Pierderea sarcinii..."missed abortion"
Raspunsuri - Pagina 9
Liana30 spune:
Tia nu mi s-a recomandat FIV eu am hotarat sa merg la Timisoara
unde se face asa ceva dar nu neaparat sa fac daca nu este cazul..cei drept nu am discutat cu doctorul despre Fiv mi-a spus ca dupa ce rezolvam cu cauterizarea discutam...acum eu stiu ce o sa discutam?????? nu stiu...voi afla atunci... stii ceva eu am fost la Timisoara pe 15 iulie si m-a programat pe 9 august la cauterizare stii ce nu inteleg eu? de ce asa tarziu?
si altceva sa fie rana aceasta o cauza ca nu am mai ramas gravida????
si totusi sunt 3 ani de la ultima sarcina pierduta....
tu ce zici?
Liana
monu spune:
corail, nu stiu ce are PC dar nu ma lasa sa il trmit. da-mi te rog adresa ta de e-mail sau trimite un puncticel la adresa mea de e-mail ca sa ti-l pot trimite
corail spune:
monu, ti-am scris PM.
monu spune:
varianta pe scurt si in romana a articolului
PIERDERILE DE SARCINA
Noile cercetări au demonstrat că 80% din pierderile de sarcină neexplicate ar putea fi atribuite factorilor imunologici iar noile terapii ar făcut posibil ca peste 80% dintre cei afectați să poată duce o sarcină la termen.
Aproximativ 15-20% din totalul de sarcini au ca rezultat avortul iar riscul de pierdere a sarcinii crește cu fiecare pierdere de sarcină succesivă. De ex., riscul de avort la prima sarcină este de 11-13%. La următoarea sarcină consecutivă riscul de avort crește la 13-17%. Dar riscul la o a treia sarcină după 2 pierderi succesive crește la 38%.
Mulți dr. nu trimit pacientele la analize decât după 3 pierderi succesive ale sarcinii. Cu toate acestea, datorită riscului foarte mare pe care îl reprezintă o a 3-a sarcină după 2 pierderi succesive, Colegiul American pentru Obstetrică și Ginecologie recomandă acum analize după a 2-a sarcină pierdută, și în special în cazul femeilor peste 35 ani.
Există 4 probleme diferite care țin de sistemul imunitar și care pot duce la pierderea sarcinii: anticorpii antifosfolipidici, anticorpii antitiroidieni, anticorpii anti nucleari și anti coagulantul lupus. 30% din femeile cu pierderi inexplicabile ale sarcinii ar putea fi pozitive datorită unei probleme la sistemul imunitar.
Tratamentul autoimun
Tratamentul pentru factori ridicați autoimuni include doze scăzute de heparină, aspirină și prednison (un steroid care scade inflamația) și care se dă pentru scăderea nivelului de anticorpi.
Tratamentul cu aspirină uneori în combinație cu heparina și prednison (în cazuri grave) pot crește fluxul sângelui către placentă prin inhibarea tendinței de coagulare la femeile cu un nivel anormal de anticorpi. Datorită complicațiilor crescute pe care le ă prednison în sarcină este recomandat ca acesta să fie prescris acelor femei care nu răspund la aspirină și heparină.
O altă metodă care a avut succes în tratarea factorilor autoimuni este injectarea intra venoasă cu imunoglobulină.
Pierderile repetate ale sarcinilor pot fi cauzate de următorii factori cunoscuți în momentul de față:
- probleme cromozomiale
- boli ale mamei (textul original spune în interiorul mamei) (ex. lupus eritematos sistematic, boli congenitale ale inimii, probleme grave cu rinichii hipertensiune, diabet necontrolat, boli alte tiroidei, infecții intrauterine)
- probleme ale balanței hormonale
- dereglarea sistemului imunitar
- uter anormal (anormalități congenitale ale uterului, uter fibromatos, cervix cu probleme)
- factori de mediu sau al stilului de viață (alcool , droguri, fumatul, expunere la radiații sau agenți toxici)
În cazul sindromului antifosfolipidic urmează o serie de teste care se fac pentru anticorpii antifosfolipidici cu valorile normale:
Anti-Phospholipid Antibodies (APA) IgM IgG IgA
Anticardiolipin (ACA) .131 - .173 .209 - .254 .192-.212
Phosphoethanolamine .362 - .478 088 - .222 .046-.073
Phosphoinositol .136 - .178 .175 - .236 .093-.122
Phosphatidic Acid .137 - .214 .104 - .132 .131-.155
Phosphogylcerol .168 - .242 .143 - .185 .102-.139
Phosphoserine .101 - .134 .082 - .188 .123-.143
Phosphocholine .152 - .198 .131 - .170 .092-.219
Alloimmune Risk Tests
Natural Killer Cells
Reproductive Immunophynotype (RIP) 3-12%
Leukocyte Antibody Detection (LAD) >10%
Embryo Toxicity Assay (ETA). <37% Artesia
Lupus - LikeAntibodies
Lupus-like Anticoagulant Antibodies (APA) 33.5 - 44.5 seconds
Kaolin ClottingTime 33.5 - 44.5 seconds
Platelet Neutralization Assay 33.5 - 44.5 seconds
Dilute Russel viper Venom Time 33.5 - 44.5 seconds
Antithyroid Antibodies (ATA) Antinuclear Antibodies (ANA)
Thyroglobulin <1:7 ssDNA
99
dsDNA 89
Sm 40
RNP 83
SSA 91
SSB 73
Histone 96
Sci-70 32
Thyroid microsomal (thyroid peroxidase) autoantibodies <1:72
ELISAs Gel agglutination tests <1:72
Danelutza spune:
Si eu am avut un avort cind aveam 7 saptamini de sarcina, in luna mai ar fi trebuit sa fiu mamica. Greseala mea a fost cred, cind m-am apucat ca o nebuna sa fac curatzenie generala si am ridicat niste fotolii, sau poate nu... Si va spun si de ce, pentru ca in ziua cind am pierdut sarcina, au constatat la ecograf ca am un fibrom extrauterin. Prima intrebare de femeie disperata a fost daca mai pot ramine insarcinata, medicii m-au incurajat ca se poate. Cred ca de frica fibromului, care nu se poate opera, nu am mai ramas insarcinata.
monu spune:
varianta completa si in lb engleza
Immunology May Be Key To Pregnancy Loss
By Carolyn B. Coulam M.D. and Nancy P. Hemenway
Until the last decade, there was little a couple could do if they suffered from recurrent pregnancy losses. Miscarriages that couldn't be attributed to chromosomal defects, hormonal problems or abnormalities of the uterus were labeled "unexplained," and couples would continue to get pregnant, only to suffer time and again as they lost their babies. New research, however, indicates that as many as 80 percent of "unexplained" losses may the attributable to immunological factors-and some new therapies are enabling up to 80 percent of those affected to carry a baby to term.
