Consider preparing for pregnancy as training for a great race.
This is a race of endurance, not speed; a race in which a
teammate must be carried; and a race that must be finished
without being short of breath. This race both figuratively
and literally requires great cardiovascular conditioning.
Outcome has everything to do with the state of your body (and
mind) at the start of a pregnancy. Many unprepared women have
had pregnancy thrust upon them; fortunately, youth and good
health will overcome most obstacles. The truth remains that
those nine months of development in the womb can affect the
health of a child for a lifetime. So plan. The greatest chance
for a good pregnancy outcome occurs when the body is at maximum
harmony—metabolic balance. See preconception
counseling fact sheet.
Implantation of the embryo occurs about
five days after ovulation. Very shortly after implantation,
small amounts of human chorionic gonadotropin (hCG)
must be produced to prevent the failure of the corpus luteum,
the power-house of progesterone production. Even before a
missed period, the early hormonal changes are often translated
into fatigue, breast tenderness, and frequent urination. These
feelings may be especially prominent if fertility drugs have
been used and cysts remain on the ovary. Many report flu-like
symptoms, which in part may be due to the immunologic reaction
to implantation. Most, but certainly not all, women have a
“second sense” that they are pregnant.
All pregnancy tests, whether the one
bought in the local pharmacy or the blood test in a physician’s
office, detect hCG. HCG is made by the primitive placenta
(trophoblast) as it embeds into the uterine wall.
Except under very unusual conditions, hCG is present only
during pregnancy. The qualitative tests give a yes or no answer
by a color change. Using sensitive assays, it is possible
to give a numerical result (quantitative hCG). A positive
test indicates a pregnancy has occurred even if subsequent
tests are negative. Any positive test is an important finding,
in that it signifies that a number of important steps have
had to take place. If a period date has passed, do the test
before calling a physician because “Did you do a pregnancy
test?” is often the first question asked.
Yes. If the test turns positive you are pregnant. False positive
tests are very unlikely. If a test is negative, it means that
it may be too early for the measurement. Home pregnancy tests
(HPT) are based on hCG in urine causing a chemical reaction
resulting in a color change of a specifically designed dye
indicator. There needs to be 25-50 IU of hCG in the urine
for the test to change colors (become positive). Home pregnancy
tests turn positive about the time of the first missed menstrual
period, or twelve to fourteen days after ovulation. Delayed
ovulation may occur in patients with irregular or prolonged
cycles and will delay a positive pregnancy test. Tests are
rarely negative at any time two weeks after ovulation. A false
negative test rarely occurs outside of timing errors.
Two weeks after ovulation, the hCG level should be 15-200
IU/L. After this, the level approximately doubles every forty-eight
hours over the next two weeks. A multiple pregnancy has a
faster rise in hCG level. In cycles where supplemental hCG
was used for ovulation induction, as long as eight days from
the hCG injection may be required before it has cleared the
system and the pregnancy test is valid. Slower hCG rises may
be a sign of an ectopic pregnancy or impending pregnancy loss.
A falling level is an ominous sign for the health of the pregnancy.
Progesterone levels may be evaluated at the same time as hCG
and can help in the differentiation between healthy and problematic
pregnancies. Ectopic (tubal) pregnancies may be associated
with low progesterone levels, but the progesterone level alone
will not distinguish between an ectopic and intrauterine pregnancy.
Because progesterone is secreted episodically, levels may
vary between samples and minor ups and downs of several points
are of little importance. Unlike hCG, which should steadily
rise, progesterone levels remain relatively constant in early
pregnancy. Progesterone levels can be considered as reassuring
(usually above 20 pg/ml,) probably indicating a compromise
in the pregnancy (less than 10 pg/ml). Levels between 10-20
pg/ml are often associated with normal pregnancy. Lower progesterone
levels more often indicate a problem with the pregnancy than
a problem with progesterone production by the ovary.
Most pregnancy losses are due to genetic abnormalities present
from the point of conception. Progesterone may prolong such
a pregnancy, but it will not prevent the destined loss. There
is no evidence that progesterone supplementation has a detrimental
effect on the embryo/fetus other than a postponement of the
inevitable miscarriage.
