These readers' comments/questions touch on a variety of issues of general interest - severe cervical dysplasia in pregnancy, protein S deficiency in a woman who lost a pregnancy at 24 weeks, and recurrent miscarriages associated with different chromosomal abnormalities. I want to thank all my readers for the wonderful queries that are coming in the door every day. I know there are many readers out there who greatly appreciate and will benefit from the fact that you have generously shared your stories, questions, and concerns.
At Mon Sep 17, 08:00:00 PM 2007, Anonymous said… I have been diagnosed with severe cervical dysplasia, and I have just found out I am pregnant. I'm very scared and would love to hear about what I may be facing in the weeks and months to come.
Kenneth F. Trofatter, Jr., MD, PhD said… To Anonymous Sept 17: Different physicians have different approaches during pregnancy. The first step is to perform a thorough colposcopic examination of the cervix and biopsy those areas that are the most highly suspicious. This is usually a simple office procedure. If an 'adequate' exam can be performed, ie., the upper limits of the transformation zone in the cervical canal can be clearly visualized, and the biopsies show no evidence of 'invasion', it is usually safe enough to follow you through the pregnancy. Personally, I would repeat the colposcopic exams in each trimester, but as I said, different providers may have another approach.
If the upper limits of the transformation zone cannot be adequately assessed and/or the biopsies are suggestive of microinvasion or invasion, your doctor will probably consider performing a cervical 'conization' which is a large wedge-shaped resection of the transformation zone. Further recommendations for care will depend on findings of that surgical specimen. At the time of a conization, I will often perform a cervical cerclage prior to the actual conization, as a means of reducing risk of bleeding during the procedure and, possibly, premature labor later in the pregnancy. If nothing worse than high-grade intraepithelial neoplasia is found during the pregnancy, ie., there is no evidence of invasive disease, you will be more thoroughly evaluated 6-12 weeks following delivery. Even some high-grade lesions will regress spontaneously once you are unpregnant! Good luck and thank you for reading. Let me know how things turn out. Dr T
At Thu Sep 06, 10:16:00 AM 2007, soumya said... I lost my pregnancy at 24th week on July 17th. My GYN said that my protein S was low. She told me that it might be low because of the pregnancy and retested my 5 weeks after delivery - but I still had low protein S. My cousin who is a general practitioner said to wait for 3 months to test again for protien S and we would know for sure if there is a deficiency. If it turns out that I really have a protein S deficiency, what are the treatments and how many months should I wait before I get pregnant again? What kind of doctor should we visit the next time.
Kenneth F. Trofatter, Jr., MD, PhD said... To soumya Sep 6: Sorry for the delay in responding to your query. I am so sorry to hear about your pregnancy loss at 24 weeks. It would be helpful if you could tell me a little more about the events surrounding that loss. For example, did the baby die before the delivery? Was the baby normally grown? Did the baby have any abnormalities? Did you have any bleeding or a fever before you lost the baby? Was your blood pressure elevated or did you have preeclampsia?
Regardless, protein S is important because it helps break down blood clots. It is often reduced during pregnancy and recovers to normal levels by 6-12 weeks after delivery. When your doctor checks it again, ask your doctor to have the laboratory perform a studies that look at the "functional protein S and protein C activities". This is a better way to assess the significance of an apparent protein S deficiency. By the way, did you have any other blood work done (e.g., antiphospholipid antibodies, lupus anticoagulant, factor V Leiden, prothrombin mutation, antithrombin III, MTHFR, factor VIII levels) and do you know the results?
If the protein S turns out to be low, or if you have any other laboratory evidence of a 'thrombophilia' (increased tendency to clot and/or reduced ability to break down clots), and your pregnancy history is consistent with the loss having possibly been the result of this, then my usual routine would be to begin folic acid (2-4 mg)and low-dose aspirin (81 mg) prior to conception and add either heparin or low-molecular weight heparin (e.g., enoxaparin) as soon as a pregnancy is confirmed. Thanks for reading and for a very good question. Best wishes for the future. Dr T
At Mon Sep 17, 02:07:00 PM 2007, Anonymous said... I just had my third miscarriage. The first one, I didn't have tested and the second one was a partial molar pregnancy. After the waiting period was over, I got pregnant for the third time and lost the baby in week 6. The baby was forund to have 47 chromosomes. My doctor thinks it's a fluke and that my husband and I just had bad luck. Do you suggest trying again or do you think I have a chromosome condition?
Kenneth F. Trofatter, Jr., MD, PhD said... To Anonymous Sept 17: From what you describe, I would have to agree with your doctor at this point. You have probably just had a string of bad luck. The first pregnancy could have been lost either because it simply was a first pregnancy and your immune system didn't figure out how to help it hang on or that baby could have had a chromosomal abnormality. The last two pregnancies were clearly chromosomally abnormal, but they were also different abnormalities. If you are anxious enough, consider having chromosomal studies done on you and your husband. - but, I bet now they will be normal.
There may be some individuals who are at increased risk for recurrent aneuploidy for reasons that we don't thoroughly understand. Some genetic counselors will tell you that having a documented aneuploid pregnancy increases your risk to as much as 1% that you will have another. You did not tell me your age, but if you are less than 38, this is higher than your age alone risk. I would recommend to anyone who has had chromosomally abnormal pregnancies that when they conceive again, they seriously should consider having combined first trimester screening for aneuploidy, regardless of their age. Thank you for reading and I certainly wish you better luck in the future. Dr T.