4 Recurrent Miscarriage, Dr Karen Buckingham

okay sorry goodie everybody and welcome back to fertility week and this webinar is the fourth out of a series of five and it's going to be on returnable all right so fertility New Zealand is a registered charity and it's been operating for 20 years we are here to help people through their fertility Internet's we do this by from information standard number and support we also provide support and we do this by a number of support groups there are throughout the country and we also provide advocacy so tonight's webinar presented by dr. Karen Buckingham from brick premier here in Auckland and she specializes in recharacterize carriage the format is going to be the talk and then we're going to do questions at the end and we'll do that by you can just pop them into that chat box down here in the corner and yeah so and hope you enjoy the talk and I'll be Karen take it away thank you right thanks very much and welcome everybody to tonight's talk on recurrent pregnancy loss as you can see I'm a specialist and reproductive medicine and I have a special interest in recurrent pregnancy loss and although I don't run it anymore I used to be in charge of the recurrent pregnancy loss clinic at the Green Lane clinical center so home I thought I'd approach this talk would be to tell you a bit about what recurrent pregnancy loss is and also maybe some other risk factors that can contribute to it as well as talk about some of the causes and how we might investigate a couple who are experiencing recurrent pregnancy loss talk about the treatment and the management of it and yeah I've also got some slides at the end they're being put together by our counselor to try and help people cope with the emotional impact of recurrent pregnancy loss so if you ask any questions as we go through and I'll try and answer them either during the talk or a decision at the end so firstly recurrent pregnancy loss or miscarriage we know miscarriage is really common you know to fix at least 15 to 20 percent of all pregnancies it's a really common phenomenon but it's least common to experience miscarriage after miscarriage after miscarriage and so although it is different definition recurrent pregnancy loss classically replaced the occurrence of three or more consecutive miscarriages were losses prior to the 20th week of pregnancy that's sort of the standard definition we use in this country and the number of people the part the percentage of population that affects is probably about 1% so it's still not uncommon there are some risk factors for a current pregnancy loss and it'll be no surprise to hear that the biggest risk factor for it is advancing maternal age and this group is a really good reminder that as a woman ages who are fertility that's the blue line declines quite markedly but if you look at the red line that's showing you that as all men ages her risk of miscarriage increases almost exponentially so I know the scraps a little bit small but if you can see down at the bottom when a woman's over 45 she has an almost 95 93 percent chance of that pregnancy ending in a miscarriage and I guess it's no surprise that you know as we leave it later in life to start our families we're much more likely to have miscarriages and I particularly like this quote that cerebellar erosion is paper in 2012 that women in their forties are a hundred times more likely to suffer recurrent pregnancy loss due to chance alone compared to women in their twenties I think we need to be in that in mind and we're thinking about investigating one however it's not just oh sorry I'm not gonna say the reason for miscarriage increasing as a woman gets older is that unlike men who makes sperm all the time we're born with all the eggs were ever going to have and so if an eggs been sitting in our body for 40 years it doesn't divide or work quite so properly as it could have done when it was you know only 20 years old so it's because our eggs are older that miscarriage is much more likely to heppen it's not just the woman's age though paternal age makes an impact as well although I'm probably not as marked as a woman but we know that if man is over the age of 45 he's much more likely to suffer a miscarriage with a partner and take longer to impregnate their partner so again if you have that combination of an older man and not a woman you're going to be much more likely to be at risk of miscarriage or recurrent pregnancy loss another risk factor for recurrent pregnancy loss can be someone's previous reproductive history so if someone to a live birth in the past I've been much more optimistic about that couple having a further life birth conversely if they've always had miscarriages or pregnancy losses then I'm a little release optimistic about them and as you can see and this is quite an old study but the risk of miscarriage increases with every successive pregnancy loss having said that after three miscarriages your risk of another miscarriage is about 33% so you've still got it probably at least a 70% chance of an ongoing life this subsequently it does depend a little bit on what the cause of your pregnancy loss is and I've just put this example here of a genetic cause of a translocation a translocation is where the chromosomes are the normal number of chromosomes but they're rearranged in different ways and there's various types but depending on where your friends look at what chromosomes or translocation effects may give you a different risk of having a miscarriage so for example if you have a 20 to 22 translocation you're almost always going to miscarry whereas a fewer translocation affects chromosome 13 or 14 your risk of miscarriage