About 15 to 20 percent of all pregnancies result in miscarriage, and the risk of pregnancy loss increases with each successive pregnancy loss. For example, in a first pregnancy the risk of miscarriage is 11 to 13 percent. In a pregnancy immediately following that loss, the risk of miscarriage is 13 to 17 percent. But the risk to a third pregnancy after two successive losses nearly triples to 38 percent.
Many doctors do not begin testing for the cause of pregnancy loss until after three successive miscarriages. However, because the risk of loss to a third pregnancy after two successive miscarriages is so high, the American College of Obstetrics and Gynecologists (ACOG) now recommends testing after a second loss-especially for women over the age of 35.
There are two major reasons for recurrent spontaneous abortion (RSA), or miscarriage. One is that there is something wrong with the pregnancy itself, such as a chromosomal abnormality, that curtails embryonic development. (A fertilized ovum is an embryo until 10 weeks gestation, and a fetus thereafter. Most miscarriages, though not all, occur between six and eight weeks, with expulsion taking place four weeks later, between 10 and 12 weeks.)
The best way to find out if the pregnancy itself is the problem is to test the chromosomes of the aborted embryo. While in many cases this is not an option, requesting genetic testing after a dilation and curettage (D&C) for a missed abortion can often give couples some definitive answers about what went wrong. An alternative is genetic testing for the couple, called "karyotyping." This involves a blood test for each partner so that both sets of chromosomes can be evaluated for abnormalities which may cause RSA, or which may be passed on to children.
The other cause of RSA, and the category into which immunological problems fall, is an environmental barrier to pregnancy-something wrong with he environment in which the pregnancy grows. In addition to immunological problems, other possible environmental causes of pregnancy loss are hormonal (not enough of necessary hormones to sustain the pregnancy) and anatomic (such as structural abnormalities of the uterus).
Anatomic problems may be detected with a hysterosalpinogram, hysteroscopy or hysterosonogram. Assessment of the hormonal environment looks at hormone levels and uterine response at the expected time of ovulation and implantation, usually through an endometrial biopsy or high level ultrasound examination.
The final way to determine an environmental cause of multiple miscarriage is through immunologic testing.
Immune System
The immune system, one of the most intricate and complex systems in the body, functions as the first line of defense against disease. It works by identifying proteins as normal or foreign. The immune response to a foreign protein is to neutralize or destroy the antigen. An antigen is a protein marker on the surface of a cell that identifies the cell as "self" or "nonself" An antigen can cause the production of antibodies. Antibodies are complex compounds made by the white blood cells (WBCs) that combine with specific antigens to destroy or control bacterial infections. As bacteria enter the body, WBCs produce antibodies to provide protection against illness.
Immune Causes of Recurrent Pregnancy Loss
The immunologic causes for pregnancy loss and implantation failure are the result of abnormalities in antibody responses. These responses fall into two categories: autoimmune and alloimmune.
Contributions to a pregnancy represent the pairing of genes from both man and woman. Autoimmune represents the immunologic response of the mother to a pregnancy ("self-immune" problems). Autoimmune disorders that can cause rejection of a pregnancy mean the woman is rejecting her own proteins-in other words, treating them like they are an invading illness. Autoantibodies are antibodies which attack one's own antigens.
Alloimmune problems indicate a mother's response to the man's genetic contribution to the pregnancy ("other-immune" problems). Alloimmune disorders are the rejection of a protein from the man. Both kinds of immune disorders can be determined with blood tests.
AUTOIMMUNE FACTORS
There are four different autoimmune problems that can cause RSA. A woman may have one or more of these underlying problems: antiphospholipid antibodies; antithyroid antibodies, antinuclear antibodies and lupus-like anticoagulant. Thirty percent of women with "unexplained" RSA will test positive for an autoimmune problem.
Antiphospholipid Antibodies
In pregnancy, phospholipids act like a sort of glue that holds the dividing cells together, and are necessary for growth of the placenta into the wall of the uterus. Phospholipids also filter nourishment from the mother's blood to the baby, and in turn, filter the baby's waste back through the placenta.
If a woman tests positive for any one of variety of antiphospholipid antibodies (APA), it indicates the presence of an underlying process that can cause recurrent pregnancy loss. The antibodies themselves do not cause miscarriage, but their presence indicates that an abnormal autoimmune process will likely interrupt the ability of the phospholipids to do their job, putting the woman at risk for miscarriage, second trimester loss, intrauterine growth retardation (IUGR) and pre-eclampsia.
While testing for anticardiolipins (cardiolipins are a kind of phospholipid) is standard in some infertility clinics, this test alone cannot identify the presence of all underlying autoimmune processes that causes RSA. A panel of tests for antibodies to six additional phospholipids is recommended to determine the presence of APA. Testing positive for one or more kind of antiphospholipid antibodies indicates the woman has the immune response that can causes RSA. (See the full range of APA tests in the accompanying chart.)
The markers tested for each of seven phospholipids include IgM, IgG and IgA. These are circulating immunoglobulins (proteins that ward off potential harmful invaders). In some patients, measuring these 21 markers can identify elevations of immunoglobulins to unknown proteins, and signal some as-yet-unidentified process exists that can trigger RSA.
About four percent of women with recurrent miscarriage test positive for lupus-like anticoagulant, and nine percent of individuals diagnosed with SLE have a positive lupus anticoagulant test, or activated partial thromboplastin time (APTT). APTT is an adequate screening test for lupus-like anticoagulant antibodies, but there is a high incidence of false positives. Women who have a positive APTT should also have more specific tests, such as Kaolin clotting time, Russel viper venom assay and the platelet neutralization assay a to confirm the presence of lupus anticoagulant antibody activity. And, since some women do not test positive until they are pregnant or have suffered a pregnancy loss, repeat testing during early pregnancy is highly recommended when there is a history of RSA.
Because some circumstances can cause false positives for these tests, it is important to determine persistent positive levels by repeating the tests in six to eight weeks.
