Also see Fact
sheet - Early
Pregnancy and Pregnancy Loss
Early loss of a twin pregnancy
Endometrial biopsy for luteal phase defect
Multiple pregnancy losses
2 Losses, endometrioma, Lupron
2 Losses, trisomy 18, luteal phase defect
Small for dates
Vanishing twin
Polyps
Hypertension, hypothyroidism, dermoid cyst, pregnancy loss
Pregnancy loss, congenital uterine anomaly
Pregnancy loss & fibroid
Pregnancy loss at 15 weeks
19 weeks pregnant after 3 losses before 12 weeks
Age 38, miscarriage of twins after clomiphene / IUI
Two miscarriage (12 and 15 weeks) & two children
Pregnancy loss & hysterosalpingogram (HSG)
Pregnant & low progesterone
Pregnant at 12 weeks with no fetal heart beat.
Irregular periods & miscarriage
Questions after an abnormal ultrasound at 24 weeks
Question I recently miscarried
at 7 weeks, 2 days. (At 6 weeks they reported I had twins,
but at 7 weeks, there was only one fetus with the sac measuring
small at 6 weeks, 1 day -- but with a strong heartbeat). The
ultrasound in the emergency room showed that the baby's heart
was still beating while the fetal sac had completely collapsed.
I was told it was just a matter of time before the heart would
stop and the miscarriage would complete itself. I've since
learned that this is highly unusual. Although this was my
first miscarriage, I've had all the blood work for recurrent
miscarriage and everything has returned normal. I'm very healthy,
normal weight, 38-years-old, single, and got pregnant on my
fourth IUI with Clomid and gonadotropins. I want to try again,
but I'm very concerned since it seems as if it was not a random
chromosomal error but something about me. But so far, there
seems to be nothing obvious to treat. I should tell you that
my family has a rather extreme history of early onset heart
disease. It's been suggested that this might have something
to do with the miscarriage -- that my blood vessels are starting
to weaken(considering my age) and could not handle the blood
flow necessary to maintain the placenta. I would greatly appreciate
any insight/advice you can offer.
Comment: Pregnancy loss is a severe
emotional and psychological wound. The wound will heal in
time, but the scar never totally disappears. Each person experiencing
pregnancy loss first blames herself; "it must be my fault."
It almost never is. In your particular case, the offender
is probably your birth certificate. Not good news, but statistically
a fact. Even as young as 30 the risk of pregnancy loss starts
to rise. Pregnancy loss is very common after age 40. It probably
was a "random chromosomal error". Your chance for
another random error is significantly increased. I would disagree
that the collapse of the sac was unusual. I see this relatively
often immediately before the pregnancy is loss and I question
its diagnostic significance. Cardiovascular disease may affect
uterine vessels the same as the other blood vessels of the
body. If you had (and have) normal blood pressure, I would
think the possibility of a vascular origin of the loss much
less likely, but it cannot be excluded. Some have used cardiolipin
antibody as a marker of cardiovascular disease. For your long-term
health, a "baby" aspirin a day (less than 325 mg)
may be of health benefit. However in general, studies have
not shown that aspirin helps in early pregnancy loss. Its
use should be discussed with your obstetrician. The decision
to try again is certainly personal, but supportive information
including how well you responded to the stimulation protocol
and what the day 3 FSH/estradiol blood level (a marker of
egg stores) was/is should be considered. sst
Question: My doctor wants me to
have a biopsy of the uterus lining. He thinks I might have
a luteal phase defect as a cause of my recent pregnancy loss.
Do I need this?
Comment: During an endometrial biopsy,
a small sample of the uterine lining is taken as close to
a period as possible (days 24-26 of a 28 day cycle). A pathologist
then "dates" the endometrium according to established
standards for that day of the menstrual cycle. If the histologic
dating of the sample lags the menstrual dating by 2 or more
days, there is said to be a luteal phase defect (LPD). Some
question whether there is such an entity as LPD. I really
do not want to against the advice of your doctor but, personally
I have strong negative thoughts abut endometrial biopsy in
evaluation of pregnancy loss and infertility. Endometrial
biopsies are imprecise, expensive, and painful when performed.
Most importantly, endometrial biopsy probably does not alter
therapy. Treatment of a luteal phase defect by progesterone
or clomiphene can is standard. Why not just treat with out
the biopsy when there is any chance of the so-called LPD.
