Diagnosing The Cause Of Recurrent Miscarriage

Unfortunately, you may already have suffered one or more miscarriages before a thorough evaluation is performed. Work with your doctor to try to find the cause of your recurrent miscarriages. Talk with your doctor about your medical history, your experiences during past pregnancies, and any risk factors or medical conditions that you may have. Your doctor will want to perform a complete physical examination and will also likely order many diagnostic tests in an attempt to determine a cause for the miscarriages. Following is a checklist of possible tests and studies that you may be asked to undergo:

• Blood tests: Your blood will be checked for progesterone level, certain viruses, diabetes, thyroid function, blood-clotting disorders, other immune disorders.

• Pelvic infection testing: The vagina and uterus may be swabbed and the swabs sent to the laboratory to test for infection.

• Genetic evaluation: The miscarriage tissue, you, and your partner may be tested for the presence of abnormal chromosomes.

• Ultrasound: Ultrasonic sound waves are used to create an image of your pelvis on a monitor and your pelvic anatomy can be evaluated for possible problems.

• Sonohysterogram: In this specific type of ultrasound of the uterus, sterile water is first injected into the uterus for better viewing and evaluation of potential abnormalities.

• Hysterosalpingography: This is a special type of x-ray (called fluoroscopy) of the uterus and fallopian tubes performed after injection with dye. It helps detect some problems within the uterus and pelvic anatomy. However, HSG is best suited to determine the openness of the fallopian tubes.

• Hysteroscopy: A narrow telescope-like device is inserted into the uterus to view the inside of the uterus and check for abnormalities.

Remember that even if no underlying cause is found, many women go on to have future successful pregnancies. If you and your doctor do find an underlying cause, treatment options are available so that you can hopefully enjoy future successful pregnancies.

Ectopic Pregnancy

If you've endured an ectopic pregnancy, you know how difficult that experience can be. You are initially excited with your newly positive pregnancy test. Your emotions run high as you experience the excitement and joy associated with those early days of pregnancy. However, within a few weeks, you start to bleed or perhaps experience one-sided pelvic pain. An ultrasound shows that the pregnancy is not located within your uterus. Instead, the pregnancy is growing somewhere else, perhaps within your fallopian tube or another place in your pelvis. With tremendous sadness and concern, you must come face-to-face with your ectopic pregnancy.

WHAT IS AN ECTOPIC PREGNANCY? WHAT HAPPENS TO MY BODY?

An ectopic pregnancy is a pregnancy that implants and grows outside of the uterus. The most common site for this to occur is in the fallopian tube. However, ectopic pregnancy can also occur in the ovary, the cervix, or elsewhere within the pelvic cavity.

Actually, when you stop to think about it, it's a wonder that more pregnancies don't implant within the fallopian tube. That's because even under normal circumstances, fertilization (the union of the sperm and egg) occurs inside one of the fallopian tubes. Within a few days, as the fertilized egg continues to develop, it is supposed to move into the uterus to properly implant and grow. However, in the case of an ectopic pregnancy, the fertilized egg never makes it to the uterus. Instead, it tries to grow within the tube. Rarely, it may attach itself to an ovary or another pelvic organ.

The two primary symptoms of ectopic pregnancy are vaginal bleeding and onesided pelvic pain. These may vary in intensity depending on how far the pregnancy has progressed. Ectopic pregnancies are dangerous because they may lead to rupture of the fallopian tube, along with severe hemorrhage. In extreme cases, the intra-abdominal bleeding can become catastrophic and even fatal to the woman. (See Figure 2.1.)

WHO IS AT RISK? WHAT CAUSES ECTOPIC PREGNANCY?

Ectopic pregnancy occurs at the rate of about one in 60 pregnancies. However, it has been reported with the incidence closer to approximately one in 30 pregnancies when IVF (in vitro fertilization) is used.

Sometimes ectopic pregnancy happens for no apparent reason. However, certain risk factors have been found to increase the chances for ectopic pregnancy. These risk factors are:

• History of severe pelvic infections

• Endometriosis

• Cigarette smoking

• Increasing maternal age

• History of infertility

• Prior surgery on the fallopian tubes

• Prior pelvic or abdominal surgery (scar tissue)

• Previous ectopic pregnancy

HOW IS ECTOPIC PREGNANCY DIAGNOSED?