The live birth rate for a patient with untreated APA ranges from 11 percent to 20 percent. Individuals with recurrent pregnancy loss and/or implantation failure, venous or arterial, thrombosis, thrombocytopenia, elevated APTT or a circulating lupus-like anticoagulant are among those at risk for development of APA. Also at risk may be women experiencing infertility associated with endometriosis, premature ovarian failure, multiple failed in-vitro fertilization, and unexplained infertility. With treatment, the live birth rate for women with APA increases to 70 to 80 percent.
Antinuclear Antibodies
Antinuclear antibodies react against normal components of the cell nucleus. They can be present in a number of immunologic diseases, including: systemic lupus erythematosus (SLE or Lupus), progressive systemic sclerosis, Sjorgen's syndrome, scleroderma polymyositis, dermatomyositis and in persons taking hydralazine and procainamide or isoniazid. In addition, ANA is present in some normal individuals or those who have collagen vascular diseases. The presence of ANA indicates there may be an underlying autoimmune process that affects the development of the placenta and can lead to early pregnancy loss.
Histones are proteins which combine with the DNA of the cell nucleus to govern the development of tissues. Histones are the smallest building blocks of DNA. Antibodies to these histones mean the mother is developing an immunity to histone components of DNA. The mechanism by which ANA cause pregnancy loss is not known. (See the accompanying chart for specific ANA tests.)
Antithyroid Antibodies
Women with thyroid antibodies face double the risk of miscarriage as women without them. Increased levels of thyroglobulin and thyroid microsomal (thyroid peroxidase) autoantibodies show a relationship in an increased miscarriage rate, and as many as 31 percent of women experiencing RSA are positive for one or both antibodies. Chances of a loss in the first trimester of pregnancy increase to 20 percent, and there is also an increased risk of post-partum thyroid dysfunction. Therefore, antithyroid antibody testing should be routine in women with a history of two or more losses or thyroid irregularities.
It is important to note that when only the hemagglutination blood test is used, one out of five women with thyroid antibodies will not be correctly screened. More sensitive tests, enzyme linked immunosorbant assays (ELISAs), or gel agglutination tests, have become the standard for thyroid antibodies associated with recurrent pregnancy loss.
Autoimmune Treatments
Treatments for autoimmune risk factors include preconception administration of low-dose heparin (an anticoagulant produced naturally by the body), aspirin and prednisone (a steroid to decrease inflammation ). Heparin is administered (at 5,000 10,000 units) every 12 hours, subcutaneously, and is used to treat women with APA syndrome and to combat possible clotting problems. Prednisone (40-60 mg. per day) is given to decrease autoantibody levels, provide blood-thinning and anti-inflammatory reactions, and reduce the risk of clotting. Aspirin is a prostaglandin inhibitor which decreases agglutination of the platelets (clotting), and has some anti-inflammatory action.
Aspirin therapy, sometimes in concert with heparin and prednisone in severe cases), can increase blood flow to the placenta by inhibiting the tendency for clotting in women with abnormal levels of autoantibodies. Because of complications of pregnancy are significantly higher with prednisone, however, it is usually recommended for women who do not respond to aspirin and heparin therapy.
Another successful method for treatment of autoimmune factors is intravenous immunoglobulin (IVIg), a process which infuses the mother with antibodies from thousands of donors in the general population. The basic effect of IVIg is like neutralizing a large military force (the mother's dangerous antibodies) armed with weapons. The army is still present after administering the IVIg, but it is disarmed. The donor immunoglobulin keeps the attacking antibodies busy and away from the developing fetus.
Among women with the combined problems of APA and elevated NK cells who achieve pregnancy with preconception treatment, the subsequent live birth rate is about 70 percent. The initial treatment of choice is usually low-dose heparin and aspirin therapy because obstetrical complications, such as preterm birth, premature rupture of the membrane and gestational diabetes, are more common with prednisone. IVIg, while very effective, is also quite costly --- roughly $10-30,000 for treatments throughout pregnancy ($39 to $145 per gram, depending on the distributor). However, among women for whom pregnancy loss occurred even with preconception use of heparin and aspirin, IVIg remains an alternative that may allow them to carry a pregnancy to term.
ALLOIMMUNE FACTORS
There are two possible reasons that women with alloimmune problems lose their pregnancies in miscarriage: Either her immune system does not recognize the pregnancy, or she develops an abnormal immunologic response to the pregnancy.
Successful pregnancy has been associated with the presence of circulating "blocking antibodies." These are antibodies that are formed by a woman's immune system when she is pregnant, and they "mask," or disguise the pregnancy so it is not recognized as "foreign." Pregnancies that end with RSA have been associated with the absence of these blocking antibodies.
Recently, an antigen identified as R80K has been identified on the surface of syncytiotrophoblasts, the outer layer of cells covering of the chorionic villi of the placenta. These cells are in contact with maternal blood. R80K is a kind of protein marker to which the blocking antibodies respond during a successful pregnancy. The antibodies to this antigen react in a specific way to the antigens from the father's genetic material in the developing embryo, and thus create the protective, blocking antibodies.
For some women who lack the blocking antibodies, immunization with their husband's white blood cells may be an effective treatment. However, a leukocyte antibody detection assay (LAD) should be performed prior to initiating this treatment.
Also, IVIg treatment may be effective for some women who lack blocking antibodies because the immunoglobulin, which comes from thousands of donors, appear to contain small amounts of antibodies to R80K.
Leukocyte Antibody Detection Assay
Performed after a series of suspected losses when a woman is not pregnant, the Leukocyte antibody detection (LAD) test indicates a woman's physiologic response to pregnancy. Women who test for high levels of leukocyte antibodies have a history of carrying pregnancies longer than women who exhibit low levels. Women who have low levels of leukocyte antibodies generally had pregnancies that ended by week 12, or their immune systems did not respond to the stimulus of pregnancy by creating blocking antibodies. Only women with low levels of LAD are candidates for immunization with their husbands' white blood cells (leukocytes), so it is recommended that this assay be done prior to initiating an immunization protocol.
Natural Killer Cells
WBCs that belong to the innate or primitive group of cells that kill anything perceived as foreign . They kill abnormal invaders, including virally-affected cells. Some types of NK cells produce a substance called tumor necrosis factor (TNF), which might be described as your body's version of chemotherapy, and is toxic to a developing fetus. Patients who have high levels of these cells are at risk for implantation failure and miscarriage.