Biopsy can be valuable in some cases of abnormal bleeding
when there is difficulty in evaluating the endometrium by
ultrasound, or if cancer must be excluded.
Question: I have been having miscarriages
(8 of them) over the past 7 years and the doctors don’t
know why. I went to Florida for a vacation and went to a hospital
with another miscarriage. The doctor said that I reject the
fetus. What does this mean?
Comment: My list of reasons of miscarriage
in the first trimester in order of occurrence and with percent
of occurrence follows. This is only my own estimate. 1) Endocrine/genetic
70% 2) anatomic/ structural 20% 3) inherited genetic 5% 4)
other include infection, immunologic, and chronic maternal
medical problems 5%. Your case is much too complicated and
I have much too little information about the pregnancy losses
to even guess at a cause or quote statistics for the risk
for an additional pregnancy. I am not a large proponent of
the immunologic causes (rejection) of pregnancy loss. I am
sure that it occurs, but I believe is very uncommon. I mostly
favor hormonal causes related to egg quality and structural
causes that are usually diagnosed by ultrasound and hysteroscopy.
sst
Question: I am now 35 years old.
My husband and I tried to conceive for over a year and a half
on our own. Then he had a sperm count test; it was OK. After
taking Clomid for two months, I was pregnant for the first
time. When we went for the first ultrasound the heartbeat
was low. I had to have an injection because I am Rh negative.
By the end of that week I had a miscarriage. After months
of waiting, I went back on the Clomid for five months, increasing
and changing the days I took them. Eight months after my miscarriage,
I found out I was pregnant again, but this time I started
bleeding on week six. I took progesterone suppositories two
times a day, but it turned out that this pregnancy was identified
as ectopic, and I had a D&C in week 7. I had to have a
shot of methotrexate to stop anything that had not been gotten
by a second D&C I had month later (because my hormone
level was still up). All of the next month I was at the doctor's
office each week checking blood for hCG levels. During this
time I have had countless ultrasounds. The doctor was concerned
about a cyst on my ovary that has not changed since prior
to the pregnancy (measuring 3.2 x 3.6). After a month of ultrasounds,
the cyst still showed no change, so surgery was scheduled
for two months thereafter. I had a laparoscopy to remove what
was found to be a "chocolate" cyst. Now the doctor
wants me to take Lupron to stop my periods for four months
while my body heals from the endometriosis lesions they found.
Is this right? What are the side effects and will this really
help me? We have been through so much while trying to have
a baby that we want more than anything. Now I am also concerned
about my age. Is there anything else that can be done?
Comment: This is a particularly complex
case, not because of each single problem which can all be
treated, but because of the at least 3 issues identified and
how to move from here (not pregnancy) to there (a successful
pregnancy). First, by use of clomiphene, it appears that you
do not ovulate well. Second, at laparoscopy endometriosis
was found. It is possible that endometriosis can affect the
tubes and make ectopic pregnancy more likely. Regardless,
there is now evidence of tubal disease a third factor. If
there was only the endometrioma and it was removed, I am not
sure Lupron injections are the right answer. If the endometriosis
was more widespread and especially if there was endometriosis
of the tubes, Lupron may improve fertility. At 35 you have
a margin of time, but a definite plan perhaps aggressive plan
needs to be established. The side effects of Lupron are those
of menopause. sst
Question: I got pregnant with
my son in 3 months; however, it has taken us 2 years to get
pregnant again. I did get pregnant once only to find out that
baby had Trisomy 18. I lost the baby three months later and
then had a subsequent D & C. What are the chances of Trisomy
18 happening again? Will it most likely take another 2 years
to get pregnant again? How aggressive should we be? I usually
don't ovulate until day 22 or 23 on a 31-day cycle. Is my
luteal phase too short? What can be done about this?
Comment: It is not a luteal phase defect,
but a follicular phase defect (delayed ovulation) that is
the most likely reason for the pregnancy loss. We know that
ovulation past day 14 is associated with a greater chance
of infertility and pregnancy loss. I would look for the common
theme between your inability to conceive and the pregnancy
loss. I would think it might be altered ovulation. Sometimes
clomiphene will help with an ovulation problem. Overall the
chance of recurrence is probably very slightly greater. I
would probably not let this deter you, but if questions remain,
a genetic consultation may be in order. sst
Question: While I was at the hospital
passing a kidney stone, I was told by a perinatologist that
my uterus was small (I am 38 weeks and it is measuring 36
to 37) but he said it was ok because the baby is the right
size. I didn't get to ask him what that meant or why it is
happening. Could you give me any insight on this?
