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Fruit of the Womb
Fruit of the Womb

Recurrent Pregnancy Losses: There are ALWAYS Causes, but They May Not be Related

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The following comment was recently received and obsterical history the patient shares is a reminder that even though we would like to have a single 'problem' to treat, sometimes poor outcomes may be the result of a string of isolated events...

• 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
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