Early Pregnancy Loss

Early pregnancy loss: Does it have to recur to deserve an evaluation?

In the past, in Ob/Gyn teachings, it was felt that a couple needed to suffer three miscarriages and to carry a diagnosis of "habitual miscarriage" to be deserving of a work-up for possible sources of this tragic outcome. Increasingly many physicians are doing appropriate testing after only two losses. Dr. Goldstein has published research on and advocates evaluation of pregnancy failure as early as the first failed pregnancy. Two major advances in the last decade have made this approach possible. The first is the use of endovaginal ultrasound from very early stages of the missed menstrual period and positive home pregnancy test. This allows identification of the pregnancy and following of its normal landmarks when it is so small that you could not even see it with the naked eye. Using this approach, I have had virtually no miscarriages in this practice in more than ten years. I have the same amount of early pregnancy failure but I have been able to diagnose it before it is spontaneously passed. Pregnancy loss (miscarriage) takes place one to four weeks after the pregnancy loses its viability. The reason I see all pregnant patient two weeks after the first visit is to be sure the embryo is growing, normal landmarks are achieved and cardiac activity is observed. In those unfortunate cases where the embryo loses its viability, if the diagnosis is made prior to spontaneous passage it allows for elective dilatation and curettage (removal of the products of conception in a sterile controlled fashion) prior to the onset of bleeding, cramping, hemorrhaging and the need for an emergency room visit and an emergency D&C. Performing elective D&C allows the isolation of just the early pregnancy tissue in a sterile fashion so that chromosomal analysis can be performed.

Previous studies have indicated that approximately 50% to 70% of such failed pregnancies will have abnormal chromosomes. Dr. Goldstein's research seems to indicate that this figure may indeed be even higher. Almost all of abnormal chromosomes are due to an egg or sperm that was imperfect and this is nature's way of taking care of the problem. Trisomy 21 (Down's syndrome) is the heartiest of the chromosomal abnormalities and the only one that survives. Trisomy 13 and 18 can reach full term but do not effectively survive. There are however trisomies of all other known chromosomes but these rarely survive out of the first trimester. Such chromosomal abnormalities are the result of aberration of meiosis (remember from high school biology meisosi and mitosis). You have 46 chromosomes. Your husband has 46 chromosomes. You have to reduce the egg and sperm to 23 chromosomes so that when they come together the embryo has the correct number of 46 chromosomes. That process of reducing to 23 chromosomes is known as meiosis. It is frankly quite imperfect and many egg and sperm are made with an abnormal chromosome number.

If analysis of the failed pregnancy material reveals the chromosomes of the embryo to be abnormal then this should not be a repetitive situation and no further work-up is necessary. If, however, the chromosomal make-up of the failed pregnancy reveals normal chromosomes in the embryo then work-up of the other nonchromosomal sources of pregnancy failure can and should be embarked upon. These include certain entities such as antiphospholipid syndrome (diagnosed by blood test), unusual infections with organisms known as the T strain mycoplasmas (diagnosed with cultures), uterine defects such as septations or duplicated horns (diagnosed with ultrasound and/or fluid enhanced ultrasound). Often these tests are negative but they are worth performing in patients if the chromosomes on the failed are normal.

Dr. Goldstein has been a pioneer in the use of endovaginal ultrasound and identifying the normal landmarks of early pregnancy and the progression of early pregnancy on ultrasound. He has championed this concept of chromosomal analysis on failed pregnancies so that couples do not have to undergo second or third losses before appropriate testing. Feel free to ask him for further information of this important and timely topic.

©2004 Steven R. Goldstein, M.D.