Comment: What is most important is that
he told you that the baby was the right size. If a question
remains, you should ask the perinatologist directly. sst
Question: I am a high school biology
teacher and I am researching information about twins. I have
been given secondhand information via talk radio shows and
other mothers about the number of twins that are conceived
versus the number of actual twin resulting births. Since I
began as a twin but my other twin did not survive development,
I am curious about this information.
Comment: There are numerous articles
about the "vanishing twin" especially in the infertility
literature. The drugs we use to promote ovulation increase
the incidence of multiple pregnancies. Since ultrasound scans
are performed very early in pregnancy, we often see a twin
that fails to develop. I see this on a monthly, if not weekly
basis. I know of no reason to expect an increased loss of
one twin. The rate of twin loss should equal the routine risk
of a miscarriage with a single pregnancy multiplied times
the risk of twinning in that individual. There is evidence
that twinning is slightly higher in older women who would
also expect to have a higher rate of miscarriage. sst
Question: I have heard several
conflicting opinions about endometrial polyps as a cause of
miscarriage. I underwent d & c and polyps were removed.
Subsequently I conceived but miscarried the next month. Ultrasound
with infiltration was done two months later and polyp with
filling defect was discovered so I underwent hysteroscopy.
Can polyps grow back or were they behind in the D & C?
Do I have a legitimate concern that the polyps caused my miscarriage
or will cause a miscarriage in the future?
Comment: Polyps are common. New polyps
can form relatively quickly. There is also new evidence that
hey can resolve without intervention. Small polyps may be
missed or incompletely removed at D&C. Perhaps the best
way to ensure their removal is by hysteroscopy with direct
visualization. Whether polyps cause miscarriage at all, or
how big they must be to cause a pregnancy loss is controversial.
Polyps greater than 1 cm (about 1/3 in) are more likely to
be of concern and probably should be removed. sst
Question: I got pregnant but I
had to undergo a D&C as the fetus had stopped developing.
Then I found out that I had hypothyroidism and high blood
pressure. I started medicine for my thyroid problem and after
two months the tests came back normal. Then it was detected
that I had a dermoid cyst in my right ovary and it had to
be removed. I got pregnant but again I had a miscarriage.
The doctor advised me to let nature take its own course and
now I have been bleeding for the last 10 days but it has reduced
a lot. My questions are 1. Is there any chance that anything
may remain inside my body that may be harmful? How can I confirm
it? 2. What do you think is going on and what tests should
I have?
Comment: You present with a number of
possible problems. On the thyroid issue make sure the thyroid
replacement is adequate. Not only hypertension, but also the
medications used to treat it can be detrimental on fertility
and pregnancy. Make sure this is well controlled. Use the
least medication possible and try lifestyle measures to try
to normalize your blood pressure. Dermoid cysts are relatively
common and almost always benign. I assume it was completely
removed and that should be the end of that problem. Still,
any surgery can cause pelvic scarring. It is a good sign that
a pregnancy was established so quickly and your chance of
a future successful pregnancy would appear quite high. To
confirm the pregnancy loss is complete, I suggest that the
hCG be measured to make sure it has fallen to zero. If there
is persistence of bleeding, an ultrasound is useful to help
evaluate the uterus and in your case, recheck the ovary. Your
blood pressure needs to be rechecked to see if it has returned
to normal. If the blood pressure was only elevated in your
pregnancy you may have phospholipid antibody syndrome. Make
sure your TSH level a marker of thyroid disease is normal.
In situations like this there is no substitute for a close
working relationship with your physician. sst
Question: I just had a D&C
done this week. I went in for an ultrasound at 11 weeks and
was told the baby's heart was not beating. I was told the
baby looked as though it had been dead for four weeks. At
the 7-week ultrasound, the technician informed me that I had
an unusual shape to my uterus (she said it had a dimple in
the top with a small horn on each upper side). I have had
two other children (now 3 and 1) and have had many ultrasounds
without anyone telling me that I had this unusual shape. They
are now suggesting that I have dye studies done to see if
I need surgery in order to fix the shape of my uterus (which
they also call anteverted). Is this necessary? Also, I was
in a car accident late last year. Could this have changed
the shape of my uterus? I definitely want more children, but
I do not want unnecessary studies done that might be harmful.
