Repetitive Miscarriages: Engender Fear and Require Patience
Thursday, December 06, 2007
Kenneth F. Trofatter, Jr., MD, PhD
Hello-
Thank you so much for the work that you do for RPL (recurrent pregnancy loss). I have read Fruit of the Womb and the segments on RPL. My question is: I am a 29 year old with no successful pregnancies and my husband is 31. We are both in good health. I have had two very early miscarriages within the last 6 months. One was natural (aborted spontaneously and completely) and the other was completed by a D&C. Both times no fetal pole (embryo) was found and my doctor said the second was a possible blighted ovum. Since in both there was no fetal pole found, would this be more of a immunological issue or hormonal one. Or still, could it be random chromosomal issues?
I am concerned and scared to try again and have been going to a reproductive endocrinologist (RE) who said he will treat me with baby aspirin, estrogen in the first half of the cycle to help my uterine lining and progesterone in the second half of the cycle. No other issues have been found except for that I am a possible carrier for Group B Strep...would the Group B Strep be causing the miscarriages? I am at a loss as to why this happening and since everything has come back normal it does scare me. I also went to see a herbalist and they tested my saliva for thyroid antibodies and I did have those, but they were not evident in the blood test that the RE performed.
I have regular menstrual cycles, check my temperature (basal body temperature) every day and ovulate. I read your suggestions on what you do for women with unexplained pregnancy losses. Would you suggest that same plan for some one like me? I don't want to have a third miscarriage as I know my percentage from there increases to have subsequent miscarriages. I am sorry this was so long, I am just so worried and don't know if my RE path is covering all my bases?
Thank you again for all your help to so many women.
Dana
To Dana:
Let me start with a couple of questions back at you: Specifically, you said that “no other issues have been found” and it would be helpful to know what specific studies have been done and, if possible, the results? Also, how did you find out that you are “a possible carrier for Group B Strep?” Was GBS detected in a urine culture? Is there any family history of recurrent pregnancy loss, blood-clotting disorders, or autoimmune diseases? You have regular periods but are they usually painful?
Regardless, my assessment of your situation is as follows: If you have regular cyclic menses and ovulate regularly in midcycle, the likelihood is that you do NOT have a significant hormonal problem. So, to answer your first question, your losses are most likely the result of an inadequate or inappropriate immune response to pregnancy (i.e., your immune system has not quite figured out yet that it’s supposed to help the baby survive) or the result of conceiving babies that were chromosomally abnormal. In the latter instance, this could be either ‘random’ aneuploidy or the result of either you or your husband carrying a balanced chromosomal rearrangement. Other possibilities include abnormalities of the uterine cavity, such as fibroids, polyps, or a congenital uterine defect and/or endometriosis which may be a more common cause of RPL than previously recognized, particularly in women who have delayed child-bearing until their 30’s. In the reading that I have done over the years, I have never seen an association between GBS carrier status and recurrent early pregnancy losses. However, chronic GBS carriers may not have an adequate immune response to the bacterium and, hypothetically, that might be the result of a subtle underlying defect (hyporesponsiveness?) in the immune response and be reflected in similar problems when it comes down to recognizing a pregnancy appropriately.
In the absence of finding specific abnormalities to ‘treat’, your RE doctor is taking a sensible empiric approach to therapy. I understand how hard it is to undergo repetitive miscarriages, since my first 3 babies ended up the same way, but at this point the hormonal support and aspirin are a reasonable first step. You could add a prenatal vitamin and extra folic acid to the mix as well. If your next pregnancy is lost, you will probably need a more thorough evaluation before conceiving again and/or a more aggressive approach to empiric therapy. How about if we cross that bridge if we come to it? Remember, the odds are in your favor that you will be successful, regardless of what we do as physicians!
Dr T
Labels: recurrent pregnancy loss, RPL
14 Comments:
At Fri Dec 07, 10:58:00 AM 2007,
JS said…
Dear doctor Trofatter, let me just say that you're so great that I'm always touched when I read your posts and comments. You're such a special doctor! You know how to help us, but the same time you're able to understand our feelings. You're a doctor who really cares. Thank you so very much for helping us!!
Dear Dana, I'm sorry for your losses. I had two missed m/c in a row and almost could have written your post 2 years ago. My third pregnancy was happy, healthy and uneventful! As doctor Trofatter said, the odds are in your favor that you will be successful next time! I also was on baby aspirin and progesterone as doctor Trofatter suggests! Best of luck!
JS
At Fri Dec 07, 04:10:00 PM 2007,
Dana said…
Dr. Trofatter-
Thank you so much for your response! It means so much to me! I have had a sonohystergram, endometrial biopsy, and all the recurrent loss blood work, thyroid etc. The Group B Strep was detected from my endometrial biopsy. It was in the "broth" of the sample. I am just not sure where I got it from - maybe the D&C? There is no history in my family or my husband's of clotting issues, or recurrent pregnancy loss. Both of us have healthy parents and were all able to have babies without difficulty. All the above tests came back normal. We also had the chromosomal test done and that was fine for both of us too. My TSH was 1.66 which is good I think. The only thing that is "abnormal" is that my endometrial lining is measuring at 5.8 - which is too low and so I will take Estrace starting on Day 8 of the cycle that we want to conceive. What are your feelings on Natural Killer Cells, do you feel that test would be or is appropriate in my situation. Are there any other immune tests such as an Embryo Toxic Factor Blood Test that maybe I should ask for? Is there any harm in taking a low dose baby aspirin for a length of time? Thank you again for taking the time to talk to me, it really does mean so much.