At the same time, there may be some theoretical value in progesterone
supplementation in that it may relax the uterus’ smooth
muscle and prevent contractions. Theoretically, progesterone
may also help the body accept the pregnancy by suppressing
the immune response. In many ways a pregnancy is like an organ
graft from a different person.
Traditionally, progesterone has been
used in an attempt to overcome inadequate progesterone production
from the ovary (the so-called luteal phase defect).
Actually, the problem usually arises in the follicular phase
and therapy should be aimed at correcting the problems with
follicle growth and ovulation rather than covering up the
trail. Progesterone supplementation in the luteal phase may
be more important for cycle regulation than luteal support.
It may better prepare the next cycle and most often will not
delay menses.
A reasonable plan is to measure hCG
and progesterone as soon as a home test turns positive. Progesterone
supplementation may be started with borderline or low progesterone
levels. Supplementation is continued until levels normalize
and the viability of the pregnancy can be ascertained by ultrasound.
After nine weeks, the placenta is capable
of making all necessary progesterone and the ovaries could
be removed without detrimental effect on the pregnancy. Conclusive
benefit for use of progesterone is lacking in any clinical
situation other than with IVF and GnRH analog use.
Overall, the usefulness of supplemental progesterone is thought
to be limited and has not passed scientific scrutiny One relatively
well conducted study a has shown supplemental 17-hydroxyprogesterone
given by weekly injection, improves pregnancy outcome, but
these findings have not been confirmed.
Pregnancies are dated by weeks since the last menstrual period
(LMP). The typical pregnancy lasts 280 days or 40 weeks from
the last menstrual period. A due date can be calculated by
the formula of adding twelve months minus three months plus
one week to the LMP to predict the estimated delivery (due)
date (EDD). A term pregnancy is one that has gone on for between
37 and 42 weeks before the baby is delivered. If over 42 weeks,
the pregnancy is said to be post-dates and under 37 weeks,
preterm.
Historically, conception was thought to occur during menstruation
and pregnancy was dated from the onset of the last period.
The tradition remains, but it is subject to several flaws.
First it is common for patients with longer cycles to have
ovulated later in the cycle. The number of days that ovulation
occurred past day 14 must be added onto the due date. The
second problem occurs because there may be a slight amount
of bleeding during either ovulation or the implantation process
so the pregnancy may be off by two to four weeks.
Pregnancy is divided into three trimesters
of three months each. The first trimester is one of rapid
change and adaptation to pregnancy. Virtually every single
body part has some degree of change. The second trimester
is a time when all generally seems 'right with the world'
and complications are uncommon. In the last trimester, pregnancies
become very tiring as the delivery day approaches and I have
never heard anyone say, “if this could only go on for
a little longer.”
Risk is a relative term. Given what can go wrong, every pregnancy
ever achieved has risks, some may even say high risks, whether
associated with infertility, infertility therapy, or not.
Do you need to see a specialist in perinatal medicine? Probably
not.
Certainly it appears that the risk of miscarriage is increased
in mothers with PCOS as are the risks of gestational diabetes,
pregnancy-induced hypertension (PIH, toxemia, preeclampsia),
unusually small (growth restricted), large (macrosomia) babies,
and c-section rates. All of these are more common in first
pregnancies and after many pregnancies. Some risks may be
independently related to increased pre-pregnancy weight, others
to insulin resistance regardless of weight. Pregnancy risks
for women over age 35 are also at slightly higher, but not
"high" risk.
What is most important is that an obstetric practice is found
that provides education, answers to your questions, follows
a systematic process allowing early identification of potential
problems, and cares for you and your partner as individuals.
Believe it or not, there are a lot of practices out there
that meet these requirements.
YES. Early ultrasound scan can be used to precisely date a
pregnancy and serve as a bench mark to better understand the
cause of pregnancy loss, if it were to occur. The best reason
for an early scan is to give a great sense of relief that
all is well. If there is a problem, why not find out as quickly
as possible? Not all physicians and insurance companies share
this view.