Comment: It was not the car accident.
The pregnancy loss may have been due to a possible uterine
abnormality, but this seems unlikely with your past history
of successful pregnancies. Most abnormalities in the uterus
are minor birth defects. About 5-15% of pregnancy loss is
due to anatomic/structural causes. Most of these losses occur
after 8 weeks and are associated with bleeding, cramping,
and loss of an otherwise normal pregnancy. It is possible
that a loss could occur earlier depending on the implantation
site. A hysterosalpingogram (HSG) is the usual screening test
for uterine for abnormalities. By the history of fetal demise
before 8 weeks and previously normal pregnancies, I am not
sure that I would not rush to surgery, but understand that
if your doctors have found an abnormality on ultrasound, they
should follow-up on it. Your chances of a successful pregnancy
outcome should be very high. sst
Question: I am 39 years old and
have been trying to get pregnant for almost two years. In
that time I have been pregnant twice and both times miscarried
within the first six weeks. I finally went to a fertility
specialist. He discovered I had a bacterial infection (ureaplasma)
and we treated that with antibiotics but I have not gotten
pregnant again since. All my hormone levels are normal but
on a recent sonogram it appears I have a polyp and/or a submucosal
fibroid. I will be getting these removed. How likely is it
that these are causing my miscarriages and infrequent conceptions?
I just couldn't get a straight answer from my doctor.
Comment: The reason for lack of a straight
answer is that it is impossible to know whether indeed this
is the problem. Still removal of uterine polyps is a straightforward
procedure during a hysteroscopic examination. Hysteroscopy
will also allow a thorough evaluation of the inside of the
uterus and likely exclude other problems that could hamper
fertility. The evidence thus far suggests that smaller polyps/fibroids
(less than 10 mm) usually are not the cause of problems with
pregnancy. Your physician may be also cautious in that it
is impossible to exclude age as an important and complicating
factor. Age is a good reason to be aggressive with evaluation
and therapy. sst
Question: I'm 26 years old. My
husband and I were trying to conceive for two years. We were
finally sent to an RE for an intrauterine insemination (IUI)
after several tests had been done. It didn't work, so, of
course, I got frustrated. So I decided to stop Clomid and
everything else. I bought the Clearplan™ fertility monitor
and got pregnant the first time. We were so excited! I thought
everything was going great. We saw the heartbeat twice at
8 weeks and 12 weeks, but at 15 weeks I woke up bleeding.
They saw no heartbeat on the screen and I lost the baby. Why?
Nobody knows. Everyone keeps saying it was a freak thing.
Somebody has to know something. I had a D&C the next morning.
I was just wondering if anyone could tell me any ideas of
what could have happened? I didn't feel sick or any pain the
night before. My doctor wants me to start trying again after
two normal periods
Comment. Your story is not typical for
pregnancy loss with all going so well at 12 weeks. Most genetic
and embryonic causes of loss are evident in the 12-week scan.
This is a case where a very detailed medical history and the
events surrounding the loss history are very important. Pregnancy
loss in the mid-second trimester often has a different cause
than a first trimester loss (less than 12 weeks). Anatomic
factors, specifically, uterine abnormalities and cervical
incompetence are more likely. Immunologic problems such as
cardiolipin antibody syndrome increase in possibility. There
is an answer to why your pregnancy was lost, but unfortunately
we may never know what it is. It is still very likely that
this was a chance event and will not recur. There is no textbook
answer for either you or your obstetrician. Since this was
the first loss, most doctors would not recommend any intervention
or additional testing at present unless there is some more
in the history than is given above. Do your best to deal with
the uncertainty and press on.
Question: I am 30 years old and
am currently 19 weeks pregnant. I have had three prior consecutive
miscarriages, the first at 6 weeks, the second at 8 weeks,
and the third at 12 weeks. My doctor suggested we wait three
to six months before trying again, which we did. Anti-cardiolipin
tests and fetal tissue testing came back negative in the last
pregnancy. I then had an endometrial biopsy done which showed
a luteal phase defect. My doctor then prescribed progesterone
replacement and gave the go ahead to try again. I don't drink,
smoke, drink caffeine or do any other drugs. My question is
can I dare relax yet?
