Recurrent Pregnancy Loss: What Is It? What Are The Causes? What Is The Evaluation?

recurrent pregnancy loss what I want you to know and what I wish I had known [Music] hi friends I am Dr Natalie Crawford I'm a board-certified ob gyn and REI I'm a fertility doctor this is National infertility awareness week which is a week really near and dear to my heart for two reasons one because I'm a fertility doctor this is what I do every day but also because I was you or I was that person I had infertility specifically I had recurrent miscarriages and I now have two amazing kids and they're seven and they're eight but I remember what it was like wondering if it would ever happen and I remember what it was like losing that naive joy that some people get with pregnancy because I was so worried every moment that I would lose the pregnancy or that something would go wrong so in this video we're going to be very quick but I do want to go over what I want you to know about miscarriage what I want you to know about having multiple miscarriages and the typical evaluation and then just some basic things about what it is that you can do or how to advocate for yourself first of all infertility is really common now we call it one out of every six is going to have infertility miscarriage is also common the hard thing about miscarriage is that so many pregnancies actually miscarry before you may even know that you're pregnant so it is a little bit different if you're undergoing fertility treatments or taking early pregnancy tests but if you're waiting to a missed period to check a pregnancy test you may actually just have a late period by a day or so but have been pregnant and not even know that and there was a study published in 1988 called the incidence of early pregnancy loss in the New England Journal of Medicine this was a landmark study where they chucked urinary concentrations and everybody throughout their entire menstrual cycle and cut a lot of data about what was happening and what they found is that 22 percent of people had an unrecognized pregnancy loss and when you combined the incidence of those unrecognized and recognized losses the total rate was over 30 percent however reassuringly 95 percent of people who had a pregnancy loss went on to concede within the next two years so most people were able to eventually get pregnant with a clinical pregnancy however this does show us that a lot of pregnancies must carry very early so if this is happening to you you are not alone we typically quote the rate of miscarriage one out of five or one out of four depending on your age if you're 30 or 35 but it's important to know that as you get older the incidence of miscarriage increases and this is directly proportional to your age and this graph is a great representation increase in miscarriage as you get older this is associated with a decrease in natural pregnancy rates these things correlate together based on what we call age-related aneuploidy abnormal chromosome number and this is the top cause of miscarriage no matter how old you are the way that I think about this is that our eggs are kept inside our ovaries until we ovulate but our eggs are held in a stage of cell division called meiosis and that's when our chromosomes are paired up in the middle and held apart by these meiotic spindles they separate into that egg that has a 23x when you ovulate so when you ovulate at 18 they've been sitting there shorter than when you are 25 or 40 so the older you are the longer your chromosomes have been held in place and the increase and chromosome errors you're going to see direct correlation what can you do if you're having an increase in aneuploid loss well one option here is going to be IVF and the reason why is because you could do genetic testing and by identifying embryos that have the genetic capability that is going to decrease your time to pregnancy and increase your option to get to live birth miscarriage rates are lower with genetically normal or euploid embryos so that's going to be the option if you are older if you are younger you might have an increased prevalence of aneuploidy we think that happens in some people when we fall into the Unexplained pregnancy loss category but that leads us to question what are the explained causes so let's just walk through the quick things that can cause recurrent pregnancy loss what the workup should be and what you should know so an anatomical defect in the uterus specifically a uterine septum is one of the most common causes a septum's actually a birth defect so this is where the uterus is formed in two different pieces they elongate fuse together and then this midline septum failed to reabsorb I have a whole video on this so you can learn more but this is surgically correctable another thing that could possibly cause miscarriage could be scar tissue inside the lining or uterine fibroids projecting anything that could interfere with implantation moving on from uterine issues we want to to move in to tubal disease so just thinking about tubal disease and understanding it tubal disease can predispose you to an ectopic pregnancy and not all ectopic pregnancies get to the point where they can be diagnosed clinically meaning the vast majority of them are just going to miscarry naturally before you would get to the stage where you could detect a pregnancy so things like endometriosis prior chlamydia infection prior abdominal surgery or inflammation might contribute to tubal disease then we're going to get into clotting disorders so we talk about a clotting disorder if your body has an increased tendency to clot because of a genetic issue or an autoimmune disease then you're at risk to have clotting in the small vessels that connect the placenta and Maternal Fetal vasculature this can lead to pregnancy loss and if found can be treated with aspirin or Lovenox or often the both of them together this however typically is a later pregnancy loss I've actually clinically seen it in both ways but the class history is somebody who has a second trimester loss when you really were dependent on those blood vessels for that connection in reality remember that the placenta is not really functioning until after nine weeks gestation so if you're having many really early pregnancy losses that doesn't really appear to be a contributing factor for why because that progesterone is being made by the corpus luteum that said I