Ultrasound scan will show a pregnancy in the uterus when the
hCG level reaches about 1500 IU, or about five weeks after
the last menses. An hCG level over 2500 IU without evidence
of an intrauterine pregnancy should raise the suspicion of
an ectopic pregnancy. Fetal heart activity is usually seen
at about six weeks after last menses (four weeks after conception).
At eight weeks the embryo measures about 1 cm and movement
can sometimes be seen. If all parameters are normal to this
point, the risk of miscarriage has markedly dropped and there
is an excellent chance the pregnancy will progress to term.
At ten weeks gestational age (eight weeks after conception,)
the embryo measures about 23 mm (one inch,) all the foundation
has been laid for the various organ systems and the embryo
becomes a fetus. At twelve to fourteen weeks a detailed analysis
of the body systems can be performed by ultrasound and most
anatomic abnormalities excluded.
An early scan to determine viability and dating and a second
for an anatomic survey would seem to be reasonable.
Pregnancy is not a disease; it is a normal physiologic process
(condition). Even though pregnant women can be a little difficult
to get along with at times, they are sturdy creatures. There
is no evidence that work, exercise, stress, or travel have
adverse effects on pregnancy. Stress is always a danger—in
pregnancy, in medicine, and in life. This is one you will
have to handle yourself.
If you have a question about any activity,
ask yourself two questions. First, does this seem like the
wrong thing to do and second, if something were to happen
would I blame myself? If the answer to either is yes, don't
do it. Do not be faced with the comment “I knew I shouldn't
have, but….” It is amazing how many questions
can be answered by this exercise; it’s really common
sense after all. If in doubt—ask.
Follow these guidelines:
Stop short
- don't push. This may mean getting off work early,
working less, or giving up a commitment. No one is as dependent
on you as your baby. Give yourself a margin of safety.
Listen
to your body. It will tell you what's going on in there.
If you are tired, rest. If you are hungry, eat. If you are
sleepy, sleep. If you think there's a problem, have it evaluated.
In general, obstetricians have become
much more lenient about what is considered “normal”
weight gain in pregnancy and have focused more on good nutrition.
If the expectant mother “eats right”, weight gain
is thought to be less important. The average weight gain in
pregnancy is about 12.5 kg (28 lbs.,) but this still leaves
a margin of at least five pounds or so. If over thirty pounds
are gained, it becomes much more difficult to return to pre-pregnancy
weight. Weight gain in the first trimester is variable and
there can be considerable increase due to fluids retention,
if fertility drugs which have been used. In the second and
third trimesters, about one pound per week is appropriate.
Dieting in pregnancy specifically to lose weight is definitely
out. Still, it is common for obese patients not to gain, or
possibly to lose weight, in the early stages of pregnancy.
The very obese may gain little weight throughout the entire
pregnancy.
Average caloric intake for women of
normal weight and height should be 2100-2500 cal with somewhat
less in the first trimester. Diets under 1800 cal are not
recommended. The pregnancy itself will require about 300 additional
calories a day over your standard dietary needs. Even more
calories will be needed while breast-feeding. The entire calorie
cost of the pregnancy is about 80,000. It has been suggested
that intake of simple type carbohydrates (sweets) increases
maternal weight gain and fetal growth more than with complex
carbohydrates (starches). The U.S. governmental guidelines
suggest 20% of the diet should come from protein, 40% from
carbohydrate, and 40% from lipids.
Pregnant PCOS patients are a higher risk for development of
gestational diabetes. As a suggestion, those with PCOS or
a strong family history of type 2 (adult onset) diabetes should
consider themselves to have gestational diabetes (GDM) right
from the start. Women with PCOS should ask their obstetricians
for diet information and nutritional counseling. It really
doesn't matter how many do not develop gestational diabetes,
only how many do. Why wait until thirty weeks and to consider
what might have been done? Besides, the pregnant diabetic
diet is complete and offers good nutrition.