The proportion of NK cells is determined by a reproductive immunophynotype (RIP) test, which looks for cells that have the CD56+ marker. An NK (CD56+) cell range above 12 percent is abnormal. A patient with high NK cell activity will respond very well to intravenous immunoglobulin (IVIg) therapy. In fact, the live birth rate with preconception IVIg is more than 90 percent, compared to 20 percent without treatment.
Embryo Toxicity
Cells make proteins called cytokines. Different cytokines do different things. Some stimulate growth of cells, some inhibit growth. The proinflammatory cytokines stimulate inflammatory response, while others inhibit inflammatory response of cells. The embryo toxicity assay (ETA) is looking for cytokines which kill embryos.
Embryotoxic factors have been identified in as many as 60 percent of women with recurrent, unexplained miscarriage, and also reported among women endometriosis-associated infertility.
For the ETA, blood serum from the woman is incubated with mouse embryos. If the embryos die, a toxin (to the embryo) cytokine is present. IVIg therapy controls these cytokines and allows a pregnancy to progress.
Alloimmune Treatment
For a women who exhibits low levels of LAD, immunization with her husband's white blood cells results in about a 10 percent increase in the chance of live birth (to 60 percent) over the live birth rate without treatment. And risk of complications for these women, such as intrauterine growth retardation (IUGR), preterm birth and birth defects, are generally diminished with treatment.
Immunization can also be performed with seminal plasma vaginal capsules, inserted twice weekly from preconception to the 28th week of pregnancy. There is about a 15 percent increase in the live birth rate with this treatment compared to no treatment.
IVIg is also an effective, though more costly, treatment for women with low LAD levels. Research shows that there is a 28 percent increased live birth rate among women in this category who received IVIg, compared to women given a placebo.
For women with elevated LAD levels, IVIg is the recommended treatment. The dosage is 500 mg. per kg (2.2 lbs.) of weight per month. When treatment is started prior to conception and continued through 28 weeks of gestation, the overall success rate of IVIg is 70 percent. IVIg is also recommended for treatment of elevated circulating natural killer (CD56+) cells, circulating embryotoxins and unexplained recurrent miscarriage.
SUMMARY
As much as 40 percent of unexplained infertility may be the result of immune problems, as are as many as 80 percent of "unexplained" pregnancy losses. Unfortunately for couples with immunological problems, their chances of recurrent loss increase with each successive pregnancy.
Certainly, couples with RSA (two or more) would benefit from the full range of available immunological testing, especially if a woman is older than 35. And, because immune problems are often the cause implantation failure, couples with good embryos that fail to implant during IVF procedures are also good candidates for immunological screening.
Medical researchers have begun to pay attention to the problems of recurrent pregnancy loss, and ongoing genetic and immunologic research will continue to improve the diagnosis and treatment of this heartbreaking problem.
The following chart includes the full range of Autoimmune and Alloimmune Risk Tests and their "normal" ranges as conducted by Dr. Coulam at the Center for Human Reproduction in Chicago, Ill. Other labs and doctors may use different norms. The full range of tests is about $1,300.
Autoimmune Risk Tests
Antiphospholipid Antibodies (APA) Each of three markers, IgM, IgG and IgA, are tested for the following phospholipids, for a total of 21 different markers.
(see table)
Carolyn B. Coulam, M.D. is Medical Director at the Sher Institute in Chicago, Ill., and has served as a member of INCIID's Advisory Board since the organization's inception. Nancy P. Hemenway is an INCIID cofounder and serves as the INCIID Executive Director
Other links:
Clinical Trial: Intravenous Immunoglobulin for Treatment of Recurrent Pregnancy Loss
National Institutes of Health Consensus Development Conference Statement re: IVIg Treatment of Disease and Safety
INCIID Disclaimer
Anti-Phospholipid Antibodies (APA) IgM IgG IgA
Anticardiolipin (ACA) .131 - .173 .209 - .254 .192-.212
Phosphoethanolamine .362 - .478 088 - .222 .046-.073
Phosphoinositol .136 - .178 .175 - .236 .093-.122
Phosphatidic Acid .137 - .214 .104 - .132 .131-.155
Phosphogylcerol .168 - .242 .143 - .185 .102-.139
Phosphoserine .101 - .134 .082 - .188 .123-.143
Phosphocholine .152 - .198 .131 - .170 .092-.219
Alloimmune Risk Tests
Natural Killer Cells
Reproductive Immunophynotype (RIP) 3-12%
Leukocyte Antibody Detection (LAD) >10%
Embryo Toxicity Assay (ETA). <37% Artesia
Lupus - LikeAntibodies
Lupus-like Anticoagulant Antibodies (APA) 33.5 - 44.5 seconds
Kaolin ClottingTime 33.5 - 44.5 seconds
Platelet Neutralization Assay 33.5 - 44.5 seconds
Dilute Russel viper Venom Time 33.5 - 44.5 seconds
Antithyroid Antibodies (ATA) Antinuclear Antibodies (ANA)
Thyroglobulin <1:7 ssDNA
99
dsDNA 89
Sm 40
RNP 83
SSA 91
SSB 73
Histone 96
Sci-70 32
Thyroid microsomal (thyroid peroxidase) autoantibodies <1:72
ELISAs Gel agglutination tests <1:72
Repeated Miscarriage
Miscarriage, often called spontaneous abortion by doctors, is the loss of a pregnancy before 20 weeks. It occurs in about 15 percent to 20 percent of all pregnancies. Most happen in the first three months. Many miscarriages take place before a woman even knows that she is pregnant.
Three or more miscarriages in a row may be called repeated miscarriage. Special tests are needed to try to find the cause.
This article will explain:
What causes repeated miscarriage
What tests and procedures might be needed
What special care might be needed during pregnancy
Even if you have had repeated miscarriages, you still have a good chance to have a successful pregnancy.
Causes
After several miscarriages, you may wonder whether you will ever be able to have a healthy baby. Be hopeful. The chances of having a successful pregnancy are good even after more than one miscarriage.
Often, the reason for repeated miscarriage is not known. Sometimes, though, it has a certain cause. Known causes include:
Chromosomal problems
Illness in the mother
Hormone imbalance
Disorders of the immune system
Abnormalities of the uterus
Environmental and lifestyle factors
If you have had more than one miscarriage, each may have had a different cause.