If your doctor suspects that you have an ectopic pregnancy, he or she will perform certain tests. The doctor will likely perform a pelvic exam, check your blood pressure and pulse, perform an ultrasound, and draw your blood to check your pregnancy hormone levels. The diagnosis of ectopic pregnancy may not be apparent right away. Sometimes it takes a few days of observation and additional testing before the diagnosis is clear. The use of sophisticated ultrasound technology and accurate hormonal monitoring now makes it possible to detect most ectopic pregnancies when they are still in the very early stages. Early diagnosis helps to lessen your chance of tubal rupture and severe hemorrhage.

Figure 2.1. Ectopic Pregnancy

Ectopic site of embryo

Figure 2.1. Ectopic Pregnancy

Ectopic site of embryo

Cut-away view of uterus

Illustration copyright © Nucleus Medical Art, all rights reserved, nucleusinc.com

Cut-away view of uterus

Illustration copyright © Nucleus Medical Art, all rights reserved, nucleusinc.com

HOW IS ECTOPIC PREGNANCY TREATED?

Many people wonder if the developing ectopic pregnancy can be removed from the tube (or another pelvic location) and be transplanted properly into the uterus. Unfortunately, despite much emerging technology in the field of reproductive medicine, transplanting an ectopic pregnancy has not yet been accomplished. Therefore, all ectopic pregnancies must be ended.

Once the diagnosis of ectopic pregnancy has been made, treatment is largely based on how far along your pregnancy has progressed and what symptoms you are experiencing. Sometimes the medication methotrexate may be used to dissolve the pregnancy. (Methotrexate is best known as a chemotherapy medication to treat cancer patients.) If successful, this medication allows you to avoid surgery and keep your fallopian tube intact. If the medication does not work as intended, surgery may eventually be required.

If your pregnancy is further along or if the tube has already ruptured, surgery is often required. In most cases, the surgery can be performed through a small incision with the laparoscope. The laparoscope is a thin telescope-like device with light that is inserted through a small opening in your abdomen. Other times, especially if significant blood loss has occurred, a larger incision and hospital stay may be required. In either case, some or all of your fallopian tube may need to be removed. If your entire tube is removed, then you must rely on your remaining fallopian tube for future pregnancies, which is certainly possible.

Follow-up care after an ectopic pregnancy is very important. Your blood should be checked several times over the next two to three weeks to ensure that the pregnancy hormone continues to decrease and return to zero. When you become pregnant again, you should see your doctor immediately for an ultrasound and hormonal blood evaluation.

Molar Pregnancy

If you have undergone a molar pregnancy, you've likely experienced a whole array of emotions and concerns. Of course, you are initially excited when your pregnancy test turns positive. Perhaps you've even shared your good fortune with friends and family. Then, within a few weeks, you notice that something doesn't seem quite right with your pregnancy. Perhaps you begin to experience vaginal bleeding. Or maybe your uterus seems larger than you would have expected. You consult with your doctor, who draws your blood to check for hormones and also orders an ultrasound. Sadly, your hormonal blood levels are extremely high, and the ultrasound shows that your uterus is filled with abnormal tissue. The doctor explains molar pregnancy to you, and your dreams for a baby suffer a crashing blow.

WHAT IS A MOLAR PREGNANCY? WHAT HAPPENS TO MY BODY?

Molar pregnancy is a rare condition that results in growth of placenta-like abnormal tissue within the uterus. A molar pregnancy can also be called a hydatidiform mole or gestational trophoblastic disease.

Like a normal pregnancy, a molar pregnancy is also originally formed from a fertilized egg. Of course, in the case of a normal pregnancy, the fertilized egg grows and develops into a fetus and placenta. With a molar pregnancy, a genetic error occurs, and the fertilized egg grows abnormal cells and fills the uterus with a mass of placenta-like tissue.

The two different types of molar pregnancy are complete (the most common type) and partial. A complete molar pregnancy comprises entirely abnormal placentalike cells; no fetus is present. Partial molar pregnancies have the same abnormal cells present in complete moles but also contain an extremely malformed fetus with fatal defects.

The main symptom of molar pregnancy is first-trimester vaginal bleeding. In addition, some women notice that their belly is growing faster and larger than they expected. The enlarged belly may be caused by the mass of placenta-like tissue within your uterus or sometimes by enlarged ovarian cysts. The ovarian cysts are large fluid-filled sacs within your ovaries and are caused by molar pregnancy hormones.

WHO IS AT RISK? WHAT CAUSES MOLAR PREGNANCY?

Molar pregnancies occur in about one in 1,000 pregnancies. Women younger than 20 or older than 40 appear to be at increased risk. The cause of molar pregnancy is not completely understood. Various theories point to a defective egg, abnormalities within the uterus, or nutritional deficiencies. Diets low in protein, folic acid, and carotene may be a risk factor. More research is needed to better identify the risk factors and causes of molar pregnancy.