There is evidence that exercise during pregnancy can reduce
the incidence of GDM. Pregnancy is not the time to start aerobic
training, but gentle, steady exercise will prepare you for
the rigors of parenthood. There are specific exercise programs
for pregnancy. Yoga gets high marks. Research has shown that
women who are very physically can keep up their activity without
significant harm to their babies, although birthweight may
be lowered.
Develop a mental image of a small engine inside you that is
always running. It runs best when there is a constant and
even supply of fuel. Too much and the engine gets flooded,
too little and the tank starts to run a little dry. For the
mother, this means rather than three big meals a day, think
six small meals. Think grazing, not gorging. You will still
consume the same amount of calories; they will just be spread
out. You will feel better and so will baby.
There will be bleeding, or at least spotting, in about one
in three pregnancies. About 50% of these pregnancies eventually
will be lost. While there is no such thing as “normal
bleeding,” bleeding does not necessarily indicate a
serious problem. With pregnancy, the cervix softens and the
surface may easily bleed with even minimal trauma, such as
an exam or intercourse. During implantation, which occurs
at about the first missed menstrual period, a small amount
of bleeding or spotting may be seen. Bleeding may also occur
during the process of placenta formation (placentation) when
the intimate relationship between the fetal and maternal blood
circulation is established. A general rule is the greater
amount of bleeding and the more cramping, the greater the
chance of pregnancy loss. I have been amazed at the how much
bleeding can occur and the pregnancy still continues normally.
So first of all, DON’T PANIC. CALL YOUR PHYSICIAN. REST.
Although there is a great tendency to want immediate reassurance,
it may be more diagnostic to wait eighteen to thirty-six hours
at home. Too quick an assessment can be falsely reassuring.
Of course, if the pain is severe or the bleeding heavy, a
more emergent evaluation may be warranted.
A miscarriage is loss of pregnancy
before twenty weeks gestation. In the medical community this
is more widely called a spontaneous abortion. After twenty
weeks a pregnancy loss is called a stillbirth. There
have been pleas to use the more widely understood term miscarriage
to designate the undesired, or spontaneous loss of pregnancy,
but the term abortion is still used by most physicians
to describe all losses regardless of cause.
The time surrounding a miscarriage is a time of intense feeling
of failure and despair. An emotional scar will almost always
remain regardless of future pregnancy success.
A couple in their mid-twenties having intercourse regularly
will usually take about three months to become pregnant. It
is possible that most women who are regularly ovulatory and
not using contraception achieve a pregnancy in most months,
but the pregnancy is lost soon after conception and goes unnoticed.
One in four couples will have a recognized miscarriage. The
chance of a miscarriage after a positive pregnancy test is
8-15% for all pregnancies in all age groups. This rate increases
to about 15-25% in women over age thirty-five and those who
have irregular menstrual cycles. Overall, about 80% of couples
with two miscarriages, and 50-60% of couples after four losses
still will have a successful pregnancy. As the pregnancy progresses,
the risk of miscarriage decreases. Over 90% of miscarriages
occur during the first twelve weeks.
The circumstances around the miscarriage are extremely important
in determining the cause of the pregnancy loss. A detailed
history, clinical and ultrasound findings should be carefully
recorded. Perhaps most important is the number of weeks gestational
age at which the loss occurs. This may be difficult to determine
in some cases because accurate dating has not been made. The
number of weeks between loss of viability of the pregnancy
and its clinical diagnoses is unknown and the length of the
pregnancy often is over estimated. Early first trimester losses
are most often due to genetic and hormonal causes. Later first
trimester losses, after eight weeks, may be a result of uterine
anomalies. Second trimester losses are often due to disorders
of the placental-maternal unit and sometimes due to chronic
diseases. While genetic problems are less common, they are
still possible. Losses during the third trimester are often
maternal in origin and may be related to various diseases
of pregnancy including diabetes and hypertension.
When a pregnancy is lost often determines the cause of the
loss. The following are general guidelines.
