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Support for anyone experiencing a miscarriage or looking for support from others who have been there.

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Postby zodiacbaby » Fri Apr 10, 2009 10:04 am

What is a miscarriage?

A miscarriage (spontaneous abortion) is any pregnancy that ends spontaneously before the fetus can survive. The World Health Organization defines this unsurvivable state as an embryo or fetus weighing 500 grams or less, which typically corresponds to a fetal age (gestational age) of 20 to 22 weeks or less. Miscarriage occurs in about 15-20% of all recognized pregnancies, and usually occurs before the 13th week of pregnancy. The actual percentage of miscarriages is estimated to be as high as 50% of all pregnancies, since many miscarriages occur without the woman ever having known she was pregnant. Of those miscarriages that occur before the eighth week, 30% have no fetus associated with the sac or placenta. This condition is called blighted ovum, and many women are surprised to learn that there was never an embryo inside the sac.

Some miscarriages occur before women recognize that they are pregnant. About 15% of fertilized eggs are lost before the egg even has a chance to implant (embed itself) in the wall of the uterus. A woman would not generally identify this type of miscarriage. Another 15% of conceptions are lost before eight weeks' gestation. Once fetal heart function is detected in a given pregnancy, the chance of miscarriage is less than 5%.

A woman who may be showing the signs of a possible miscarriage (such as vaginal bleeding) may hear the term "threatened abortion" used to describe her situation.

What causes a miscarriage, and what are the tests for the different causes?

The cause of a miscarriage cannot always be determined. The most common known causes of miscarriage in the first third of pregnancy (1st trimester) are chromosomal abnormalities, collagen vascular disease (such as lupus), diabetes, other hormonal problems infection, and congenital (present at birth) abnormalities of the uterus. Chromosomal abnormalities of the fetus are the most common cause of early miscarriages, including blighted ovum (see above). Each of the causes will be described below.

Chromosomes are microscopic components of every cell in the body that carry all of the genetic material that determine hair color, eye color, and our overall appearance and makeup. These chromosomes duplicate themselves and divide many times during the process of development, and there are numerous points along the way where a problem can occur. Certain genetic abnormalities are known to be more prevalent in couples that experience repeated pregnancy losses. These genetic traits can be screened for by blood tests prior to attempting to become pregnant. Half of the fetal tissue from1st trimester miscarriages contain abnormal chromosomes. This number drops to 20% with 2nd trimester miscarriages. In other words, abnormal chromosomes are more common with 1st trimester than with 2nd trimester miscarriages. First trimester miscarriages are so very common that unless they occur more than once, they are not considered "abnormal" per se. They do not prompt further evaluation unless they occur more than once. In contrast, 2nd trimester miscarriages are more unusual, and therefore may trigger evaluation even after a first occurrence. It is therefore clear that causes of miscarriages seem to vary according to trimester.

Chromosomal abnormalities also become more common with aging, and women over age 35 have a higher rate of miscarriage than younger women. Advancing maternal age is the most significant risk factor for early miscarriage in otherwise healthy women.

Collagen vascular diseases are illnesses in which a person's own immune system attacks their own organs. These diseases can be potentially very serious, either during or between pregnancies. In these diseases, a woman makes antibodies to her own body's tissues. Examples of collagen vascular diseases associated with an increased risk of miscarriage are systemic lupus erythematosus, and antiphospholipid antibody syndrome. Blood tests can confirm the presence of abnormal antibodies and are used to diagnose these conditions.

Diabetes generally can be well-managed during pregnancy, if a woman and her doctor work closely together. However, if the diabetes is insufficiently controlled, not only is the risk of miscarriages higher, but the baby can have major birth defects. Other problems can also occur in relation to diabetes during pregnancy. Good control of blood sugars during pregnancy is very important.

Hormonal factors may be associated with an increased risk of miscarriage, including Cushing's Syndrome, thyroid disease, and polycystic ovary syndrome. It has also been suggested that inadequate function of the corpus luteum in the ovary (which produced progesterone necessary for maintenance of the very early stages of pregnancy) may lead to miscarriage. Termed luteal phase defect, this is a controversial issue, since several studies have not supported the theory of luteal phase defect as a cause of pregnancy loss.

Maternal infection with a large number of different organisms has been associated with an increased risk of miscarriage. Fetal or placental infection by the offending organism then leads to pregnancy loss. Examples of infections that have been associated with miscarriage include infections by Listeria monocytogenes, Toxoplasma gondii, parvovirus B19, rubella, herpes simplex, cytomegalovirus, and lymphocytic choriomeningitis virus. Abnormal anatomy of the uterus can also cause miscarriages. In some women there can be a tissue bridge (uterine septum), that acts like a partial wall dividing the uterine cavity into sections. The septum usually has a very poor blood supply, and is not well suited for placental attachment and growth. Therefore, an embryo implanting on the septum would be at increased risk of miscarriage.

Other structural abnormalities can result from benign growths in the uterus called fibroids. Fibroid tumors (leiomyomata) are benign growths of muscle cells in the uterus. While most fibroid tumors do not cause miscarriages, (in fact, they are a rare cause of infertility), some can interfere with the embryo implantation and the embryo's blood supply, thereby causing miscarriage.

Invasive surgical procedures in the uterus, such as amniocentesis and chorionic villus sampling, also slightly increase the risk of miscarriage.


What does NOT cause miscarriage?

It must be emphasized that exercise, working, and sexual intercourse do not increase the risk of pregnancy loss in routine (uncomplicated) pregnancies. However, in the unusual circumstance where a woman is felt by her physician to be at higher risk of spontaneous abortion, she may be advised to stop work and intercourse. Women with past history of premature delivery and other specific obstetrical conditions might fall under this category.