Dana
At Sun Dec 09, 05:32:00 AM 2007,
Dana said…
Dr. Trofatter-
Thank you so much for your response! It means so much to me! I have had a sonohystergram, endometrial biopsy, and all the recurrent loss blood work, thyroid etc. The Group B Strep was detected from my endometrial biopsy. It was in the "broth" of the sample. I am just not sure where I got it from - maybe the D&C? There is no history in my family or my husband's of clotting issues, or recurrent pregnancy loss. Both of us have healthy parents and were all able to have babies without difficulty. All the above tests came back normal. We also had the chromosomal test done and that was fine for both of us too. My TSH was 1.66 which is good I think. The only thing that is "abnormal" is that my endometrial lining is measuring at 5.8 - which is too low and so I will take Estrace starting on Day 8 of the cycle that we want to conceive. What are your feelings on Natural Killer Cells, do you feel that test would be or is appropriate in my situation. Are there any other immune tests such as an Embryo Toxic Factor Blood Test that maybe I should ask for? Is there any harm in taking a low dose baby aspirin for a length of time? Thank you again for taking the time to talk to me, it really does mean so much.
Dana
At Mon Dec 10, 07:18:00 AM 2007,
Anonymous said…
Dear Dr. - I am 6wk 4 days pregnant and just had an ultrasound, have seen the heartbeat - however, they have told me there is hemorraging - does this mean a miscarriage is inevitable? Is it safer to let the miscarriage happen naturally or have a d&c? I have bee through both. thank you
At Tue Dec 11, 10:23:00 AM 2007,
Dana said…
Dear JS:
Thank you so much for your post. I am so hopeful after reading it, how was the progesterone administered just wondering, how long did you take the baby aspirin? Really, you had the same thing I haven't met anyone who has - this means so much!
Dana
At Fri Dec 14, 01:24:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Dana Dec 7/9: Dana, you probably do not need those other studies done at this time (and they are expensive and probably would not change your management). Sometimes aspirin can upset your stomach (or even cause an ulcer) and can increase your risk for bleeding complications as well. But one baby aspirin per day is usually not much of a risk for those things. In your caes, the benefits probably far outweigh the small risks. Good luck and please stay in touch! Dr T
At Fri Dec 14, 01:44:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Dec 10: If you have not had any bleeding to this point in the pregnancy, your ultrasound probably showed a 'subchorionic hemorrhage.' These are not at all unusual in early pregnancy (and probably 'over-called' with regard to their actual significance) and they do NOT necessarily mean you will lose the pregnancy. So best of luck to you and let us know how things turn out. I certainly would NOT recommend having a D&C until you clearly had lost the baby even if you are doing some bleeding. Dr T
At Wed Jan 30, 04:33:00 AM 2008,
Anonymous said…
Hi dr, I really hope you can reply. I am 27, and have a daughter, aged 6 from a previous partner, then I met my current partner and 4 years ago now had 2 miscarriages, a normal miscarriage at 5 weeks , then a missed miscrriage, went for 12 week scan and was told the baby had died at 8 weeks and had a d+c, then had my son, 11 months last march and have just had my 3rd miscrriage 2 weeks ago, this was also a missed miscarriage, baby had again died at 8 weeks, Me and my partner now have to go for tests. I am so confused as to why this has happened? Can you please help me as to why this has happened? I also teste positive for strep b whilst pregnant with ,my 11 month old. I would love to try again but really could not face another miscarriage. Please help, thanks soo much , angela, 27 xx
At Wed Jan 30, 05:59:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Angela Jan 30: Despite the miscarriages, since you have successfully had one child with your current partner, the risks are higher that the babies you lost were chromosomally abnormal. In fact, that pattern of miscarriages related to chromosmal abnormalities in young women like you is frequently seen if one of the two of you has a chromsosomal rearrangement such as a balanced translocation. Of course ther are lots of other possibilities in your case as well, but why don't you have some testing done and then get back to me. I will have a better idea about your prospects for having more children once you get some more information. If you have not looked through the series I wrote on recurrent early pregnancy loss (in March and April of 2007), that can provide you with what to expect in terms of workup and treatment. Good luck to you. Dr T
At Wed Feb 27, 06:52:00 PM 2008,
Anonymous said…
Hello Dr T.,
I really hope you can help me understand my case as well as you have been able with some many other moms. I'm 33 years old and have a healthy 4 years old with whom I enjoyed a beautiful pregnancy free of worries. However, last year my husband and I began planning on the next baby. We began trying and 4 months later I got pregnant. Unfortunately, at 4 weeks it ended up in a loss that cleaned up naturally. We kept trying, and 9 months later I got pregnant again. This time the Doctor did some blood work and found that my thyroid was off the range so he increased my synthroid doses from .88 to 0.112.He also put me on progesterone cream to apply vaginally. I was fine until I reached the 6th week, when they told me at a routine visit that there was no heartbeat anymore and the embryo was smaller than expected. In addition there was a little blood cloth close to the sac.