- First trimester: EMBRYO—hormonal and/or genetic
in origin
- Second trimester: UTERUS—less often genetic
and more often anatomic
- Third trimester: MATERNAL—immunologic, medical
complications
Various terms are used to describe the circumstances surrounding
the pregnancy loss, each term taking into account when the
loss occurred, clinical findings, ultrasound findings, cause,
and whether the loss is recurrent. This has resulted in confusing
and overlapping terminology. Listed below are several clinical
distinctions used to characterize pregnancy loss.
- Blighted ovum
- Missed abortion
- Threatened abortion
- Incomplete abortion
- Complete (spontaneous) abortion
The first evidence of a pregnancy on
ultrasound is the gestational sac containing a smaller
yolk sac as definitive evidence of an intrauterine
gestation (pregnancy). Occasionally an irregular structure
appearing to be a gestational sac, a “pseudo sac,”
can be seen with an ectopic pregnancy.
A pregnancy that has implanted, but
has failed to grow to the stage where an embryo can be identified
on ultrasound scan is called a blighted ovum. Evidence
of a pregnancy is seen by ultrasound by the presence of a
yolk sac, but because it lacks evidence of an embryo, it is
often called an “empty sac.” These pregnancies
are uniformly believed to have a genetic or endocrine reason
for their poor outcome. Although gestational sacs vary somewhat
in size, smaller sacs are worrisome. A larger or smaller yolk
sac can be an early indication of an endangered pregnancy.
In the early stages of pregnancies that will subsequently
be lost, progesterone levels may be normal or decreased. HCG
titers may increase normally or more slowly. The cause of
a blighted ovum is virtually always a problem with the conceptus
itself, rather than the uterus or maternal factors. While
male factors may contribute, the blighted ovum is more commonly
of oocyte origin—the reason for the designation of a
blighted ovum. Most are a result of genetic abnormalities
in eggs that are satisfactory to be fertilized and go through
the early stages of development, but not sufficiently normal
for further development. Usually, there is insufficient tissue
for genetic testing on these pregnancy losses.
Sometimes, an early pregnancy will spontaneously “resorb”
and no intervention is necessary. In other cases, there may
be persistence of the pregnancy requiring either a D&C
to remove the pregnancy. Since the pregnancy is small, care
has to be taken with the dilation and curettage procedure
to avoid missing the pregnancy. In some cases, it is wise
to do the procedure under direct ultrasound guidance. The
D&C is performed in an outpatient a same day surgery facility.
A missed abortion is diagnosed
when viability of the pregnancy has been lost, but there has
been no expulsion of the pregnancy. The blighted ovum is an
early type of missed abortion in which fetal heart activity
was not identified. Fetal heart activity may have also been
seen, but then lost. In some cases, a short time in wait for
spontaneous loss may be given before intervention. This may
be especially important as a time to accept that the pregnancy
will not continue.
Like the blighted ovum, most cases of missed abortion in the
first trimester are due to problems in the conceptus. In some
cases, there is a much greater chance that this has been a
sporadic and non-reoccurring problem related to egg quality
rather than an inherited genetic problem. The blighted ovum
and missed abortion are the most common types of pregnancy
loss in PCOS and a hormonal etiology should be suspected in
all cases.
In cases of a threatened abortion
there is bleeding but the cervix is closed. When the cervical
canal opens, miscarriage is usually inevitable. If
only a portion of the pregnancy has been lost, the miscarriage
is said to be incomplete and intervention is warranted
in all cases. Often there will be a complete and
total expulsion of the pregnancy. If the ultrasound scan shows
that there are no retained products of conception, bleeding
is slowing and the cervical opening is closed, no operative
intervention is needed.
After three, some authorities say two,
consecutive pregnancy losses, diagnosis of recurrent
or habitual pregnancy loss is made. Every pregnancy
loss is associated with despair, but there are few that grieve
more deeply and fear more intensely than those who have had
repeated pregnancy losses. It is a common feeling that an
additional loss could not be withstood.