The fetus inherits 23 chromosomes each from its mother and father to make 23 pairs. The 23rd pair determines the sex of the fetus: XX is female and XY is male
Chromosomal Problems
More than half of miscarriages in the first 13 weeks of pregnancy are caused by problems with the chromosomes of the fetus. Chromosomes are tiny structures inside the cells of the body. Each carries many genes. Genes are the basic units of heredity. They determine all of a person's physical makeup, such as sex, hair and eye color, and blood type.
Problems with the number or structure of chromosomes, or with the genes they carry, can lead to miscarriage. Often this is nature's way of ending a pregnancy in which the fetus was not growing as it should and would not have been able to live.
Most chromosomal problems occur by chance. They have nothing to do with the mother's or father's health. They are not likely to occur again in a later pregnancy.
In a small number of cases, though, problems with the parents' chromosomes can cause repeated miscarriage. There are tests to find out whether chromosomal problems are a factor in repeated miscarriage.
Illnesses in the Mother
Certain illnesses in the mother have been linked to a greater risk of repeated miscarriage. These include:
Systemic lupus erythematosus and other autoimmune disorders
Congenital heart disease
Severe kidney disease, especially when linked with high blood pressure (hypertension)
Diabetes that is not controlled
Thyroid disease
Intrauterine infection
Sometimes treatment of the illness can improve the chances for a successful pregnancy. This is even more true if the illness is under control before a woman becomes pregnant. Other illnesses may need care or close watching during pregnancy.
Hormone Imbalance
Progesterone is a hormone that prepares the lining of the uterus during the second half of the menstrual cycle to nourish a fertilized egg.
If the egg is not fertilized, it is shed with the uterine lining during the menstrual period. If the egg is fertilized, hormones prepare the uterus for pregnancy.
Early in pregnancy, enough progesterone must be made to maintain the pregnancy. If not, miscarriage will occur. If tests show that a woman's body is not making enough progesterone, her doctor may prescribe supplements to correct the problem.
Disorders of the Immune System
The immune system is designed to recognize and attack foreign substances within the body. Antibodies are formed to help the body fight off disease and heal itself in case of infection. Normally, the mother's body protects the "foreign" fetus from attack by her own antibodies. It is thought that this protection may be absent in the blood of some women who have had repeated miscarriage.
Other immune system problems are caused by differences between the mother and the fetus and even between the mother and the father. For instance, the mother's immune system may produce antibodies to the cells of her body. This can cause pregnancy loss. Tests can be done that may help find problems with the immune system.
Abnormalities of the Uterus
Several abnormalities of the uterus are linked to repeated miscarriage:
Congenital abnormalities. These are defects present from birth. For instance, a woman may have a uterus that is divided into two sections by a wall of tissue (septate uterus).
Uterine fibroids (leiomyomata). Uterine fibroids are benign growths (not cancer) made up of uterine muscle tissue.
Incompetent cervix. An incompetent cervix is one that begins to widen and open too early, in the middle of pregnancy, without any sign of pain or labor.
Most of these can be treated with surgery.
Environmental and Lifestyle Factors
The risk of miscarriage may be increased in pregnant women who:
Smoke
Drink alcohol
Use illegal drugs
Are exposed to high levels of radiation or toxic agents
Diagnosis
Because repeated miscarriage has many possible causes, your doctor will need a great deal of information to diagnose the problem. You will be asked about your medical history and past pregnancies, as well as your lifestyle and work setting. A complete physical exam, including a pelvic exam, also may be done.
Your doctor also may suggest some or all of these tests:
Blood tests to detect any problems with hormones or the immune system
Chromosomal testing of both you and your partner
Genital tract cultures to detect infection
Chromosomal testing of tissue from the miscarriage, if available
Procedures that also might be done include:
Endometrial biopsy. In this procedure, a sample of the tissue that lines the uterus is taken and looked at in a lab under a microscope.
Hysterosalpingography. This is an X-ray of the uterus and fallopian tubes. It is taken after the organs are injected with a small amount of fluid.
Hysteroscopy. In this procedure, the doctor inserts a hysteroscope - a thin, telescope-like device - through the vagina and cervix to view the inside of the uterus.
Laparoscopy. This is a surgical procedure in which a slender, light-transmitting device, the laparoscope, is used to view the pelvic organs.
Ultrasound. In this procedure, sound waves are used to view the internal organs.
Special Care for Future Pregnancies
Sometimes the problem that caused the miscarriages can be treated. Surgery may help some problems of the uterus and cervix. Treatment with antibiotics can cure infections. In other cases, hormone treatment may help.
If chromosomal problems are found in the parents, your doctor may advise genetic counseling. A genetic counselor can help you and your partner learn what risks a genetic problem might pose for future pregnancies. The fetus can be tested for some problems in future pregnancies by amniocentesis or chorionic villus sampling.
Coping with Repeated Miscarriage
What You Can Do
If you have had repeated miscarriage, future pregnancies should be planned, diagnosed early and watched. You can improve your chances of having a successful pregnancy in the future by doing certain things:
Have a complete medical workup before you try to get pregnant again. It may be that the cause of the miscarriages can be found and treated by your doctor.
If you think that you might be pregnant, see your doctor right away. The sooner you seek prenatal care, the sooner you can receive any special care that you may need.
Follow your doctor's instructions. He or she will tell you what you need to do to keep yourself and your fetus as healthy as you can.
The loss of a pregnancy - no matter how early or how late - can result in feelings of grief. You may be troubled and even overwhelmed by grief and discouragement. For many women, the emotional healing takes longer than the physical healing that follows a miscarriage.
Grief can cause you to blame yourself although you did nothing wrong. You might find yourself thinking about the early days of your pregnancy, searching for a clue that would explain the loss. You also may find yourself angry at your partner or other loved ones.
Other signs of emotional stress might include:
Headaches
Loss of appetite
Not being able to sleep
Feeling tired
Having trouble concentrating
Your feelings of grief may differ from those of your partner. You are the one who felt the physical changes of pregnancy. Your partner also may grieve, but he may not express his feelings the same way you do. He may feel that he has to be strong for both of you and may not share his hurt and disappointment. This may create tensions between the two of you just when you need each other the most.
Emotional pain is as real as physical pain, even though the injury cannot be seen or touched. If you feel sad, allow yourself to grieve. Grieving will help you accept the loss and get on with your life.
