Fruit of the Womb
Fruit of the Womb

Recurrent Early Pregnancy Loss: To Treat or Not to Treat...

The readers who sent in the comments below related to recurrent early pregnancy loss (RPL) have what we could consider to be 'borderline' indications for 'treatment' and several questions related to their therapy. But, the fact remains, they have both repeatedly lost babies early. Many of you with with RPL have or will find yourself in similar situations and will be likely to have similar concerns. In my responses, I express my approach to their management given the circumstances detailed in their comments. Let me remind you up front, there is no 'right' (or proven and agreed upon) and no 'wrong' way to manage their care. Under these circumstances, you could put two Maternal-Fetal Medicine or REI physicians in the same room and come up with 10 different approaches!

• At Thu Nov 29, 06:12:00 AM 2007, Anonymous said…

I have written in the past about 2 miscarriages I had this year...and now I'm having my 3rd. I have a single mutation C677T MTFHR. My LMP (last menstrual period) was 10/12 and I was tested positive for hCG around 11/7 and my doctor prescribed 40mg of Lovenox. I was also taking Advanced natalcare prenatal vitamin. On 11/21 my doctor did an US and did not see anything in sac. The doctor said to not be concerned yet since I could have my dates wrong, but I know I conceived on 10/25 using fertility monitor. On 11/21 I was started on 200mg of prometrium. 11/28 they did another ultrasound and still no embryo, just empty sac. Do you have any advice you can give me for a future successful pregnancy? Who should I see next as a specialist? Are there anymore tests I need to get done? My doctor did bloodwork and found no issues except the MTFHR mutation which he said may not even be a cause.

I have had D&Cs in March and July of this year following the loss of my other two pregnancies. My doctor wants to see me again to confirm this loss on 12/6. Should I have another D&C? I find it mentally helps me get over it faster than waiting for it to happen naturally, but have concerns what a third D&C will affect the uterus and future pregnancies...Please help...I'm so desperate to find hope and a cause.

• At Sun Dec 02, 08:25:00 AM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous Nov 29: I am so sorry again for your losses. I am also sorry that I have no way to easily find your earlier correspondence to me or my responses. That's one disadvantage of the way this blog is set up.

I will be honest with you, it is highly unlikely the single MTHFR C677T polymorphism alone is causing your miscarriages this early, although I don't disagree with the attempt at 'empiric therapy' either. I generally will start the prometrium in mid-luteal phase after ovulation (even before conception is confirmed)rather than at '4 weeks' into the pregnancy and then continue it until 8-12 weeks after confirming a viable embryo. Refresh my memory if you can on what other tests have been done and then I will be in a better position to tell you what could be done. Are you seeing any sort of specialist at this point?

As far as the D&C goes, I have mixed emotions. It is a natural response to just want to get this over and move on, but I sometimes wonder if there might not be some advantage to future pregnancies from an 'immunologic response' standpoint until waiting until your body begins to reject the current pregnancy and you start bleeding. You are at very low risk for complications at this point and might consider that.

Repeated D&Cs can cause damage to the cervix at its internal opening and that could increase your risk for cervical incompetence when you finally do successfully get through first trimester. D&Cs can also cause damage to the lining of the uterus (the endometrium) resulting in scarring and adhesion formation that can also impair fertility. In its most severe form (Asherman’s syndrome), this scarring can cause your endometrium to stop cycling so that you don’t even have periods even if you are ovulating normally. However, the endometrium is also very resilient and it is unusual for this to happen in the absence of infection. To reduce the risk of infection with early miscarriages, I usually suggest having either a medical evacuation of the uterus (using misoprostol) or a D&C if you haven’t completed the miscarriage spontaneously within 48-72 hours after starting to bleed and cramp.

Thanks again for reading and feel free to get back to me with your answers to my questions.
Dr T

At Thu Nov 29, 03:41:00 PM 2007, Sarah said…

I've had three early miscarriages and I tested positive for two copies of MTHFR A1298C. I have also tested borderline positive for anticardiolipin anitibodies. I have seen a hematologist who thought that my miscarriages would not have been caused by that. However a fertility doctor does think so. I am taking folic acid, vitamin B6, vitamin B12, low-dose heparin from cycle day 5, low-dose aspirin, and 10 mg prednisone. I am feeling very anxious because of the disagreement between the two doctors and I just wondered if the things I have tested positive for could have caused the miscarriagess at 5-6 weeks. Or am I taking all of this medication for no reason?

Thanks Sarah

At Sun Dec 02, 08:45:00 AM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Sarah Nov 29: The honest answer is WE DON'T KNOW! That's the usual cause of disagreement between 'experts.' We don't know if your losses are the result of the individual factors for which you have screened 'positive', the combination of the individual factors, or something else entirely different (or combined with those other factors!) for which you have not yet been tested! The important fact is that you have lost 3 pregnancies very early and the 'empiric therapy' upon which you have been placed is relatively low risk to a developing baby.

But, I would suggest, in the absence of any other history or 'risk factors', if you successfully get through the first trimester on the current treatment regimen that your doctor consider getting you off the prednisone and the heparin by 20 weeks. Any beneficial effect on the development of the baby’s placenta should have been accomplished by that time and prednisone increases your risk for other complications in pregnancy such as gestational diabetes, premature rupture of membranes, and early delivery as a consequence of the latter. If your baby is showing normal growth at 26-28 weeks by ultrasound and is having no trouble pushing blood through the placenta as determined by Doppler flow studies, you are probably well on your way to a successful outcome. By the way, are you seeing the REI doctor for any reasons other than your miscarriages? Best of luck to you, thanks for reading, and let us know how things turn out!

Dr T
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