About 1% of couples trying to conceive will have three or
more losses. The best news is that even after three successive
losses, the chance of a successful pregnancy is generally
greater than 70% and after four losses, still 60%. Usually
after successive losses, a medical evaluation should be initiated.
In the early stages, this may consist of nothing more than
tracking temperatures, using ovulation detection kits, and
possibly using luteal progesterone levels.
When evaluating pregnancy, most physicians go through the
process of a mental listing then an exclusion of the possibilities
based on individual characteristics. In the final analysis,
if it isn't one cause, it must be another.
- Endocrine/genetic
- Anatomic
- Inherited
- Infectious
- Chronic disease
- Immunologic
- Unexplained
Previously, it was thought that over 50% of recurrent pregnancy
losses were unexplained. We now know that many of these cases
are due to subtle hormonal abnormalities. Unless another reason
can clearly be identified, such as a strong family history
of pregnancy loss or clearly evident uterine abnormality,
it may be reasonable to treat with clomiphene or possibly
progesterone before extensive testing is performed. After
three losses, a karyotype can be considered, if no other cause
is evident. Even if the genetic studies are abnormal, that
does not mean a normal pregnancy is impossible.
Pregnancy losses that occur after a
normal pregnancy has been established and all appears to be
progressing well followed by cramping and loss of the pregnancy
are more likely due to congenital anatomic abnormalities in
the uterus. These can be identified by either hysterosalpingogram
(HSG) or hysteroscopy. There are approximately 15%
false positive and negative rates with the HSG and it may
fail to identify the more subtle anomalies such as a uterine
septum. It is unclear whether congenital anomalies of the
uterus cause infertility, but it is clear that it is associated
with a greater risk of recurrent pregnancy loss and preterm
labor. Milder forms are easily corrected by hysteroscopic
surgery. It is important to note that there is a high incidence
of associated abnormalities of the urinary tract and an intravenous
pyelogram is indicated when a uterine anomaly is identified.
The more severe uterine anomalies may be easily seen on ultrasound
scan. MRI has been suggested for a definitive diagnosis; however,
this is very costly and the information can be gained by other
sources.
The chance of an inherited genetic condition that is passed
from either the mother or father as the cause of recurrent
pregnancy loss is about 3-5% of cases. These can be identified
by karyotype performed on a blood sample. These can be very
valuable, but are also extremely costly. Karyotype should
probably not be performed in individuals with fewer than three
pregnancy losses. Even if a genetic defect has been identified,
it may not prevent a normal pregnancy but it may indicate
that the chance of a recurrent pregnancy loss is greater.
Both mycoplasma and ureaplasma have been identified with a
greater risk of pregnancy loss. While there are tests to detect
their presence, testing can be inconclusive and it is often
easier to treat with a two-week course of antibiotics than
identify the specific organism. The chances of recurrent pregnancy
loss due to infection are probably very slim, but the treatment
is easy and sometimes rewarding.
Patients with virtually any type of chronic disease may be
at increased risk for recurrent pregnancy loss. Chronic diseases
such as high blood pressure and diabetes create much higher
risk for recurrent loss. An under-appreciated chronic disease
may be obesity. Chronic disease probably primarily affects
establishment of the maternal fetal circulation. The best
treatment in these cases is preconception counseling and making
sure that the disease is under the best control possible before
a pregnancy is attempted.
Clearly, many of the immunologic diseases have multiple organ
system involvement and have a higher rate of pregnancy loss.
An uncommon but particularly dangerous type of recurrent pregnancy
loss is the anti-phospholipid antibody syndrome characterized
by hypertension, poor fetal, and placental development. There
are a number of small infarctions that occur in the placenta
due to a disorder in the blood clotting mechanisms. Pregnancies
are most often lost in the mid-second to early third trimester.
A variety of therapies including aspirin, heparin, corticosteroids,
and immunoglobulin injections have been tried. Aspirin and
heparin have been shown to have benefit in some trials with
marginal success.
Our greatest problem is that there is no extensive testing
without clinical associations and no proven efficacious therapy
exists. There still could be very important developments in
this field.