Comment: Most endocrine and ovulation
defects cause pregnancy loss in the first trimester. I would
not tempt fate by telling you all is well. Once in the second
trimester we generally start to breathe easier about previous
first trimester losses. Most of the reasons that cause early
loss are now passed. Often a more advanced ultrasound survey,
the so-called "genetic ultrasound" will give further
reassurance. sst
Question I recently miscarried
at 7 weeks, 2 days. (At 6 weeks they reported I had twins,
but at 7 weeks, there was only one fetus with the sac measuring
small at 6 weeks, 1 day -- but with a strong heartbeat.) The
ultrasound in the emergency room showed that the baby's heart
was still beating while the fetal sac had completely collapsed.
I was told it was just a matter of time before the heart would
stop and the miscarriage would complete itself. I've since
learned that this is highly unusual. Although this was my
first miscarriage, I've had all the blood work for recurrent
miscarriage and everything has returned normal. I'm very healthy,
normal weight, 38-years-old, single, and got pregnant on my
fourth IUI with Clomid and gonadotropins. I want to try again,
but I'm very concerned since it seems as if it was not a random
chromosomal error but something about me. But so far, there
seems to be nothing obvious to treat. I should tell you that
my family has a rather extreme history of early onset heart
disease. It's been suggested that this might have something
to do with the miscarriage -- that my blood vessels are starting
to weaken (considering my age) and could not handle the blood
flow necessary to maintain the placenta. I would greatly appreciate
any insight/advice you can offer.
Comment: Pregnancy loss is a severe
emotional and psychological wound. The wound will heal in
time, but the scar never totally disappears. Each person experiencing
pregnancy loss first blames herself; "it must be my fault."
It almost never is. In your particular case, the offender
is probably your birth certificate. Not good news, but statistically
a fact. Even as young as 30 the risk of pregnancy loss starts
to rise. Pregnancy loss is very common after age 40. It probably
was a "random chromosomal error". Your chance for
another random error is significantly increased. I would disagree
that the collapse of the sac was unusual. I see this relatively
often immediately before the pregnancy is loss and I question
its diagnostic significance. Cardiovascular disease may affect
uterine vessels the same as the other blood vessels of the
body. If you had (and have) normal blood pressure, I would
think the possibility of a vascular origin of the loss much
less likely, but it cannot be excluded. Some have used cardiolipin
antibody as a marker of cardiovascular disease. For your long-term
health, a "baby" aspirin a day (less than 325 mg)
may be of health benefit. However in general, studies have
not shown that aspirin helps in early pregnancy loss. Its
use should be discussed with your obstetrician. The decision
to try again is certainly personal, but supportive information
including how well you responded to the stimulation protocol
and what the day 3 FSH/estradiol blood level (a marker of
egg stores) was/is should be considered. sst
Question: What can cause late
miscarriage? I recently lost a baby at over 15 weeks into
my pregnancy, although the ultrasound showed that he was about
12-week size. We found out that he had died only when I was
spotting before he had passed from my body. I miscarried naturally
at home, and oddly, my water broke and there was very little
bleeding until after he came out. His little body was formed
so perfectly, a baby boy three and a half inches long, it's
hard to believe that there was any chromosomal defect and
that he would thrive that long if there were some major problem.
We want to try again but will stop if there's another miscarriage.
Please tell me ANYTHING I could do or have checked to prevent
or reduce the risk of this happening again. Is a thyroid problem
or a low progesterone problem a possible cause? My history
is this: I miscarried at 12 weeks in my first pregnancy, then
went on to have two healthy pregnancies. Then I had this most
recent miscarriage at 15 weeks. I am 27 years old, normal
periods, no problem getting pregnant, my husband and I both
have healthy lifestyles and no known medical problems.
Comment:
This was a late first trimester miscarriage. There is often
a discrepancy between the loss of viability and when the demise
is discovered or the pregnancy lost. The most frequent time
of pregnancy loss is between 5 and 8 weeks, but there seems
to be another peak around 12 weeks. We do not know why this
is, but it is still most often of genetic origin. By having
children, some of the causes of miscarriage such as serious
abnormalities of the uterus have been excluded. If a careful
history by your obstetrician has not disclosed a problem,
I would be reassured. It is not unreasonable to check a thyroid
stimulating hormone level for thyroid problems. Low progesterone
is most often not a cause, but a result of an abnormal pregnancy.