Are there lifestyle factors associated with miscarriage?

Smoking more than 10 cigarettes per day is associated with an increased risk of pregnancy loss, and some studies have even shown that the risk of miscarriage increases with paternal smoking. Other factors, such as alcohol use, fever, use of nonsteroidal anti-inflammatory drugs around the time of embryo implantation, and caffeine use have all been suggested to increase the risk of miscarriage, although more studies are needed to fully clarify any potential risks associated with these factors. Of course, alcohol is a known teratogen (a chemical that can damage the developing fetus), so pregnant women are advised to abstain from drinking alcoholic beverages.

What are the symptoms of a miscarriage?

Cramping and vaginal bleeding are the most common symptoms noticed with spontaneous abortion. The cramping and bleeding may be very mild, moderate, or severe. There is no particular pattern as to how long the symptoms will last.

Vaginal bleeding during early pregnancy is often referred to as a "threatened abortion." The term "threatened" abortion is used since miscarriage does not always follow vaginal bleeding in early pregnancy, even after repeated episodes or large amounts of bleeding. Studies have shown that 90-96% of pregnancies with fetal cardiac activity that result in vaginal bleeding at 7 to 11 weeks of gestation will result in an ongoing pregnancy.

What will the doctor look for during an examination with suspected miscarriage?

A woman's cervix might have some bloody discharge, but nothing else unusual will be characteristic of threatened abortion. Some women will have mild uterine tenderness during the manual examination of the uterus. The doctor may look to see if the cervix is dilated and will check to see if the uterus is enlarged to an extent appropriate for gestational age of the pregnancy.

How is threatened abortion evaluated?

Pelvic ultrasound is used to visualize fetal heartbeat and to determine whether a pregnancy is still viable. The ultrasound examination can also distinguish between intrauterine and ectopic pregnancies. The doctor may also order blood levels of serial human chorionic gonadotrophin (HCG) to help determine the viability of a pregnancy if the ultrasound examination is not conclusive. During the evaluation, the woman may be advised to rest and avoid sexual intercourse (activity).

What are common terms a woman might hear during evaluation for miscarriage?

1. Miscarriage (spontaneous abortion) is termination of pregnancy before the fetus is viable (able to survive).

2. Complete abortion describes spontaneous (not intentionally induced by medication or procedures) passage of all fetal and placental tissue. This is common prior to 12 weeks' gestation.

3. Incomplete abortion is when some, but not all, the fetal and placental tissue is expelled.

4. Products of conception refers to the combination of fetal and placental tissue.

5. Threatened abortion is when a miscarriage does not actually occur, but there is vaginal bleeding from the uterus. The cervix will not be dilated and does not show signs of imminent passage of fetal and placental tissue.

6. Missed abortion describes a fetal death in the uterus prior to viability, but the products of conception are not passed.

7. A septic (infectious) abortion is caused by bacterial infection and accompanied by fever, chills, pain, and a pus-containing discharge.
What treatment can a woman expect when she has had a miscarriage?

The central goal of the doctor in this situation will be to try to figure out whether the woman has passed all of the tissue from the fetus and placenta. If she has passed all the tissue, she may only require observation by medical personnel. On the other hand, a woman who has not passed all of the tissue (incomplete abortion) will usually need suction dilation and curettage of the uterus to remove any retained products of the pregnancy. This procedure is done with local anesthesia, and sometimes antibiotics may be prescribed for the woman.

When should a woman receive evaluation for underlying causes of pregnancy loss?

Currently, most practitioners will not initiate an extensive medical evaluation for a single pregnancy loss, since the chance of having a normal pregnancy subsequent to even two consecutive miscarriages is 80-90%. For women with recurrent pregnancy loss, an evaluation will focus on the pattern and history of the prior miscarriages. Three consecutive miscarriages would suggest a woman should receive further evaluation.

Thus, the following tests are considered for women with three consecutive miscarriages. Blood testing can be done to identify chromosomal abnormalities in the couple that could be transmitted to the fetus. The couple can each appear completely normal but still carry chromosomal defects, which, when combined, can be lethal to the embryo. This type of testing is called karyotyping, and it is performed on both members of the couple. A hysterosalpingogram (HSG) can identify anatomical abnormalities within the uterus. Antinuclear antibody, anticardiolipin antibody, VDRL, RPR, and lupus anticoagulant are some of the blood tests used to diagnose autoimmune diseases that can cause recurrent miscarriage. As described above, some of these illnesses will already by apparent to the woman and her doctor, but not all cases. Other antibody tests may be performed as well.

Can something be done to prevent future miscarriages?

The treatment of recurrent miscarriage depends on what is believed to be the underlying cause. This often is not as simple as it sounds. Careful evaluation may turn up several potential factors which alone or together may be responsible for the losses. If a chromosomal problem is found in one or both spouses, then counseling as to future risks is the only option for the couple, since there is currently no method to correct genetic problems.

If a structural problem is encountered with the uterus, surgical correction could be contemplated. It should be emphasized that just because a structural abnormality is found, it does not necessarily mean that it caused the miscarriage. Removal of a fibroid or uterine septum does not guarantee a future successful pregnancy, since the fibroid or uterine septum may not have been the cause of miscarriage in the first place.

Adequate control of diabetes and thyroid disease is critical in trying to prevent recurrent pregnancy loss in women with those conditions. For women with immunologic problems, certain medications are being studied that may be useful in achieving successful pregnancy outcomes. Blood thinners such as aspirin and heparin can, in some cases, prevent further pregnancy loss.