Above all, don't blame yourself for the miscarriages. Self-blame is self-punishment, and you do not deserve punishment. You need and deserve love, support, and reassurance.
Reach out to those closest to you and ask for their comfort and support. Talk to your doctor. There may be support groups in your area that are eager to help. Counseling can help both you and your partner if you think that you can't deal with your feelings alone.
Finally . . .
Even if you have had repeated miscarriages, you still have a good chance to have a successful pregnancy. This is true even if the causes of the past pregnancy losses cannot be found. Future pregnancies will need prompt and early care. Your doctor will check your pregnancy closely and provide any special care you may need as your fetus grows.
Glossary
Amniocentesis: A procedure in which a small amount of amniotic fluid is taken from the sac surrounding the fetus and tested.
Chorionic Villus Sampling (CVS): A procedure in which a small sample of cells is taken from the placenta and tested.
Chromosomes: Structures that are located inside each cell in the body and contain the genes that determine a person's physical makeup.
Repeated Miscarriage: Consecutive loss of three or more pregnancies before 20 weeks of gestation. Also called habitual abortion.
Earlier Screening for Fetal Chromosomal Anomalies
Posted 01/12/2004
Summary
In this NIH-sponsored study conducted at 12 U.S. centers, women with pregnancies between 74 and 97 days' gestation were offered screening for trisomies 21 and 18; screening involved risk estimates based on maternal age, blood levels of pregnancy-associated plasma protein A and free ß-human chorionic gonadotropin, and sonographic measurement of nuchal translucency. Fetal chromosomal status was determined by prenatal karyotype analysis if invasive testing was performed or by phenotype evaluation in live births. A total of 8216 women without histories of trisomy 21 or 18 pregnancies were included in the analysis.
Overall, 61 cases of trisomy 21 (prevalence, 1 in 135 pregnancies) were identified: 5 resulted in spontaneous abortions, 15 were electively terminated before week 15, 25 were terminated at week 15 or later, and 16 resulted in live births. In addition, 11 cases of trisomy 18 (1 in 747) were identified.
Using risk-based cutoff values comparable to those currently used for second-trimester screening, early screening identified 85.2% of trisomy 21 cases (false-positive rate, 9.4%) and 90.9% of trisomy 18 cases (false-positive rate, 2.0%). Among women aged 35 or older, 89.8% of fetuses with trisomy 21 and 100% with trisomy 18 were identified. Among the 9 patients with false-negative first-trimester tests for trisomy 21, 7 underwent second-trimester screening; results were positive in 6.
Comment
Compared with second-trimester screening for chromosomal abnormalities, first-trimester screening offers couples greater privacy and earlier information. Women with positive screening results can undergo chorionic villus sampling (CVS) to confirm the results, rather than wait to undergo amniocentesis later in pregnancy -- thus affording the option of earlier, safer termination of pregnancies. However, fewer than half of the women who carried fetuses with trisomy 21 and who chose to terminate their pregnancies did so before 15 weeks' gestation. This observation suggests that limited access to both CVS and abortion might reduce the benefits associated with earlier screening. In addition, some experts express concerns regarding standard measurement of fetal-nuchal translucency. In selected centers, first-trimester screening now can be implemented. However, editorialists suggest that second-trimester screening remain the standard of care, pending results from other studies and revision of practice guidelines.
-- Andrew M. Kaunitz, MD
Source
Wapner R et al. First-trimester screening for trisomies 21 and 18. N Engl J Med 2003 Oct 9; 349:1405-13.
Mennuti MT and Driscoll DA. Screening for Down's syndrome -- Too many choices? N Engl J Med 2003 Oct 9; 349:1471-3.
Obstetrics and Gynecology
September 2002 (Volume 100, Number 3)
Antiphospholipid Syndrome in Pregnancy: A Randomized, Controlled Trial of Treatment
Farquharson R, Quenby S, Greaves M
Obstetrics and Gynecology. 2002;100(3):408-413
Summary
This interim analysis found that aspirin alone is as effective as aspirin plus heparin in the management of recurrent pregnancy loss associated with antiphospholipid syndrome.
This prospective, randomized study compared the effects of low-dose aspirin with low-dose aspirin plus low molecular weight heparin (LMWH) in the management of recurrent pregnancy loss in association with antiphospholipid syndrome. Women between 18 and 41 years of age with a history of 3 consecutive pregnancy losses or with 2 losses plus a fetal demise were recruited. Antiphospholipid antibodies (lupus anticoagulant and anticardiolipin immunoglobulins G and M) were measured on 2 different occasions.
All potential candidates were screened for other etiologies of recurrent loss (genetic, uterine, autoimmune). Eligible patients were randomly assigned to receive either 75 mg of aspirin or 75 mg of aspirin plus 5000 U of LMWH from the first trimester on. Analysis was based on intention-to-treat and also on actual treatment. A total of 119 women were screened; 98 were randomized (47 to aspirin alone and 51 to aspirin + heparin). Eleven patients from the aspirin group switched to the other group, whereas 13 women from the aspirin + heparin group switched to aspirin alone.
At baseline, maternal age, parity, gestational age, number of previous losses, and laboratory evaluation were similar in the 2 groups. In the aspirin group, there were 34 deliveries and 13 losses during the study period, whereas in the heparin + aspirin group there were 40 live births and 11 losses (OR, 1.39; 95% CI, 0.55%-3.47%). Birth weight, gestational age at delivery, the incidence of preterm delivery, hypertensive complications, and need for cesarean delivery were similar between the 2 groups. Most of the losses were first-trimester losses; there was one loss at 30 weeks in the aspirin group and 2 losses during the second or third trimester in the other group.
When the analysis was restricted to actual treatment only, obstetric outcome and delivery data were similarly not different. This interim analysis found that aspirin alone is as effective as aspirin plus heparin in the management of recurrent pregnancy loss associated with antiphospholipid syndrome.
Clinical Commentary
Antiphospholipid syndrome is an autoimmune disease that can lead to characteristic obstetric complications. Women with this syndrome frequently have recurrent early losses or complications later in pregnancy. Otherwise unexplained hypertensive disorders or second- or third-trimester losses are characteristic problems. The circulating antiphospholipid antibodies lead to a procoagulant state, which can compromise placental flow and may lead to fetal loss or severe growth restriction. The 2 most common antibodies are anticardiolipin and lupus anticoagulant.