If there is a family history of diabetes, perhaps a glucose
tolerance test and insulin level should be performed. I would
recommend early and repeat ultrasound monitoring and if an
additional pregnancy is lost, then chromosome studies should
be performed. The later nature of the pregnancy loss also
suggests that there could be structural problems in the uterus
and a HSG may be in order. By far the most important part
of your history is your two healthy children. This gives you
an excellent chance of another successful pregnancy. sst
Question: I am 33 years old and
had two miscarriages two years ago. Since then my husband
and I have been trying to get pregnant with no luck. I am
going to have a tubal patency test soon and wonder what it
is, what it can detect, and what's next?
Comment: A hysterosalpingogram (HSG)
is a screening test usually performed in a hospital x-ray
department in order to evaluate the contour of the uterine
cavity and to determine if the tubes are patent (open.) During
an HSG, liquid dye is passed through an instrument placed
in the cervix. Passage of the dye and outline of the uterus
and tubes can easily be visualized by a special x-ray technique
called fluoroscopy. Some women conceive after an HSG without
additional therapy. This is thought to be due to a "flushing
out" effect on the tubes and the removal of small bits
of scar tissue. HSG is an excellent method to evaluate the
possibility of some congenital abnormalities of the uterus,
but its overall usefulness is questioned. We know with the
establishment of pregnancy that at least one tube must be
open. About one in three cases will give a false HSG reading.
Either there will not appear to be a problem when there actually
is, or the test will be read as abnormal when no abnormality
exists. If the HSG is abnormal, a laparoscopy and/or hysteroscopy
are needed for confirmation and treatment. If the test is
negative and nothing has been found, the results can’t
be completely trusted and a laparoscopy or hysteroscopy may
be necessary to exclude a problem. It is relatively common
for the tube to have a muscle spasm during the procedure and
appear blocked when in reality, it is open. The ability of
the tubes to be freely mobile is very important. The tubes
may be open, but scarring (adhesions) may prevent the tubes
from capturing the egg at ovulation. Open tubes do not equal
normal tubes and often this cannot be detected by HSG. The
HSG is associated with mild to moderate pain that is usually
limited to the time during which the dye is being injected
thought the cervix. It is advisable that some type of non-steroidal
anti-inflammatory drug (ibuprofen naprosyn, aspirin, etc.)
be taken 30 minutes before the procedure. It is also useful
to have the male partner present for support. Often both of
you are allowed to see the procedure and discuss the results.
One reason for recurrent pregnancy loss
is a congenital anomaly (birth defect) of the uterus. This
problem is more often found in individuals who have lost pregnancy
at 9-15 weeks and after there has been fetal heart activity
identified by ultrasound. When a pregnancy loss occurs can
tell us much about why the loss has happened. HSG is one of
the standard tests for recurrent pregnancy loss and may be
performed before, or after, more intensive endocrine evaluation
and perhaps even a trial of clomiphene and or progesterone.
Losses before 8 weeks are most often due to hormonal and genetic
problems rather than anatomic problems. sst
Question: I have had three miscarriages
in the last two years. I am recently 5 1/2 weeks pregnant.
My doctor ordered a progesterone level test, and the results
aren't favorable. My level was a "5.” Today she
ordered another test for my hCG level. What does a level "5"
mean for my progesterone level?
Comment: 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 often are 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 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), or mid-ground
(10-20 pg/ml). Many healthy pregnancies are in this mid-ground
of 10-20. I have seen healthy babies from pregnancies that
start out with progesterone levels of 4. It seems to me that
good pregnancies can prosper on very low levels of progesterone.
However low progesterone levels can often indicate that a
pregnancy is in trouble; most likely, it was in trouble from
the time of conception. Since most pregnancy losses are due
to problems 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 a theoretical value of supplementation. Progesterone
may relax the smooth muscle of the uterus and prevent contractions.
In many ways a pregnancy is like an organ graft from a different
person. Theoretically, progesterone may also help the body
accept the pregnancy by suppressing the immune response. sst
Question: I am now 12 weeks and
3 days pregnant. I'm 24 years old, normal weight for my height,
and am in good health. I had an ultrasound five days ago that
showed my fetus to be 8 weeks and 3 days old...and I was told
that they couldn't find a heartbeat. This of course devastated
my husband and me. This is my fourth pregnancy and would be
my third miscarriage. I did carry to term (actually, he was
three weeks early) a pregnancy a few years ago. I'm confused
at how I could carry a baby for four weeks without my body
"letting go" of him/her. I am still pregnant with
the baby and have had no spotting, as of today, or irregular
pain. Could you please help me to understand how this could
happen and what this means for my future pregnancies?