The use of progesterone to increase the blood levels of this hormone is sometimes used for patients with recurrent pregnancy loss, although large-scale controlled studies that confirm the utility of progesterone supplementation have not been carried out. However, many physicians report success with progesterone therapy. Progesterone may be given as vaginal suppositories, or in tablet or gel form. In dealing with recurrent pregnancy loss, it is important to realize that even though apparently obvious problems can be corrected, a miscarriage can still occur. This is not to say that attempts should not be taken to correct identified abnormalities that have been historically associated with miscarriage. However, no treatment can be guaranteed. Even with repeated miscarriages, there is still a very good chance of achieving a successful pregnancy. Early pregnancy and pre-pregnancy counseling can help identify risk factors and allow the practitioner to provide any special care that may be needed.


epression Risk Increased After Miscarriage

New York - Miscarriage can represent a physical stress to the body of a woman as well as lead to emotional trauma affecting women and their families.

According to the National Center for Health Statistics (1997), the pregnancies of approximately half a million women annually in the United States end in miscarriage. The impact of miscarriages is further underscored by current estimates that nearly 20 percent of recognized pregnancies end in miscarriage.

In a study published in the Journal of the American Medical Association (1997;277:383-388) Dr. Richard Neugebauer and colleagues compared the risk for an episode of major depressive disorder among miscarrying women in the first 6 months after their loss of pregnancy with community women who had not been pregnant.

Dr. Neugebauer's study found that there was a significant risk of depression in women after miscarriage. Furthermore, 72 percent of the episodes of major depression occurred during the first month after the loss of the pregnancy.

The study also found that the risk for depression was substantially higher for those miscarrying women who had no children. Further, the data demonstrated that over half of the women with prior histories of major depression experienced recurrences after they had miscarriages.

The authors conclude that women should be monitored for signs of depression during the weeks after miscarriage.








Causes of Recurrent Miscarriage
Miscarriage is one of the most devastating experiences that can happen to a woman. Having one miscarriage is sadly, not that uncommon. Approximately two out of every ten pregnancies will result in miscarriage. After having one miscarriage most women go on to have a healthy pregnancy. Still there are a few women that will continue to have two, three or more miscarriages. Women are considered to have recurrent miscarriages when they have two or three miscarriages in a row. According to the American Society for Reproductive Medicine, only about one percent of women will have three consecutive miscarriages or more. Many doctors will not perform any tests until after a woman has had three consecutive miscarriages. Even with testing, doctors may not be able to determine the cause of recurrent miscarriage.

What are the causes of recurrent miscarriage?
Here are some of the most common causes of recurrent miscarriage:

Genetic/Chromosomal Defects: Up to seventy percent of miscarriages are caused by chromosomal errors. Chromosomal abnormalities are more common in women who are over thirty-five. In most cases chromosomal defects are a random occurrence and are not likely to reoccur in subsequent pregnancies. Although chromosomal errors are the cause of the majority of miscarriages, they are not usually caused by an inherited trait from mother or father. Less than five percent of couples tested will have an inherited genetic cause of such chromosomal defects.

Age: After thirty-five the risk of miscarriage increases. After age forty, more than 33 percent of pregnancies will result in miscarriage. However, keep in mind the rate of miscarriage prior to age thirty-five is about ten to twenty percent.

Uterine abnormalities: Uterus abnormalities account for ten to fifteen percent of repeated miscarriages. Some women are born with a double uterus or an abnormally shaped uterus. Other problems are scar tissue on the uterus. Uterus abnormalities may cause problems with proper implantation, create problems with blood supply to the uterus, or there may not be room for the baby to develop and grow.

Incompetent Cervix: Incompetent cervix may cause second trimester miscarriages or premature labor. Incompetent (or weakened) cervix may require a surgical procedure called cerclage. Cerclage is a surgical stitch around the cervix to help keep it from dilating prematurely.

Hormonal causes:

* Luteal phase defect – Luteal phase defect occurs when there is not enough progesterone produced during the luteal phase of the menstrual cycle. Progesterone helps to prepare the lining of the uterus for implantation and creates a nutrient rich environment for the developing baby. Some researchers believe that Luteal Phase Defect is responsible for up to forty percent of recurrent miscarriage; however, there are some questions as to the accuracy of these studies. Treatment for Luteal Phase defect includes taking progesterone supplements or suppositories with future pregnancies. There is some controversy over prescribing progesterone for miscarriage treatment. There have not been enough controlled studies to confirm its effectiveness or to ensure its safe usage during pregnancy.
* Polycystic Ovarian Syndrome – PCOS has been linked to miscarriage. Women with PCOS have higher levels of male hormones. This has been associated with infertility as well as miscarriage. Over a third of all women who have recurrent miscarriage also have PCOS. Treatment of PCOS often involves insulin-sensitizing medications. There is not enough evidence to show that this is an effective treatment for miscarriage; nor is there enough information on its safety during pregnancy.

* Other hormonal conditions: Poorly controlled Type 1 Diabetes has been associated with miscarriage. Improving blood sugars before conception will improve the outcome during pregnancy.

Autoimmune Disorders: Antibodies are designed to fight off infection in the human body. With certain autoimmune disorders antibodies fight off the developing pregnancy tissues as if it is a foreign body or infection. Antiphospholipid syndrome (APS) is an autoimmune disorder diagnosed by blood tests that detect levels of anticardiolipin antibodies and lupus anticoagulant. Antibodies, such as anticardiolipin antibodies, can cause blood clots that clog up the blood supply to the placenta. Without the placenta supplying nutrients, the pregnancy will perish. Treatment for antiphospholipid syndrome includes low dose aspirin or heparin. The research is still out on these treatments effectiveness in preventing miscarriage.

Infection: Certain infections have been linked to miscarriage. Genital infections such as bacterial vaginosis may increase a woman’s risk of having a miscarriage. Testing for infections is not routinely done in women who have no symptom of infection.