Several treatment modalities have been evaluated for the management of this syndrome. Immunosuppression and anticoagulant therapy and the combination of these have been evaluated in prospective trials. This study compared low-dose aspirin with low-dose aspirin plus heparin. Patients were selected by strict criteria. Laboratory evaluation was also appropriate, and abnormal values were confirmed with a second measurement. The initial power calculation required 110 women in each group. This study reports interim results based on 98 participants. They were randomly assigned to treatment, but placebo treatment or blinding was not used. Placebo effect should not be ruled out in any study of recurrent pregnancy loss; if there were significant placebo effect, it should have been similar in both treatment groups. In addition, it is difficult to achieve complete blinding when injections are given.
This study showed that heparin plus aspirin offered no benefit over aspirin alone. Early and late pregnancy complications were equally likely to occur. As there were no placebo or "no treatment" groups, the overall efficacy of these treatments cannot be evaluated. The findings of this study are contrary to results of other trials that found the combination of heparin and aspirin superior to single-agent treatment alone. Different inclusion criteria (number of losses, type of complication) or differences in the laboratory evaluation may explain the disparity.
This study underscores the importance of immunologic evaluation as part of the recurrent pregnancy work-up. Aspirin alone seems to be effective, and its use would be associated with fewer complications than the combination of aspirin plus heparin. The use of combination therapy should be offered to women who have more severe complications (thromboembolic) or to those who failed prior single-agent therapy. Most practitioners will probably still offer combination therapy, because earlier studies found it to be superior to aspirin alone. Further studies are needed to identify the best treatment for women with antiphospholipid antibodies and poor obstetric history.
Abstract
pupici
monu
Maruta spune:
Buna fetelor,
Monu - multumesc de intrebare, ma simt foarte bine nu prea am timp sa ma gandesc pentru ca am foarte mult de lucru; multumesc pt. email-uri.
Nique - fetelor mi se pare incredibil ce a patit Nique ! Cum te poti duce la doctor si sa-ti faca radiografie fara sa-ti puna oaresce intrebari : Vreti sa ramaneti gravida ? Luna asta v-ati protejat ? INCREDIBIL !!! Imi pare rau Nique de ce ti s-a intamplat.
Florypop - Draga mea TU esti un exemplu de urmat ! Nu trebuie sa avem incredere oarba in niste DOCTORI doar pentru ca se numesc asa. Iti doresc mult succes in continuare si nu te descuraja.
Liana30 - Multumesc frumos de incurajari Liana. Eu am fost terminata cand am patit ce am patit si nu mi-am revenit decat cand am auzit o poveste asemanatoare tie, cu o fata care a avut sarcina oprita in evolutie la 7 luni. Brusc mi-am revenit si mi-am dat seama ca ce am patit eu era "floare la ureche" si am inceput sa revin cu picioarele pe pamant. Cred ca Dumnezeu ne intinde cate o mana la toate in felul lui. Tot ce pot sa-ti spun este ceea ce imi spun mie insami " SE PUTEA SI MAI RAU ". Iti doresc multa sanatate ca-i mai buna ca toate si visurile tale sa devina realitate.
Fetelor maine merg la spital si abia vineri va mai pot scrie. Pana atunci sa auzim numai de bine !
Cu drag pentru toate fetele,
Maruta
" Cind trupul iti patimeste alearga la doctor, iar cind sufletul iti patimeste cheama un prieten, caci dulcele glas al prietenii este cel mai bun leac al durerii."
I. Golescu
Mara2004 spune:
Felicity,in Romania exista posibilitatea sa faci reclamatii.Medicii au si ei superiori,sunt consiliile medicilor,sunt institutii ale statului,exista presa... Problema este alta.
try spune:
N-am mai avut timp sa mai intru pe subiect, dar acum am revenit si raspund si eu din urma de unde ramasesem cu cititul.
"Dupa o pierdere de sarcina de 4 saptamani, este posibil ca menstruatia sa vina la 2 saptamani de la pierderea sarcinii? Nu am facut chiuretaj ci am lasat sa se elimine de la sine. De vreo 2 zile insa, culoarea sangerarii s-a transformat in rosu "menstrual" (adica rosu deschis) si am dureri menstruale. Mentionez ca sunt posesoare de chist ovarian drept(marisor) si fibrom uterin (nu foarte mare)."
Lordra, iti povestesc un pic situatia care am avut-o eu. Raman insarcinata, primul control il am programat la 12 sapt. (asa e regula aici daca nu ai avut bad hystory legat de sarcini sau alte probleme). Din sapt. 7 incep sa am regulat dureri ca de ciclu, ele devin din ce in ce mai puternice, din sapt. 10 incep sa am sangerari (de fapt mici pete maronii care au devenit rosii, apoi chegulete mici, apoi un pic mai abundente), tine treaba o sapt. si in final la 11 sapt. constat neputincioasa ca pierd bebelusul. E clar ca probleme au fost inca de la inceput, ca aceasta sarcina nu a fost una viabila (hCg-ul imi iesise de 2 ori cam "micutz" imediat ce m-am dus la doctorul de familie cand am aflat ca-s insarcianta, dar asta nu a fost semn ca trebuie sa supectez sarcina de probleme, mai ales ca a treia oara mi-a iesit hCG-ul bine). E clar si ca embrionul incetase de mult din evolutie, iar la 11 sapt. a fost doar eliminarea embrionului. Intotdeauna organismul are nevoie de un timp de procesare a informatiei dupa ce inima embrionului inceteaza sa mai bata. Avortul spontan nu se produce instantaneu, uneori e nevoie de saptamani ca organismul sa elimine singur totul (de-aia e de preferat cateodata chiuretajul dupa ce ai aflat ca bebe a incetat din evolutie, scurtezi timpul asta de asteptare ca nu stii nicodata cat e). De regula cu cat sarcina era mai maricica, cu atat timpul pana la declansarea avortului e mai mare. Am fost la medic in ziua avortului, tot asa, ma trimiteau acasa sa stau si sa astept sa se elimine tot. Nu tu chiuretaj (care eu credeam ca e necesar intr-o astfel de situatie), nu tu tratament preventiv contra unor eventuale infectii. Am insistat pe o ecografie si m-au trimis. S-a adeverit ca eliminasem tot (organismul meu lucrase "ca la carte" daca pot spune asa). In noaptea respectiva pentru ca ma luosesera durerile si sangeram (eu intelesesem ca trebuie sa se opreasca sangerarea si durerile dupa pierderea sarcinii) am plecat speriata la urgente. Acolo am mai facut o eco, totul normal, eliminasem tot, iar mi s-a spus ca n-am nevoie de chiuretaj sau ceva tratament, ca e normal sa sangerez pana la 3 sapt. dupa avort spontan.
