Wednesday, March 26, 2008

Trying Again After Recurrent Miscarriages

Photo by Andy Martintrying again after recurrent miscarriages
Valerie and John Quinones, a Brooklyn couple in their mid-30s, were more than ready for a baby. Ms. Quinones had no trouble conceiving, but miscarried her first pregnancy at 6 weeks. Soon she was pregnant again, but this time no heartbeat was detected at 9 weeks.

After those consecutive pregnancy losses, her doctor suggested a blood test that showed a rare clotting disorder that, the doctor said, might, or might not, be responsible for the problem. He suggested that as soon as she conceived again she should begin daily injections with a blood-thinning drug and continue that throughout the pregnancy.

Nine months later, Carolina Quinones entered the world at 7 pounds 9 ounces, hale and hearty.

If you know or read about all the things that can go wrong in achieving and maintaining a successful pregnancy, you will no doubt wonder how so many healthy babies manage to be born. More than half of pregnancies are spontaneously lost even before the woman has missed a menstrual period and knows that she is pregnant, and about 15 to 20 percent of recognized pregnancies are miscarried in the next few months. For couples who want a baby, these are daunting numbers.

Quick on their heels, however, are very reassuring numbers. For 80 to 90 percent of women who lose one pregnancy, the next one, even with no treatment, results in a successful birth. But the devastation is compounded and the statistics slightly less hopeful when a woman has lost two or more pregnancies. After two consecutive
miscarriages, there is a 75 percent chance that the next pregnancy will be maintained. After three miscarriages, there is a 65 percent chance.

Unproven or Useless Remedies

Myths abound as to why women experience recurrent miscarriages. The uninformed tend to blame factors like undue
stress, too much exercise, being too thin or too fat, exposure to occupational or environmental toxins, excessive use of computers or cellphones and bad habits like smoking or drinking too much coffee. Affected couples, often desperate for a solution, sometimes grasp at unproven or useless remedies. What they need instead is factual information, emotional support and, if possible, treatment based on a medically established cause.

Helped by Dr. Sandra A. Carson of
Brown University and Dr. D. Ware Branch of the University of Utah, the American College of Obstetricians and Gynecologists recently issued an updated report on what is known and not known about the causes of repeated miscarriage and its proper treatment.

Perhaps most telling is the bottom line. Approximately one woman of reproductive age in 100 will experience recurrent pregnancy loss, and in no more than half of couples will a definite cause be established. Furthermore, several reported causes are controversial, as are their treatments.

“Although a common concern of patients,” the report says, “environmental factors rarely have been linked to sporadic pregnancy loss, and no associations between environmental factors and recurrent pregnancy loss have been established.” It adds, “No association between occupational exposure or working itself and recurrent pregnancy loss have been established.” Neither have any infectious agents been proved to cause recurrent miscarriage, the report adds.

Dr. Carson said in an interview, “The overwhelming majority of recurrent miscarriages occur because something is wrong with the baby, most often a chromosomal abnormality.” This risk increases with the mother’s age and, some studies suggest, with the father’s age, because of genetic errors in the egg or sperm that result in embryos with too many or too few chromosomes.

In 2 to 4 percent of couples with recurrent loss, one partner is found with a problem, a genetically balanced rearrangement of chromosomes. He or she is normal, but when the egg or sperm is formed, it can end up with an extra chromosome piece or a missing segment, resulting in an embryo that cannot survive. In such cases, a couple may choose in vitro fertilization, with genetic analysis of the resulting embryos performed to select a chromosomally normal one for implantation.

Structural abnormalities of the uterus are found in 10 to 15 percent of women who have recurrent miscarriages, though experts disagree over whether these problems impede a successful pregnancy. Likewise, the role of
fibroids and endometriosis is controversial, and surgery to remove such extra tissue may not prevent another miscarriage.

When a Blood Thinner Can Help

An autoimmune disorder that involves the production of
antibodies to phospholipids, which are important components of blood vessel walls, can sometimes cause clots in the small blood vessels of the placenta. The resulting damage can cause recurrent miscarriage. In women with high levels of such antibodies, treatment with the blood thinner heparin and low-dose aspirin can reduce, though not necessarily eliminate, the risk of repeated miscarriage, Dr. Carson said.

While there is no good evidence that a woman’s
immunity to her partner’s tissues is responsible for repeated miscarriage, suggestive evidence indicates that an immune abnormality may occur that interferes with producing the intrauterine growth factors needed for a successful pregnancy. But there is no proven treatment for such a problem.

One popular notion to explain recurrent miscarriage is inadequate production of
progesterone, the hormone released after ovulation that prepares the uterus for pregnancy. This idea has resulted in many efforts to support an incipient pregnancy by administering progesterone, a treatment that Dr. Carson described as harmless but not likely to be effective. Some researchers suggest that if a hormonal problem exists it may begin before the egg is released and that drugs to stimulate ovulation may be more helpful.

Even after the most thorough work-up, half to three-fourths of couples with recurrent pregnancy loss “will have no certain diagnosis,” the report states. For such couples, the best medicine is good information and sympathetic counseling, combined with optimistic statistics. “Live birth rates between 35 percent and 85 percent are commonly reported in couples with unexplained recurrent pregnancy loss who undertake an untreated or placebo-treated subsequent pregnancy.”

A combined analysis of the best studies available in 1995 showed that 60 to 70 percent of women with unexplained recurrent losses would have successful next pregnancies.

Of course, every woman contemplating pregnancy would be wise to follow the recommendations of the March of Dimes to start prenatal vitamin supplements before becoming pregnant. Throughout pregnancy, eat healthfully, exercise moderately, avoid alcohol, eat fish (but avoid seafood high in mercury), limit caffeinated drinks to two a day and check with the doctor before taking medications or
dietary supplements.


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