Now, I'm in the hands of a Fertility specialist, but I'm totally clueless on what to expect and do. Not to mention the sadness and devastation that the miscarriages have brought with them.
Some of the questions for you are: if I had a normal pregnancy before, why is this happening? Am I gonna be able to hold a pregnancy again? what test(s) should I ask my doctor to do other than the routine ones?
Any help is a lot of help during this time of confusion. God bless you for the time and information you provide to each one of us.
Catalina.
At Wed Feb 27, 06:56:00 PM 2008,
cata said…
Hello Dr T.,
I really hope you can help me understand my case as well as you have been able with some many other moms. I'm 33 years old and have a healthy 4 years old with whom I enjoyed a beautiful pregnancy free of worries. However, last year my husband and I began planning on the next baby. We began trying and 4 months later I got pregnant. Unfortunately, at 4 weeks it ended up in a loss that cleaned up naturally. We kept trying, and 9 months later I got pregnant again. This time the Doctor did some blood work and found that my thyroid was off the range so he increased my synthroid doses from .88 to 0.112.He also put me on progesterone cream to apply vaginally. I was fine until I reached the 6th week, when they told me at a routine visit that there was no heartbeat anymore and the embryo was smaller than expected. In addition there was a little blood cloth close to the sac.
Now, I'm in the hands of a Fertility specialist, but I'm totally clueless on what to expect and do. Not to mention the sadness and devastation that the miscarriages have brought with them.
Some of the questions for you are: if I had a normal pregnancy before, why is this happening? Am I gonna be able to hold a pregnancy again? what test(s) should I ask my doctor to do other than the routine ones?
Any help is a lot of help during this time of confusion. God bless you for the time and information you provide to each one of us.
Catalina.
At Fri Feb 29, 04:28:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Catalina Feb 27: The best thing you have going for you isthat you have had a normal baby already. Miscarriages are very common (as many as 15-25% of all pregnancies) and there are so many reasons that you had yours. There may be a common cause or the causes may be completely unrelated, for example, the first might have been the result of your hypothyroidism and the secong could have been a chromosomally abnormal baby. I wrote a whole series on recurrent pregnancy loss in March and April 2007. If you have a chance, look to that series to learn many of the causes and what can be done to help you. Sometimes it is as simple as just getting pregnant again. I know miscarriage is always so hard, but your infertility specialist is trained to help you and will most likely be able to. Let me know what they find out! Thanks for writing. Dr T
At Mon Oct 13, 01:24:00 PM 2008,
Anonymous said…
Dear Doctor
Apologies for the length. Struggling to get answers.
Thankyou for the work you do. I hope you can help us make some sense of what may be going on with us.
I am 28 my husband is 31. We have no children yet.My cycle is normally 38days
Here is my pregnancy history -
1. feb 07 spotting - blighted ovum
erpc performed
14mths ttc later
2. june 08
spotting the same as before from day one, pregnancy confirmed , early scan 5-6 weeks , all perfect , tiny flicker they said was a heart beat bean measured 5mm, doctor pleased - 2 weeks later and no heart beat. Missed miscarriage had an erpc.
3. oct 8th - positive test, really pleased as no spotting.
11th oct sitting quietly reading a book and felt a flow. Looked and lots of blood. Admitted to hospital and examined , neck of womb closed. HCG 13th oct 296 but scan showed nothing - lining 6mm.
I have another HCG test wednesday but the hospital are almost certain that I miscarried. They say I should be approx 5 to 6 weeks I think I am approx 4 to 5 weeks.
They say if its another miscarriage they will perform some tests but say that they normally come back with no answers.
(unrelated to miscarriage)I have been tested for SLE in the past as my mum has it and I have the beginning of osteo arthritis in my knees. They said the tests were negative, however, my mums specialist says this is common as SLE can mimic many other things and can be difficult to diagnose.
Other than this I have a raised testosterone level resulting in facial hair(toldpcos without cysts). My general health is good and my husband has no health issues.
Are there any tests you can recommend that we ask for?
Why are all the miscarriages different, surely if there is an issue it will result in the same kind of miscarriage?
I really hope you can help
Mrs Locke
At Fri Oct 17, 12:13:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Mrs Locke: You have prolonged cycles and elevated testosterone and now recurrent early pregnancy losses. You could have any number of reasons for your infertility, but PCOS is certainly a good bet to be a major contributor. You need to go see a specialist in Reproductive Endocrinology who will not only thoroughly evaluate you but also devise a reasonable approach to therapy that will probably involve the use of metformin and ovulation indiction. Good luck and thanks for writing. Dr T
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