Male factor: There is some evidence that defects in the male’s sperm may cause miscarriage. It is not known how often sperm defects are the cause of recurrent miscarriage.

Unknown Causes: Many couples do not find the cause of their recurrent miscarriages. Fifty percent or more do not find a cause even after testing. Furthermore, it is possible to have different causes for each miscarriage. With this consideration it may not be possible to discover a pattern for a woman's miscarriages. The good news is that even if a woman has had multiple miscarriages the odds of having a successful pregnancy are still in her favor. In sixty to seventy percent of couples with unexplained pregnancy loss, the couple will go on to have a successful pregnancy.

Read more: Causes of Recurrent Miscarriage - http://www.justmommies.com/articles/rec ... z0CIJDsoRC





Blood clotting (thrombophilic) disorders

Although it has been known for a considerable time that a woman's blood becomes thicker in pregnancy, it has only recently been established that this process is more pronounced in some women compared with others. Blood clotting disorders (thrombophilias) can be inherited (genetic) or acquired.

Antiphospholipid antibodies, the two most important of which are the lupus anticoagulant and the anticardiolipin antibodies, cause blood to clot more easily. Women with a history of recurrent pregnancy loss who have persistently positive tests for either lupus anticoagulant and/or anticardiolipin antibodies are said to have Antiphospholipid Syndrome.

Inherited thrombophilias include Factor V Leiden, prothrombin gene mutations in the gene that codes for MTHFR, an enzyme involved in folate metabolism.

If blood clots occur in the blood vessels of the placenta, the blood flow to the baby is decreased and this can lead to either second trimester miscarriage or, if the pregnancy proceeds, to the birth of a baby that is smaller than he or she ought to be. Women with these disorders are also at risk of developing high blood pressure later in pregnancy.

For a long time, it was believed that thicker, "sticky" blood can cause first trimester miscarriages because it leads to blood clots in the developing placenta, preventing the embryo from getting the oxygen it needs. We now know that the first trimester placenta doesn't actually have any blood flowing through it- blood vessels are developing but they are plugged by placenta cells. In addition, our experience with embryos in IVF has taught us that oxygen is toxic to early embryos, so direct blood flow would be damaging.

It now appears that the antiphospholipid antibodies in acquired thrombophilias, or the proteins made by genes in inherited thrombophilias, prevent the placental cells from properly attaching to the mother's uterus. Without normal placenta development, the embryo cannot grow.


Immune disorders

The immune system is designed to recognise 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 could be absent in the blood of some women who have had repeated pregnancy loss.

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 could 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.

ormonal disorders

There are a number of hormonal disorders that are commonly associated with recurrent pregnancy loss.

The four most common hormonal disorders are:
1. Progesterone

Low levels of progesterone hormone are frequently found in women whose pregnancies are miscarrying.

However, low progesterone levels in early pregnancy reflect the fact that the pregnancy has not implanted successfully in the womb lining, rather than because the developing placenta is not producing enough progesterone to maintain the pregnancy. This is an important point - low progesterone is the effect not the cause of the miscarriage. This explains why giving women progesterone and/or hCG hormone injections in early pregnancy does not improve pregnancy outcome.

The exception to this is when we take advantage of the immunosuppressant effects of progesterone in women who are found to have immune problems.
2. Follicle Stimulating Hormone

Follicle stimulating hormone (FSH) drives the ovary to start growing follicles. Unfortunately, some women with a history of pregnancy loss are also found to have high FSH levels because their ovaries have become prematurely menopausal. Although rare, this is obviously a very important problem to identify. If FSH levels are high, the appropriate next step is referral to a fertility specialist.
3. The uterine lining (the endometrium)

At the present time the only way of determining the response of the endometrium at the time of implantation is to sample it and look at the histological (microscopic) evidence of the state of the tissues. An endometrial biopsy can be performed towards the end of your cycle (approximately day 26). This biopsy is no more uncomfortable than undergoing a cervical smear test. However, in order to be able to obtain the most useful information from the biopsy, it is important to know exactly the time of ovulation.
4. Polycystic ovarian syndrome

A pelvic ultrasound scan shows that many women with recurrent miscarriage have polycystic ovaries (PCO). This is a common condition, found in 25% of all women, in which there are multiple small cysts within the ovary. These cysts are not dangerous and cannot be removed as they are within the ovary.

Polycystic ovaries can sometimes be associated with a number of hormonal imbalances such as increased production of LH and testosterone. A number of carefully designed studies have shown that neither PCO nor high LH levels are a cause for recurrent miscarriages.

Infections

The role of vaginal infections in the causation of recurrent pregnancy loss is the subject of a new field of research.

Infection may well play a role in causing late pregnancy losses (14 weeks gestation) in a small number of women but it is unlikely to be important in causing early miscarriages.


Environment 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

Avoid these things during pregnancy - it's not just sound medical sense, it's common sense.



Unexplained loss

Although researchers are constantly trying to find new causes for pregnancy loss, there will always be some couples whose miscarriages remain unexplained.

Indeed, many cases of recurrent pregnancy loss will remain unexplained even after detailed investigations have been performed.

However, if a case of recurrent pregnancy loss is unexplained, it means that the couple in question most likely aren't affected by any of the major causes that crop up.

This is a good thing, because the prognosis for a future successful pregnancy in the unexplained group is usually better than it is for couples in which a recognised cause is identified.

If you've had more than one miscarriage, talk with your doctor:>

Investigate:>


Genetic tests - the body rejects a fetus because its genetics weren't quite right. We want to know more than why the fetus was rejected; we want to know why it was abnormal in the first place.

