Fruit of the Womb
Fruit of the Womb

Repetitive Miscarriages: Engender Fear and Require Patience

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I received the comment below from one of our readers and my response, though abbreviated, is relevant to many of our readers who have suffered unexplained pregnancy losses. She has lost two early pregnancies and, understandably, is "scared" about losing a third. Although the immediate response is to want do everything possible to avoid another loss, there is still a sequence of evaluation and 'therapy' that is both practical and reasonable. As I have said before, and conclude in my comments to her, the odds are in her favor that she will be successful, based on the information she has provided to us at this point, regardless of any specific or empiric intervention...

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
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About the Author

Dr. Trofatter is an expert on maternal-fetal medicine.

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