recurrent pregnancy loss, miscarriage, Mary Stephenson by ufv96247

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									The right tests may unlock mystery of miscarriage
                                                    ing to Dr. Stephenson. Miscarriages that occur
           more proactive, in part because they     between six and 10 weeks are associated with
           have access to more resources than       chromosome errors 50% of the time; after 10
ever before. But when it comes to miscar-           weeks, it drops to 5%, she said.
riage—particularly ones that occur before 10            It is not necessary to have a D&C to col-
weeks—they’re often left without answers.           lect miscarriage tissue: the patient can col-
    With the expanding use of ultrasound            lect her own at home. With D&C, chromo-
monitoring for ovulation induction and in           some results are obtainable 90% of the time;
vitro fertilization, more women are now aware       with expectant management, 66% of the
of preclinical miscarriages prior to six weeks      time (Stephenson et al, Human Reproduction,
of gestation. In addition, with the use of over-    2002;17:446–451). When performing a D&C,
the-counter, highly sensitive pregnancy tests,      physicians must isolate the pregnancy tissue
miscarriages are being diagnosed even before        from the specimen.
a menses is missed.                                     “Commonly, both maternal decidua and
    These factors are contributing to a rise in     miscarriage tissue are tested. Then we get a
patients seeking evaluation and management          ‘normal female’ result back, which is often in-         According to Dr. Kutteh, basic evaluations
of recurrent early pregnancy loss, which re-        correct,” Dr. Stephenson said. “The pregnancy       include:
fers to two or three or more consecutive preg-      tissue must be separated and cleaned.”              Ñ Genetic: karyotypes on both partners
nancies that end in demise before 15 weeks’             If a “normal female” result occurs, another     Ñ Anatomic: evaluation of the uterus by
gestation.                                          step can be taken: the DNA in the patient’s            sonohysteroscopy, hysterosalpingography,
    Why do early miscarriages occur? Accord-        blood can be compared to the miscarriage               or hysteroscopy
ing to Fellow Mary D. Stephenson, MD, MSc,          DNA. If the DNA fingerprinting is different,         Ñ Endocrine: Some experts, including Dr.
professor of ob-gyn and director of the Uni-        then maternal cell contamination has been ex-          Kutteh, advise testing thyroid-stimulating
versity of Chicago Recurrent Pregnancy Loss         cluded, meaning the “normal female” result             hormone levels in women with recurrent
Program, testing miscarriage tissue for chro-       is correct.                                            pregnancy loss. ACOG’s Practice Bulletin
mosomal abnormalities often provides the an-                                                               states that such tests are not required in
swer, yet many times this testing isn’t done.                                                              otherwise normal women with RPL and no
    “For decades, we’ve been evaluating the         Like Dr. Stephenson, Fellow William H. Kut-            treatments have proven beneficial in wom-
woman and her partner for recurrent preg-           teh, MD, PhD, director of Fertility Associates         en with antithyroid antibodies
nancy loss, but ignoring the miscarriage itself,”   of Memphis and ob-gyn professor and director        Ñ Immune: tests for lupus anticoagulant and
Dr. Stephenson said. “The first step should be       of reproductive endocrinology at the Univer-           anticardiolipin antibodies, both IgG and
examining the miscarriage tissue for random         sity of Tennessee, is committed to determining         IgM
chromosome errors.”                                 causes of recurrent early pregnancy loss.           Ñ Thrombophilic: Recent metaanalyses in-
    ACOG’s Practice Bulletin on the topic ac-           Dr. Kutteh believes it is particularly impor-      dicate that factor V Leiden and factor II
knowledges that many experts obtain a karo-         tant not to lose sight of established diagnostic       (prothrombin) are important risk factors
type of the tissue but states that definite rec-     and treatment strategies. Recently, he has no-          Evaluations can be completed by general
ommendations for routinely obtaining tissue         ticed that thrombophilia testing is happening       ob-gyns with up-to-date knowledge of immu-
karyotypes cannot be made (Practice Bulletin        too soon and too often.                             nology and thrombophilias, Dr. Kutteh said.
#24, Management of Recurrent Early Pregnancy            “I compare the current focus on thrombo-        Otherwise, the couple should be referred to a
Loss, February 2001, reaffirmed 2008).               philias to what happened 14 years ago when          specialist.
    Research shows that in miscarriages that        antiphospholipid antibody syndrome was rec-
occur prior to six weeks’ gestation, 70% of the     ognized as a cause of RPL,” he said. “Many
time it is due to numeric chromosome errors,        thought it was the cause of all RPLs, and they      ➜
such as trisomy, monosomy, or polyploidy.           began to overlook a careful evaluation of the
This information can help patients, but if test-    uterus. Today, thrombophilia panels are often
ing does not occur, questions remain, accord-       ordered before completing basic evaluations.”



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