I got recurrent miscarriages stating nil fetal heartbeat and IUGR. What to do next?

Question

Hello doctor,

I have been married for over three years. In these three years, I had five miscarriages. The first three times I had miscarriages in the second and third months (due to the missed heartbeat of the baby). Then the fourth time, I had a termination of pregnancy in the sixth month (due to the low amniotic fluid level of the baby); it was found in the fifth-month scan, but the baby's parts were found to be normal.

Again, for the fifth time, I had a medical abortion due to no heartbeat in the baby. I undergo all medical tests, HSG Scan, thyroid, prolactin, anti-cardiolipin Ab IgG, anti-cardiolipin Ab IgM, partial thromboplastin time (aPTT), HbA1c, LH, FSH, estradiol-17b (E2), platelet count, hemoglobin, prothrombin time (PT), control (PT), INR, bleeding time, clotting time, etc.

The karyotype test done for my husband and me reports that the chromosome analysis of cultured peripheral blood lymphocytes revealed a normal female karyotype. No clonal numerical or structural abnormalities were noted. A variant in chromosome 9 was observed with an additional heterochromatin region on the long arm. The rest of that is normal.

In that sixth month of termination of pregnancy, I took the injection Heparin 5000 IU once daily, Ecosprin 75 mg, Pregnyl 2 mg, Duphaston 10 mg, and Folvete 5 mg. Even though my pregnancy terminated due to severe oligohydramnios. But till now I have not found any solution to my problem, and the doctor was also not able to find out what the problem is. They are saying it is an unexplainable thing.

Please give me some suggestions. Four months have passed since the last miscarriage. Now give me some suggestions for the next step.

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

Learning from your history, you are a case of recurrent pregnancy loss with three continuous abortions (missed abortions) in the first three pregnancies, but you had a fourth naturally conceived pregnancy, which lasted for six months and was terminated for severe IUGR (intrauterine growth restriction) and oligohydramnios.

Your next pregnancy was again a missed abortion. With this view and your normal karyotyping and tests that you have furnished, everything seems all right. This pattern fits into the criteria of thrombophilias, which are a major cause of recurrent pregnancy losses.

As you said, you have undergone tests for anticardiolipin antibody (ACLA), thyroid, and prolactin. I need to see the reports. Further, we need to know your antinuclear antibody status, serum progesterone levels, serum testosterone, and prolactin levels as well. They are important to decide the cause and further diagnosis of RPL due to thrombophilias.

My advice for you would be:

1. Do not plan any pregnancy for another three months, as the uterus needs time (a minimum of six months) to recover from the previous pregnant state.

2. Start taking tablet Folic acid 5 mg from today for the next three months, when you can consider pregnancy again. The idea is that folic acid should be started three months prior to planning pregnancy, which would avoid any chances of congenital anomalies and malformation in the fetus and thereby missed abortions (which probably may be the cause, though there are no means to do tests on a fetus just two months old).

3. When you get pregnant, say, after three months, then as soon as you get a urine pregnancy test confirmation, you need to be started on thromboprophylaxis for thrombophilia with injection of Enoxaparin 20/40 mg s/c daily, depending on your weight, and a tablet of Ecosprin 75 mg daily for the whole of pregnancy till delivery.

4. Tablet Duphaston (Dydrogesterone) 10 mg is also to be started from the day of confirmation of pregnancy till 14 weeks.

All these can be considered, and there are ways to prevent further losses, but I would like to see all the reports, especially the above-mentioned ones. But no pregnancy for the next three months, please, and start Folic acid immediately so that your chances of missed abortion reduce due to an unknown cause in a future pregnancy, which you may plan after three months.

I hope it helps.

Thank you.

Answer 2

Hello,

Welcome back to icliniq.com.

I have seen the reports (attachment removed to protect patient identity).

Most of your reports are normal except the serum progesterone, which is on the lower side, indicating a luteal phase defect. So no problem; just follow the pregnancy plan after three months as advised and start Folic acid.

Your thrombophilia screening is normal, but it does not include the serum homocysteine value. You may get this test done to further rule out inherited thrombophilia.

Ideally, wait for pregnancy, and then we can provide progesterone support from early pregnancy as soon as the pregnancy is diagnosed until 14 weeks to prevent deficiency and support the pregnancy. Just try to remain destressed and have no plans for pregnancy for the next three months.

Have a healthy diet and enjoy these three months. Stress itself is a big factor in infertility. Get a homocysteine level done.

I hope it helps.

Thank you.