That's why we screen both partners for the gene responsible for quietening the immune response to pregnancy.

Immunological tests - Sometimes the mother's immune system seems to reject the embryo as if it were a foreign body. In others, the woman's immune system turns against her own body.

Our immunological tests are designed to see if you have any of these conditions.

Endocrinological tests - hormones play a vital role in reproduction. We test to see if an imbalance in these hormones could be the cause of your miscarriages.

Anatomical tests - we use ultrasound to investigate the uterus, tubes and ovaries looking for anatomical abnormalities. If suggested by the ultrasound scan, there are additional surgical operations we can do to treat these anomalies.

Haematological tests - there are different types of white blood cell inside the human body. Testing these can give us an indication of whether a patient is at a higher risk of miscarriage.

Biochemical tests - some disorders to do with copper metabolism and selenium intake can contribute to miscarriage and are easily screened for with a simple blood test.

Thrombophilia tests - thrombophilia describes a range of conditions that cause clots to form within blood vessels. We test to see thrombophilias are preventing the embryo from implanting in the uterus properly.

Infections tests - we look for infections which may contribute to miscarriage.

Histological tests - here we test the lining of the uterus (or endometrium) to see whether it is healthy.






thrombophilia / Clotting Disorders

Photo of familyHereditary defects in one or more of the clotting factors can cause the formation of potentially dangerous blood clots (thrombosis). Approximately 5-8% of the U.S. population has one of these clotting disorders collectively called thrombophilia, a propensity for blood clotting in which a genetic defect can be identified that often results in thrombosis.

More than 60,000 Americans die each year from venous thromboembolism; in addition, nearly half of patients with deep vein clots experience long-term health consequences that adversely affect their quality of life.

Prevention activities

CDC is helping to establish a network of thrombosis and hemostasis centers to conduct epidemiologic research on thrombosis and thrombophilia and promote the management, treatment, and prevention of complications experienced by people with clotting disorders.

CDC is conducting laboratory work to identify genetic risk factors that predispose persons to thrombophilia. Identifying these factors could help prevent complications that result from clotting.






Hypercoagulation: Excessive Blood Clotting
What is hypercoagulation?
When you get a cut, your body stops the bleeding by forming a blood clot (a thickened mass of blood tissue). Substances in your blood (called proteins) work with tiny particles (called platelets) to form the clot. Forming a clot is called coagulation. Coagulation helps when you are injured because it slows blood loss. However, your blood shouldn't clot when it's moving through your body in your blood vessels. The tendency to clot too much is called hypercoagulation. It can be very dangerous.


Why is hypercoagulation dangerous?
A clot inside a blood vessel is called a thrombus. Sometimes the thrombus can travel in the bloodstream and get stuck in your lungs. This kind of clot (called a pulmonary embolus) keeps blood from getting to your lungs. A pulmonary embolus can be life-threatening.

A clot that blocks a blood vessel in the brain can cause a stroke. A clot in a blood vessel in the heart can cause a heart attack. Blood clots can cause some women to have miscarriages. All of these conditions can also be life-threatening.


What causes hypercoagulation?
There are proteins in your body that are supposed to keep your blood from clotting too much. Some people do not make enough of these proteins. In other people, these proteins are not doing their job properly, or a person may have extra proteins in their blood that causes too much clotting.

Some people are born with a tendency to develop clots. This tendency is inherited (which means it runs in your family).

Certain situations or risk factors can make it easier for your blood to clot too much. These situations include the following:

* Sitting on an airplane or in a car for a long time
* Prolonged bed rest (several days or weeks at a time), such as after surgery or during a long hospital stay
* Surgery (which can slow blood flow)
* Cancer (some types of cancer increase the proteins that clot your blood)
* Pregnancy (which increases the pressure in your pelvis and legs and can cause blood clots to form)
* Using birth control pills or receiving hormone replacement therapy (which can slow blood flow)
* Smoking (which affects clotting)


How does my doctor know I have a problem with hypercoagulation?
Your doctor might think that you have a problem with hypercoagulation if any of the following are true:

* You have relatives with abnormal or excessive clotting
* You had an abnormal clot at a young age
* You got clots when you were pregnant, were using birth control pills or were being treated with hormone replacement therapy
* You have had several unexplained miscarriages

If your doctor suspects you have hypercoagulation, tests can check the protein levels in your blood. The tests will also show if your proteins are working the way they should to properly clot your blood.


Can hypercoagulation be treated?
Yes. Several medicines can thin your blood and make it less likely to clot. Some people with hypercoagulation only need to take blood thinners when they're in a situation that makes them more likely to form clots (such as when they are in the hospital recovering from surgery, when they are in a car or airplane for a long time or when they are pregnant). Other people need to take medicine on an ongoing basis for the rest of their lives. Your doctor will decide what treatment is right for you.


What medicines are used to treat hypercoagulation?
The two most common blood thinners are called heparin and warfarin (brand name: Coumadin). Your doctor will probably give you heparin first, because heparin works right away. Heparin must be injected with a small needle under the skin. Once the heparin begins to work, your doctor will probably have you start taking oral warfarin. Warfarin takes longer to begin working.

What are the side effects of these medicines?
Both medicines can cause you to bleed more easily. If you cut yourself, you might notice that the blood takes longer to clot than usual. You might also bruise more easily. Call your doctor if you have any unusual or heavy bleeding.

Warfarin has a stronger effect on some people than on others. If you take warfarin, your doctor will want to check you often with a blood test that shows how well the warfarin is working. Some other medicines can increase or decrease the strength of warfarin. Ask your doctor before you take a new medicine, including over-the-counter medicines, vitamins and herbal supplements. Also, talk to your doctor about foods you should avoid while taking warfarin.