Si eu am fost putin revoltata si-am crezut ca am fost tratata cum nu trebuia, dar... am citit, am intrebat si eu in stanga si-n dreapta, m-am mai documentat etc. si-am ajuns la concluzia ca totul a fost cum trebuia. Aici nu se face automat chiuretaj dupa un avort spontan decat daca avortul spontan e incomplet (iar asta se observa la ecografie). Tratament preventiv cu antibiotice nu se da. Aici antibioticele sunt date cu dramuire si nu pentru orice si in nici un caz preventiv (in Ro stiu ca se prescriau cu nonsalanta antibioticele - asa cum spunea si Felicity), ci doar daca e cazul, daca se depisteaza o infectie. Infectia presupune febra, sangerari puternice, ori eu nu aveam toate astea. Plus ca mentalitatea medicii nord americane merge un pic mai pe principiul "lasam natura sa-si faca treaba, iar daca ea da gres sau se dovedeste a nu fi capabial sa repare, atunci intervenim noi".
Dupa avortul spontan am sangerat destul de mult (mai mult ca la un ciclu obisnuit - deh, doar si captuseala uterului care se elimina, in timpul sarcinii, este mult mai groasa ca sa asigure confort sarcinii): o sapt. si-am avut niste dureri groaznice, mai ales in ovare (explicatia - semn ca ovarele s-au luptat impotriva aparitiei infectiilor). Apoi totul a reintrat in normal iar urmatoarea menstra a venit la 7 sapt. (normal este sa vina intre 6-8 sapt. dupa avort, spontan complet sau chiuretat).
Eu nu am inteles bine daca la tine a fost sangerare timp de 2 sapt. sau s-a oprit si apoi dupa 2 sapt. ti-a aparut din nou....
Cert este ca dupa chiuretaj in mod normal nu mai trebuie sa sangerezi (oricum nu mult) pentru ca prin chiuretaj se indeparteaza deja o parte din endometru (ala e de fapt ciclul nostru: la fiecare ciclu acest endometru se curata si aceste bucati se scurg sub forma de sange menstrual). La un avort spontan complet in care nu s-a mai facut chiuretaj, acest endometru se curata natural, singur, putin cate putin (de-aia sangerarea poate dura 3 sapt. si de-aia e mai abundenta).
Ecografia poate sa dea cele mai multe informatii de cum decurge un eventual avort. Dupa mine, un simplu tuseu vaginal nu poate spune daca sunt resturi placentare sau daca s-a eliminat tot. Daca s-a eliminat tot atunci nu mai e indicat un chiuretaj, daca insa nu s-a eliminat tot, chiuretajul este impus, altfel resturile respective pot da nastere la infectii urate...
In mod normal daca medicul nu ti-a zis "chiuretaj", atunci nu trebuie neaparat sa-l faci, insa era bine sa faci o eco sa te convingi ca e totul eliminat de-acolo. Iar daca ar fi sa ai vreo infectie, iti dai seama imediat: febra, sangerari mai abundente si dureri mai mari. Dupa cum vezi si eu am avut dureri dupa avortul spontan. Credeam si eu la inceput ca nu trebuie sa ma mai doara, dar in mod normal, eliminarea aia de endometru nu se face niciodata fara dureri. Ca sa se elimine aceste curatziri ale endometrului e nevoie intotdeauna de contractii (astea sunt durerile menstruale: contractii ale uterului care au ca rol eliminarea sangelui menstrual). Daca durerile sunt prea mari dupa un avort, atunci e posibil sa fie ceva in neregula.
"Oricum, eu personal n-am incredere intr-o sarcina care debuteaza cu stangul. Poate ca e mai bine ca natura sa faca selectia din timp."
In privinta asta gandesc ca si tine si sunt de acord cu asta. Nu mi-am dorit un copil cu orice pret, ci mi-am dorit un copil sanatos si am stiut ca daca el nu a putut face fatza "greutatilor" din burtica, atunci inseamna ca nu era un embrion puternic, mai devreme sau ma itarziu el ar fi cedat in fatza piedicilor pe care natura le pune in calea lor (ca si ei, chiar daca sunt mici embrioane sau celule, au si ei piedicile lor de surmontat, au si ei "testele" lor de trecut).
25+ sapt DNP 31 oct.
try spune:
Onetzica, la tine clar ca a venit prea tarziu tratamentul cu Utrogestan. Probabil deja se declansase avortul, iar Utrogestanul nu a mai putut repara nimic. De fapt, dupa cate stiam eu, tratamentele pe baza de progesteron (asa cum e si Utrogestanul sau Duphastonul) au menirea mai mult de prevenire decat de reparare. Ele nu pot repara ceva daca in cursul bunei dezvoltari a embrionului a aparut ceva. De regula cand apar pete, sangerari in sarcina mai ales daca sunt insotite si de dureri se prescrie preventiv progesteron. Sangerarile pot sa nu aiba neaparat urmari nasoale, pot sa fie si doar simple sangerari inocente care nu provoaca sau prevestesc nimic rau, insa nimeni nu poate spne dinainte cat de fatale sau nu sunt aceste sangerari, de-aia multi medici prescriu preventiv progesteron. El este hormonul principal de sustinere a sarcinii si cateodata corpul nostru nu produce progesteron in cantitate suficienta. Medicii incearca sa ajute putin prin aceste tratamente cu progesteron. El nu prezinta (pana acum) nici un pericol, intrucat surplusul de progesteron e eliminat prin urina. Aici in Canada nu se prea da progesteron decat daca ai avut antecedente de avorturi (mie la sarcina actuala, pentru ca aveam deja un avort spontan in urma, mi s-a dat progesteron preventiv, sa ajutam sarcina in caz ca eu nu produc suficient progesteron - oricum dupa cu mau mers treburile pana acum imi dau seama ca sarcina asta era oricum fara probleme, deci si daca nu as fi luat progesteron mergea totul bine), in Romania medicii recomanda mai usor progesteron la cea mai mica sangerare inca de la prima sarcina. 25+ sapt DNP 31 oct.