have seen it presenting both ways so if you've had pregnancy losses you should be screened for clotting disorders specifically if you had a second trimester loss or if you had potential placental complications and a loss like pre-term birth preeclampsia placental issues or insufficiency growth restriction then we're going to lead into other types of issues such as endocrine issues so classically this could be thyroid so uncontrolled hypothyroidism potentially autoimmune thyroid disease with really high thyroid antibodies potentially High prolactin that's not autoimmune that's endocrine but having that high prolactin can interfere with normal ovulation or the normal luteal phase which progesterone is important to opening and closing that implantation window and then we have diabetes having diabetes or an elevated sugar level in your blood and high hemoglobin A1c that can predispose you to have pregnancy loss and that is improved when you treat it just like prolactin just like thyroid so these endocrine abnormalities are easy blood tests that we can check that can sometimes improve things anything else that lives in the spectrum of ovulation disorders can also impact this so if you're having ovulation issues potentially from having low ovarian reserve maybe that is contributing potentially from having hypothalamic amenorrhea maybe that's contributing if you're getting higher we just tend to think that that luteal phase is dependent on a good follicle so if you're not growing a good follicle that might be a case where potentially having improved ovulation could benefit you or progesterone support this all falls in the category of luteal phase defect which I believe is on the spectrum of ovulation disorders gluteal phase the effect irregular periods and then going into amen over your opposite periods however Studies have shown us that if we are going to give progesterone for pregnancy loss it is important to start it before the implantation window meaning three days after ovulation so in that luteal phase when we think the corpus luteum is not making sufficient progesterone remember it's really hard to detect because progesterone is going to rise and fall in pulses throughout the entire luteal phase and I do have a really great video on progesterone if you want to dive in more to that but supplementing early can be helpful if you get a positive pregnancy as in your bleeding and you get a low progesterone and you supplement then it is too late to make a difference and there is this chicken and egg hypothesis where a poor pregnancy that's chromosomally abnormal is going to communicate to the body by not stimulating as much HCG therefore not stimulating as much progesterone and then causing a miscarriage that said in some people who have an ovulation issue giving progesterone on the luteal phase is easy and relatively low risk and potentially beneficial another thing in the spectrum of genetics and you play random chromosome abnormalities you can also have inherited abnormalities specifically what's called a balanced translocation the way I want you to think about this is your chromosomes have switched spots so that your body doesn't care where your chromosomes are they're encoding proteins to be made and they can do all of this but if they've switched spots when they go and separate now they're in the wrong place and that can cause a very high incidence of miscarriage typically we go to IVF so we can do genetic testing because there's no natural way to overcome that that is just how your body is going to split and then we have sperm issues we definitely are seeing emerging evidence that abnormal sperm shape exposure to things like marijuana smoking cigarettes and other toxins in the male partner is contributing to miscarriage and pregnancy loss there four this is a couple's thing I also say your egg quality what you can do you can't control your age but you can control how much inflammation your body has avoiding those toxins watch the video on egg quality think about what you can do to eat healthy have a lot of antioxidants get good sleep so your body can repair itself and that is controlling what you can do you should get an evaluation now after two pregnancy losses that is when we typically should draw the blood work and look at your uterus and make sure that everything is fine should you do Lifestyle Changes absolutely that's easy and what you can control should you also consider getting evaluation and treating what you find yes Studies have been mixed on baby aspirin I often put a lot of patience on it because there's very little harm but potential benefit there's some very rare things that can cause pregnancy loss like sticky platelets syndrome and we think that falls into the category of autoimmune disease do we know that autoimmune disease attacks the pregnancy particularly no is it probably through the pathway of inflammation yes but any untreated illness autoimmune or not when your body is busy fighting it off it doesn't have the resources it needs to help grow a pregnancy so I want you to take away any self-blame you did not cause your miscarriage but you're going to reframe your mindset to do what you can here going forward you're going to avoid toxins put healthy nutrients in your body get an evaluation find a doctor and a care team you trust and find a support system on National infertility Awareness Week the one thing I wish I had done different was open up to my friends and family more I never told them I was pregnant so it was hard to tell them that I was losing the pregnancy time and time again and if I could rewind the clock and after being on this side of the table so long that's the one thing I say you don't need to announce to the world but please consider telling your support system what you're going through because they can't be there if you don't let them thank you guys so much as always I appreciate you here I appreciate you helping grow this Channel please support your friends with infertility this week spread awareness one out of six is not uncommon you can always listen to the as a woman podcast for more information or you can follow along on Instagram and navigate MD thanks friends [Music]

Channel: Natalie Crawford, MD

Views: 17,214

Keywords: fertility, infertility, natalie crawford md, dr natalie crawford, as a woman podcast

Id: oMby9mdewxY

Length: 12min 6sec (726 seconds)

Published: Wed Apr 26 2023