If you're pregnant, you should not take warfarin. Warfarin can cause birth defects. Instead, you must use heparin until you deliver your baby. If you want to get pregnant and you're already taking warfarin, talk with your doctor about changing to heparin. Sexually active women who take warfarin should use birth control.


Bleeding and Clotting Disorders
Family Testing for Clotting Disorders

A "genetic thrombophilia," or an inherited predisposition to develop blood clots, affects both you and your family members. This article provides information about:

* Informing relatives of inherited risks to develop a blood clot
* Educating family members and understanding their reactions
* Advantages and disadvantages of genetic testing for the hereditary thrombophilias

Understanding Genetic Risks

Genetic changes (also called mutations) in clotting factors, like factor V and factor II prothrombin), are the most common, inherited, predisposing factors for blood clots; 5%-7% of Caucasians have factor V Leiden (a common change in the clotting factor V) and 2%-3% have a prothrombin mutation (a change in the clotting factor II). Other inherited thrombophilias include protein C deficiency, protein S deficiency, and antithrombin III deficiency. All of these conditions are inherited in an "autosomal dominant" pattern.

Autosomal dominant inheritance means that only one gene mutation is required to have an increased risk, and there is a 50/50 chance that the mutation will be present in first-degree relatives (parent(s), brother(s), sister(s), and children). Inheritance is not dependent on gender. In almost all cases, this means that if you have tested positive for an inherited blood clotting disorder, at least one of your parents will also be positive. Other relatives, including siblings, children, aunts, uncles, and cousins, may also be at risk. The Genetics of Thrombophilia contains further information about the inheritance of clotting genes.

Having a genetic predisposition does not mean that you will definitely have a blood clot or related condition (which may include recurrent pregnancy losses). Abnormal clotting of blood is a complex condition, in which genetic risks interact with non-genetic risks. Non-genetic risks may include smoking, using hormones, recent trauma or surgery, a sedentary lifestyle, or recent immobility. A blood clot will only happen if a combination of these factors is present. In fact, most people (up to 90%) with an inherited predisposition (like factor V Leiden and the prothrombin mutation) will never develop a blood clot. However, it is particularly important for those with genetic predispositions to avoid controllable risk factors that may cause them to develop a blood clot.
Telling Your Relatives about Genetic Risks in the Family

Genetic risks, by nature, affect not only you, but your family members as well. Genetics professionals often recommend that information about genetic risks be shared with other at-risk relatives. This may worry you, especially if your family does not openly communicate about health conditions. On the other hand, you may be anxious to contact your family members about their risk. In either case, it is important to think about your approach when contacting relatives and consider how they may react to the information you are presenting.

Talking with family members. You may decide to talk with family members, in person or over the phone, about your genetic test results. If you find it intimidating to explain information about genetics or blood clotting disorders, it may be helpful to have some factual information on hand to help you with your explanation. Just remember, you will likely know a lot more than your family members. It may take time for them to understand this information, and it may be helpful to provide only basic details in your first conversation.

A family letter. For some people, it is easier to contact relatives through a letter. An advantage of letter writing is that it allows you time to formulate your thoughts, versus having a telephone conversation where you may feel put on the spot. Writing a letter is also a good way to reach a number of people at one time. Also, your relatives may find it helpful to have the information in writing, so that they may process it at their own rate and have it available for future reference.
Emotional Reactions to Genetic Risk

It is likely that your various family members will have differing reactions to the news you have to share. Some may be relieved that you have found an explanation as to why you had a blood clot or related disorder. They may want to know about their own risks and if others in the family need genetic testing.

Others in your family may wish to avoid the subject altogether. They may not want to know about their genetic risks. Some may think that testing positive means that they will get sick. Genetic concepts and inheritance may be difficult to understand. Others may feel guilty or deny that a genetic risk is in the family. Education can help alleviate a number of these misconceptions.

Your parents' reactions. For some parents, learning that a genetic factor is related to a family illness may lead to feelings of guilt or grief. A parent may deny that the risk factor is genetic. A parent may also assume that he or she must not have the genetic risk factor if he or she has not had a blood clot or related problem. Some parents will feel reluctant to have genetic testing, since a positive test may make them feel responsible for passing a genetic mutation on to a child.

Other parents may have an opposite response. A parent may be intrigued by the information you have learned and may be interested in testing to see if he or she has the risk factor, too. Sometimes, learning more about genetics can help make sense of the family history. For example, it may shed light on why another relative had a blood clot, multiple pregnancy losses, or other related conditions.

There is little you can do to control your parents' response to the information. If your parent responds with feelings of guilt or grief, it is important to emphasize that genetic factors are just one small piece of the puzzle—a blood clot did not result from the genetic mutation alone. It is also important to emphasize that we all carry gene mutations that can lead to disease, and no one has control over what we pass on to our children. Parents may also benefit from speaking with others facing a similar situation. This type of support is available through organizations such as the National Alliance for Thrombosis and Thrombophilia (NATT). Lastly, if your parents are curious to learn more, they may find resources on the NATT website to be of interest.

Your children: where to go from here? If you have an inherited thrombophilia, you may wonder if your children have inherited it from you. You may be concerned and wonder if your children should be tested.

In general, medical experts recommend that children make an independent, informed decision about testing. It is not routine for children, who are otherwise healthy, to have testing, unless they have been fully informed of the pros and cons and can make an independent choice. It is also important to consider whether or not testing will influence a child's medical management. For example, testing may be more strongly encouraged for females when they are at an age where they may consider taking birth control pills, since this medication adds additional risk to the inherited risk. Testing is not as strongly indicated for boys because test results would not affect decisions about oral contraceptives or pregnancy.
Testing of other relatives

There is no right or wrong answer about who should have testing in a family. Individual decisions should be made based on a person's situation and opinions.

