/prog tests. It came back at 20 and 1.9 at 19 dpo. Later that day I miscarried again, which was at 5 weeks. I have tracked my bbt for the last 6 months and my luteal phase has always been 14 days. I have always ovulated on my own. Could I still have a progesterone deficiency? An ultrasound was also done the second time and they found 2 fibroids. One was 4 cm and another very small one. Neither were protruding in the uterus. I am still waiting for the doctor to get back to me to discuss my options, but I will probably opt to get it removed to hopefully help with the next pregnancy. Karyotyping has not been done yet, but I was told we can do it 6 weeks after my loss. We are both pretty healthy. Would you suggest any therapy for me to try next time to maximize our chances? Do you think Clomid and progesterone supplements would help in my case? I had my annual physical lab tests done shortly after my first loss and everything was normal. Please help!
At Fri Oct 16, 06:44:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Dariela Oct 11: From what you have told me, I doubt this is a progesterone problem. Indeed, this could still be 'chance' resulting from chromosmally abnormal babies even if you and your souse are chromosomally normal. It is also possible the fibroids or even subclinical endometriosis are impairing implantation. Did you have a sonohysterogram or hysteroscopy done to make sure there were no abnormalities of the uterine cavity? Certainly empiric clomid with progesterone support is generally safe enough to do, but it might not really be necessary either. You are young enough that the overwhelming odds are in your favor that you will be successful, but I know going through repetitive miscarriages is very hard. Best wishes and thanks for writing.
Dr T
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