Philosophically, even practically, the diagnosis of unexplained
pregnancy loss is hard to accept for patient and physician.
Probably most cases are either undiagnosed or misdiagnosed
problems in one of the above categories. Most cases of recurrent
loss are probably related to egg quality and therefore the
environment in which the egg develops.
Probably, this is a real tough question. Miscarriage is probably
more likely when ovulation occurs after a day 16. Miscarriage
may also be more likely with the use of fertility agents.
It is probably not he fertility drug itself that causes the
miscarriage, but that there has been further movement along
the spectrum form infertility to a healthy baby. Although
scientific information is limited, the miscarriage rate may
be higher in infertility patients who has spontaneously achieved
a pregnancy than the same patient who has used fertility medications
Probably not. Generally, all patients with impending loss
are placed on bed rest. Unfortunately, there is no scientific
proof that indicates this is of benefit. It doesn’t
hurt and it may help to ease anxiety and avoid guilt associated
with activity. Sexual intercourse should be avoided. Sex can
cause uterine contractions. Generally, once a pregnancy is
established, very little can be done to alter its course.
This becomes less true in the second and third trimester.
Stress may have an adverse effect on pregnancy. Don’t
be your own worst enemy. Remember, that nothing you did caused
the pregnancy loss. Reassurance by ultrasound can be helpful.
It is always great to see the fetal heart beating.
Good, probably excellent. In cases where no cause is discovered
and no treatment prescribed, the chance of achieving a healthy
pregnancy despite having had three miscarriages is still better
than 60%. Generally, the risk of a second loss is only slightly
higher after a single loss. Of course, the first loss rate
is probably higher than the non-PCOS population. The American
College of Obstetrics and Gynecologists (ACOG) now recommends
testing after a second loss-especially for women over the
age of thirty-five. A recent study has shown that a high percentage
of patients that conceive and miscarry during fertility therapy
will subsequently have a health baby.
The answer to this is dependent on the size and dates and
the circumstances around the loss. There are several studies
that suggest that if there is not a waiting period of six
months, there is a greater chance of a subsequent low birth
weight pregnancy. These studies were mostly performed in indigent
patients with borderline nutrition. There is also the concept
of a grieving period and a chance to get over the loss. I
believe this is a worn approach on two counts. It’s
not the concept of “jump back on the horse after being
thrown off.” It’s a matter of reaching a peace
and moving on. There must be all the processes of grieving
that accompany the death of a family member. A scar is left
that will heal but will never go away no matter what success
there is in the future. A pregnancy can be attempted as soon
as you can accept the possibility of another loss. It is common
to hear “I can’t go through that again.”
The only answer is, “then don’t try.” There
is never a guarantee of pregnancy success and virtually never
a guarantee of its failure.
Medically, it is probably prudent to wait through at least
one normal menstrual cycle after an early first trimester
loss, possibly two cycles, if the pregnancy was in the later
stages of the first trimester. Second trimester losses may
require three months. HCG blood titer should be followed to
zero.
It is surprising how many couples will quickly and even spontaneously
establish a pregnancy after a recent loss. A pregnancy loss
can have a positive effect on PCOS making the next pregnancy
both easier to achieve and more likely to be successful.
After losing a pregnancy, or with an impending loss, couples
have tremendous amounts of anxiety and despair. In actuality,
the chances of having been pregnant and delivering a healthy
child is probably much greater than their counterparts seeking
fertility therapy.
Physicians view miscarriage as common, natural and a situation
that offers little opportunity to treat (prevent). As obstetricians,
we know that miscarriage is going to occur in a certain percentage
of our patients regardless. Unfortunately, physicians can
be very matter-of-fact about pregnancy loss. This doesn’t
excuse our behavior, just explains it (partly).
You can't, you won't. There will always be the next horizon,
whether it will be the first positive pregnancy test, the
first evidence of fetal heart activity on ultrasound, a healthy
baby at birth, the first step, the first day from home, or
their 21st birthday. You will always worry. Stick to worrying
about the things you can change.
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