There are general advantages and disadvantages of testing that may be considered (below). Your family members may want to consult this list when discussing testing with a health care provider, such as a genetic counselor.
Genetic testing may be an advantage in the following circumstances:

Testing may help women weigh the risks of estrogen-containing contraceptives. Women who have an inherited blood clotting disorder have a greater risk of developing a blood clot while using estrogen (a hormone normally produced by the body, which may also be supplemented). Use of estrogen-containing birth control pills increases the chance that any woman will develop a blood clot by about 5-fold. For women with a thrombophilia, like factor V Leiden, the risk to develop a blood clot is about 32 times higher if they are taking estrogen-containing birth control pills. Clearly, thrombophilia interacts with estrogen in some way. Each woman's exact risk to develop a blood clot will vary. On average, approximately 1 out of 700 women who has factor V Leiden and uses estrogen-containing contraceptives will develop a blood clot each year. Genetic testing might be helpful for women who would choose not to use oral contraceptives due to this level of risk.

Testing may inform individuals about personal risk so they can make decisions about lifestyle changes that might lower risk. Knowing that one has an inherited thrombophilia may encourage a person to make lifestyle changes to decrease his or her risk for a blood clot. These changes might include losing weight, exercising, quitting smoking, or leading a more active lifestyle.

Testing may encourage a relative, or his or her doctor, to take symptoms of a blood clot more seriously. Blood clots are frequently misdiagnosed, as the symptoms are similar to those seen with other conditions (i.e., leg pain may be mistaken for a muscle strain). Awareness of increased risk for clotting may help your relative, and his or her doctor, to take these symptoms more seriously. This could help ensure early diagnosis and treatment of a blood clot.

Testing may affect health care management during pregnancy. All women have an increased chance to develop a blood clot while they are pregnant. However, women with an inherited thrombophilia are at greater risk. Women with an inherited thrombophilia may also be more likely to have a pregnancy loss, stillbirth, or certain complications of pregnancy. If there is a history of thrombophilia in the family, testing may be beneficial so that a woman can make informed decisions about using blood thinning medication during her pregnancy.

Before surgery, knowing that a person has a genetic thrombophilia could influence whether a doctor prescribes blood thinning medication after surgery. Also, the dose or length of blood thinning treatment may be influenced by a person's thrombophilia status.

Testing may provide peace of mind. For family members at risk, knowing for certain whether they have inherited a thrombophilia may provide reassurance.

People may choose not to get testing for several reasons. These might include:

Genetic testing may not change medical management. Many people who have hereditary thrombophilia will never develop a blood clot. Since use of blood thinners can cause serious and life-threatening bleeding, physicians very rarely put individuals who have not had a blood clot on blood thinning medication. Thus, even if an individual knows that he or she has an inherited clotting abnormality, often no therapy for prevention is currently available if one has not already had a blood clot. Because genetic testing often does not result in a change of medical management, some people feel that testing is not very necessary or helpful.

Testing positive may lead to feelings of guilt. Some parents may feel guilty that they may have passed on a hereditary thrombophilia to their children, and therefore may prefer not to have testing since this would reveal the affected parent. Other relatives may not want testing because they would feel guilty if they did not have a hereditary thrombophilia, particularly if their relative has been negatively affected as a result of having a genetic predisposition (this is called survivor guilt).

Concerns about insurance discrimination- There are federal laws to help protect people from health insurance and job discrimination. (For information, see www.dnapolicy.org/, "Project GINA"). However, these laws have limitations, and it is possible that a person with hereditary thrombophilia may have to (a) pay higher life, disability, or long-term care insurance premiums, and/or (b) get denied life or disability insurance if they test positive.

Testing may be costly- Testing may or may not be covered by insurance, depending on the reason for testing and the individual's insurance plan.

Testing may raise questions about paternity- Testing could reveal a genetic pattern that cannot be explained by inheritance (for example: a person who has one copy of the prothrombin mutation could discover that neither parent is positive.) This may lead to questions about paternity.

Individuals may be concern about labeling, infringement of privacy, and autonomy of children. There is some concern that testing children would lead to labeling. This could result in treating a child differently, due to concerns that he or she is at high-risk for illness. Making the choice to test a child who has never had a health problem may also raise concerns about privacy and autonomy. Testing a child may be an invasion of privacy and also interferes with autonomy, since the child is not able to make an independent decision about testing.

Right for Some, Not for Others

There is no definite right or wrong answer when it comes to genetic testing. There are many complexities— understanding who is at risk, dealing with emotional responses to this information, and determining if there is benefit to genetic evaluation of relatives. It is important to discuss these issues with a knowledgeable health care provider, who can assist you in identifying at-risk relatives and make recommendations regarding thrombophilia testing in your family. Genetic counselors are health care professionals who have experience and expertise in helping families with these issues.

To find a genetic counselor in your area, visit www.nsgc.org/resourcelink.cfm. This site allows you to search for genetic counselors by city, state, or hospital.

Permission to reprint this material has been granted by the National Alliance for Thrombosis and Thrombophilia (http://www.stoptheclot.org/).



yperthyroidism – or having an overactive thyroid gland – can pose special concerns during pregnancy. When the body delivers too much thyroid hormone, both the mother and the baby can suffer. Miscarriages, premature births, and intrauterine growth retardation can occur when the disorder goes undiagnosed or untreated. Pregnant women with hyperthyroidism can also develop high blood pressure, and are at greater risk of heart conditions.