HOW IS MOLAR PREGNANCY DIAGNOSED?

If your doctor suspects that you have a molar pregnancy, he or she will perform a pelvic exam to see if your uterus is larger than expected. The doctor will also order your blood to be drawn and checked for your level of pregnancy hormone, called human chorionic gonadotropin (hCG). It is normally produced by the placenta but is produced in massive quantities in the case of a molar pregnancy. Thus, if your hCG level is extremely elevated, a molar pregnancy may be more likely.

Your doctor will also order an ultrasound of your pelvis. Molar pregnancy has a very distinct look on ultrasound, so it is easy to diagnose.

If a molar pregnancy is diagnosed, you must be checked out thoroughly for other medical conditions. That's because molar pregnancy is sometimes associated with preeclampsia and hyperthyroidism. Your doctor will want to closely monitor your blood pressure and also check your blood for thyroid function. If these conditions are present, they will go away once the molar pregnancy has been terminated.

HOW IS MOLAR PREGNANCY TREATED?

Molar pregnancy is treated by removing the pregnancy with a D&C. For this procedure, you are first given anesthesia to ensure that you are comfortable. Then the doctor will open your cervix and remove the tissue from within the uterus. No further treatment is required in about 90 percent of women who undergo a D&C for molar pregnancy. However, you should know that follow-up care is very important. Your doctor will check your blood for hCG hormone levels for the next 6 to 12 months to make sure that the level returns to zero.

If your hCG hormone levels do not return to zero, your doctor may suspect that abnormal molar pregnancy cells are still present. Abnormal cells remain in about 10 percent of women who are treated with a D&C for molar pregnancy. In such cases, chemotherapy may be required to remove the remaining abnormal tissue. In extremely rare cases, hysterectomy is required. Cure rates for persistent molar pregnancy are almost 100 percent.

If you have experienced a molar pregnancy, your doctor will probably recommend waiting six months to a year before trying to conceive again. The reason is to ensure that your hCG hormone levels return to zero and also that your menstrual cycle and your general health get back to normal. Sometimes your doctor may recommend that you take birth control pills during this time to ensure that you don't become pregnant.

Once cleared to try again, you will hopefully conceive a perfectly normal pregnancy. The American College of Obstetricians and Gynecologists reports that the chances of having another molar pregnancy are only about 1 percent.

Coping Emotionally with Early Pregnancy Loss

Most women who experience early pregnancy loss go on to have a healthy pregnancy later. Even so, the loss of a pregnancy can be very difficult. Adjusting to the loss takes time and a great deal of emotional support.

You will probably go over and over the experience in your mind and try to understand what went wrong. You may even blame yourself for the loss, though it is rare that the woman is at fault.

The loss of a pregnancy can generate a wide range of emotions. Most women experience a great deal of sadness and grief. You may find yourself crying unexpectedly and breaking down, especially when you see someone else's baby. Anger, guilt, and disappointment are also emotions you can expect. You may wonder why you must endure this loss when pregnancy seems so easy for others. Some women even experience unexpected physical changes, such as headaches, reduced appetite, fatigue, and insomnia. Please know that these changes are all normal and part of a healthy healing progression.

As you begin your healing process, realize that it will take longer for your emotions than your physical pain to heal. Even a very strong person can experience the emotional impact very deeply. Be patient with yourself, and cry if you feel like crying.

Your emotional approach to this pregnancy loss may be different from your partner's. After all, you are the one who experienced the physical and hormonal changes of pregnancy. Your partner will have his own unique way of grieving. Some men feel that they must be strong for both of you and will not let his emotions get in the way. Unfortunately, this can create tension between the two of you. Communicate openly and honestly with your partner. Your feelings will improve when you are sensitive, accepting, and tolerant to each other's needs.

You may also find that it helps to share your thoughts with others. Start by talking with close family members and friends. They love you and want to share in both the ups and downs of your life. Their encouragement is crucial to helping you through this difficult and emotional time.

It may help you to speak with other women who have also experienced miscarriage. Many women state that they didn't realize how many other women had miscarriages until they started talking with others about it. You can probably find nearby support groups that are eager to help you.

If you continue to struggle with your feelings, be sure to talk with your doctor. In some cases, short-term medication may help reduce your depression and anxiety. You may also want to consider a professional counselor who can help you better cope with your emotions.

Deciding to become pregnant again is often a complex and worrisome decision. Some people believe that the appropriate time to become pregnant is when you and your partner feel physically and emotionally ready. When that time comes, hopefully you realize that the miscarriage was not your fault and you are ready to move forward.

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