Comment: I am terribly sorry but fetal
heart activity is usually seen by six weeks. With the size
of the embryo and the absence of heart activity, it is an
inevitable conclusion that this pregnancy will be lost. Every
pregnancy is special and every loss leaves a scar that may
fade, but will never disappear. The very positive news is
that you have one healthy child. This is good news not because
it can make up for the losses (or as some would say, "but
you have a healthy child") but good news from a biological/medical
standpoint. In women under age 38, a successful pregnancy
is a very strong predicator that another successful pregnancy
will be possible. By the present history and the past delivery
it seems that an anatomic cause for the losses is not very
likely. Let's examine the other causes of recurrent pregnancy
loss. It is reasonable for you and your husband to have a
blood test (karyotype) for chromosomal abnormalities. Abnormalities
are found in 3-5% of those with recurrent loss. Most likely
there is a hormonal or genetic cause that is not transmissible
but occurs at the point of conception. I start with making
sure that ovulation is occurring in a timely fashion and that
hormonal problems are excluded. Recurrent loss often arises
from delayed ovulation (ovulation after cycle day 16), and
other hormonal abnormalities including thyroid and insulin
problems that may affect ovulation and egg quality. While
implantation is clearly an immunologic event and some pregnancy
losses are from immunologic problems, most of these are due
to cardiolipin antibodies or lupus-like anticoagulant. Most
often these are second trimester losses associated with hypertension.
Pregnancy course in this incidence may be improved by aspirin,
heparin and possibly steroids, but there is only limited evidence
of the effectiveness of these agents in recurrent first trimester
loss. A possible but less common cause of loss is chronic
infection, but this may be easier to treat with a trial of
antibiotics, rather than to perform expensive and inconclusive
cultures. Having said all of this, most pregnancy losses are
due to alteration in egg quality and endocrine disturbance
and this should be the first area of investigation. sst
Question: I had a miscarriage
several years ago. I had difficulty getting pregnant again
due to my irregular cycles lasting anywhere from 28 to 36
days; therefore, I did not know when I was ovulating. I used
the ovulation predictor kits, which helped me to see about
when I ovulate, had blood tests done to check levels of progesterone,
thyroid, etc. and an HSG done. Everything looked fine. My
husband’s semen analysis came back fine. I went for
a consultation with an RE and ended up getting pregnant the
next week. I ended up carrying the baby only six weeks. My
doctor is running tests on the extraction and will do some
genetic blood tests on me to see if we can find out any answers
of why this could be happening. With the little information
that you have can you think of anything that may have caused
me to miscarry twice? Could it be that my uterus is unable
to carry a baby? Should I check into getting my cervix sewn
the next time I get pregnant? If so, who does this? Do you
have any suggestions on what I can do from here?
Comment: I think it is very unlikely
that it is the uterus. No, you should not check about having
your cervix sewn (cerclage) unless a clear diagnosis of cervical
stenosis has been made. There is no evidence that you have
cervical incompetence in the above history. The answer to
your question is probably in your second sentence. There is
a spectrum of the reproductive performance from no menses
(amenorrhea) to delivering the health baby. In the middle
are pregnancy loss and irregular cycles. I believe delayed
ovulation (ovulation past day 16) is substantial cause of
infertility and pregnancy loss. First line therapies include
progesterone supplementation in the luteal phase and clomiphene.
A common cause of cycles over 35 days is polycystic ovarian
syndrome (PCOS). About 50% of those with PCOS will also have
insulin resistance that may be reduced with metformin. sst
Question: My doctor has informed
my wife and me that our baby (24 weeks) has dilated kidneys.
They have sent us for a fetal echocardiogram, which was negative,
and have now done an amniocentesis. The results should be
back this week. We had another sonogram and one of the kidneys
has gotten better. He has explained to us what might cause
this and what might have to be done, including early delivery
if the problem gets worse. I was just looking for another
opinion on what might cause this and what our options are.
Comment: If you do not feel your
questions have been adequately answered seek a consultation
with a specialist in maternal-fetal medicine. You physician
should be very willing to refer you. sst
Also see Fact sheet -
Early Pregnancy
and Pregnancy Loss
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