While a thyroid condition can sometimes complicate the process of getting - or staying - pregnant, the good news is that when your disease is properly managed, most of you with thyroid conditions -- whether hypothyroid or hyperthyroid -- can have a safe, uneventful pregnancy and delivery. Taking your medications, keeping your thyroid levels -- including TSH and T4 -- under control, getting regular care with a specialist familiar with treating pregnant thyroid patients, and taking charge of your own health appears to be key to a successful outcome.

In some cases, pregnancy can actually lessen the symptoms of thyroid disease, and you may be one of the many women who enjoy a nine-month respite from some of the undesirable effects of thyroid conditions.

If I could urge women with thyroid disease who are contemplating pregnancy to do one thing, it would be to become educated about how thyroid dysfunction can affect fertility and pregnancy - and what to do about it. Read all you can, ask questions, and urge your doctors to perform the necessary blood tests to keep your levels in check.

Will my thyroid disease hamper my ability to get pregnant?

Sometimes - but certainly not always - thyroid disease can affect your fertility. According to Dr. Sheldon Rubenfeld, a practicing thyroidologist, and Founding Chairman of the Thyroid Society for Education and Research, fairly common problems caused by thyroid dysfunction are anovulation (no ovulation, or release of an egg) and menstrual irregularities. With no egg to fertilize, conception is impossible.

Thyroid dysfunction can halt ovulation by upsetting the balance of the body’s natural reproductive hormones. One way to tell if you’re ovulating is to test the level of a pituitary hormone called LH (or luteinizing hormone) by using an ovulation predictor kit. LH stimulates the ovaries to release an egg. The kit will show you if you have that surge in LH that indicates ovulation. If there is too much or too little thyroid hormone, ovulation might not occur. Remember...even though you may be menstruating regularly, you may not be ovulating - and may never know that fact until after years of infertility.

In addition, some women experience a short luteal phase. The luteal phase is the timeframe between ovulation and onset of menstruation. The luteal phase needs to be of sufficient duration -- a normal luteal phase is approximately 13 to 15 days -- to nurture a fertilized egg. A shortened luteal phase can cause what appears to be infertility, but is in fact failure to sustain a fertilized egg, with loss of the very early pregnancy at around the same time as menstruation would typically begin.

Dr. Rubenfeld said that "the mechanisms by which thyroid problems interfere with fertility are often unknown, but there is no question that other aspects of thyroid function affect fertility." For example, Dr. Rubenfeld said that hypothyroidism can cause an increase in prolactin, the hormone produced by the pituitary gland that induces and maintains the production of breast milk in a post-partum woman. Excess prolactin has a negative effect on fertility - sometimes preventing ovulation, or sometimes causing irregular or absent monthly cycles.

The increase in prolactin may be caused by an elevation of a hormone from the hypothalamus called TRH (or thyrotropin releasing hormone) that stimulates the pituitary gland to send out both prolactin and TSH.

Some women with hypothyroidism also have polycystic ovaries, or cysts on the ovaries, which hamper ovulation and can cause fertility problems as well.

This all sounds pretty grim. Should I even bother trying? What can I do to maximize my chances of getting pregnant?

Yes, you should bother trying - there are many, many success stories (I happen to be one of them, as it only took a few months to get pregnant with my daughter). You shouldn’t go into this thinking it’s going to be a long, arduous process. But attempting pregnancy with a thyroid condition may require a little preparation.

First of all, talk to your doctor about when you should attempt conception. Many doctors think TSH levels of 3, 4, or even 5 may acceptable to try to get pregnant. But research suggests otherwise. In 1994, a study in the Journal of Clinical Endocrinology and Metabolism looked at pregnant women with thyroid antibodies and TSH in the normal range. The study found that women with autoimmune thyroid disease had TSH values significantly higher, though still normal, in the first trimester than in women with healthy pregnancies used as controls.

The higher TSH level of the women with autoimmune thyroid disease? 1.6.

The normal TSH level for the control group of pregnant woman without autoimmune thyroid disease? 0.9. A TSH of .9 is a far cry from the so-called "normal" TSH levels of 3 or 4 or 5 that some doctors feel are no impediment whatsoever to getting -- or staying -- pregnant.

My endocrinologist at the time I was trying to get pregnant believed very firmly that most women with a thyroid problem should be maintained at a TSH level of between 1 and 2 in order to help them get pregnant -- and maintain the pregnancy.

Second, ascertain whether you’re ovulating. An excellent, empowering book is Toni Wechsler’s Taking Charge of Your Fertility.. You can learn how to use basal temperature and other fertility signs to chart your monthly hormonal cycle. You can also use an over-the-counter ovulation predictor kits, available for around $10 at the drugstore, to confirm ovulation. Or the more expensive ovulation predictor electronic devices can also be used.

What if I can't get pregnant, but my thyroid tests "normal?" Or what if I test positive for "antibodies?"

Some women who have fertility problems actually have underlying autoimmune thyroid problems, but they and their doctors are not aware. If you or someone you know is having difficulty getting pregnant, or is suffering recurrent miscarriage, thyroid antibodies should be tested.

Many doctors do not appear to know about this link between antibodies and infertility, yet it is published in conventional research journals. The respected journal Obstetrics & Gynecology reported that the presence of antithyroid antibodies increases the risk of miscarriage. And according to U.S. research reported in the Journal of Clinical Endocrinology and Metabolism, that risk of miscarriage can be twice as high for women who have antithyroid antibodies.

Researchers have also demonstrated that antithyroid antibodies can cause greater difficulty conceiving after in vitro fertilization, regardless of whether or not there are clinical symptoms of hypothyroidism. The researchers had greater success in achieving successful pregnancies when they gave low doses of heparin (an anti blood clotting agent) and aspirin and/or intravenous immunoglobulin G (IVIG) to women who had antithyroid antibodies.
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