subsequently might be 25% so some different causes will give you a different risk of a miscarriage now there's lots and lots of causes that have been postulated for recurrent pregnancy loss and I've made this table up so you can see when we're thinking about a couple with a recurrent pregnancy loss there's a number of things we team to consider we think about could there be a genetic cords so it's something about that couple that makes them more likely to have an abnormal embryo and so that's an epigenetic box when we think about the woman's uterus is there an anatomical if empty that makes her more likely to miscarry so does she have a septum in her uterus or does she have fibroids Adam and the cavity of the uterus or does she have polyps there adhesions that might stop an Umbreon plant in quite so well someone who's having second trimester miscarriages or later miscarriages sometimes the cervix can be incompetent so it doesn't hold a pregnancy quite so so well and those women can miscarry in the second or third trimester it's the whole group of possible theories about maybe it's an immune cause for women's miscarriages the only proven Amina logical cores are something called the antiphospholipid syndrome which affects maybe ten percent of couples who come a lot they are video clinic and that's a condition that's associated with other pregnancy complications such as preeclampsia or it's also can be associated with thrombo embolic events that people might have had clots in their legs or their lungs so like so it's one of the things we definitely test for to make sure they don't fall into it have X syndrome because if they did there's a specific treatment we would use for those couples I've put here question marks beside the other theories in there because although their posterior we don't actually have good evidence that they are a true cause of recurrent pregnancy loss Siege although a lot of area and inch of interest is in this area I've put this box down here called thrombophilia z– now thrombophilia is an inherited group of disorders that cause people to have a greater tendency to form blood clots so DDT's or pulmonary emboli and it's wondered whether some of those thrombophilia can be associated with recurrent pregnancy loss and I say wondered because it's a really large and contradictory literature looking at them there's many thrombin different types of thrombophilia and we think that some of those are more likely to be associated miscarriage than that and so I've just listed a few here again there's a whole box of other any hormonal endocrinology call causes so we know if someone's got really uncontrolled diabetes or very poorly controlled thyroid disease they're often more likely to miscarry it's questioned with the polycystic ovarian syndrome woman I have a greater propensity to miscarriage and sometimes women who have got high prolactin levels may be more likely to miscarry it's also this this possible condition called luteal phase defect where the luteal phase someone's cycle is amiss deficient it causes the pregnancy not to progress but again these are all a bit not quite proven there's no we're not actually sure if those conditions actually are associated there's quite a bit of work now on lifestyle factors so as we mentioned before if someone's older when they're trying to get print they're more at risk of miscarriage if someone's BMI is outside the normal range so if they're very underweight or they're very overweight their risk of miscarriage is increased if someone smokes cigarettes their risk is also increased it's a dose relation dose related response so the more they smoke the greater their risk of miscarriage equally with caffeine and alcohol we think there's also that that exposure can also increase your risk of miscarriage and it's postulated by other environmental exposures such as you know radiation from BDU screens or in acidic gases all those sorts of things we don't again have great evidence for them but it's been thought about so those are a number of causes but in fact the actual greatest you know the greatest and we finally investigate these couples is that it's unexplained we just can't find a reason for why though having those recurrent pregnancy loss at least 50% of couples will fall into the unexplained category and it probably explains that we don't actually know everything that's going on at they're very tiny microscopic interface between the embryo in the uterus so how do we investigate someone who's experienced recurrent pregnancy loss well I listed here on the list of chests that I would consider we would do that pretty routinely for most couples so we'd want to check both the parents carry times to make sure they do have a translocation additional chromosome anything like that we'd want to do some sort of assessment of the uterus so that might be doing a three-dimensional ultrasound scan or it might be doing a history helping a gram with some dyes put up inside the uterus comes out the tubes and make sure there's no abilities inside the uterus where it might be a hysteroscopy those are the sort of main investigations we would do for that as I said we test for antiphospholipid syndrome now they don't also blood tests and it's looking for some certain antiphospholipid antibodies and the names of those are the lupus anticoagulant anti kadia life and antibody and beatitude like a protein one now if someone is positive for an antibody it's not enough just to be positive once you have to have significant levels of them to itch in undeveloped 12 weeks so on two occasions 12 weeks apart so again you might have a blood test that was positive we'd ask you to repeat it in 12 weeks and if it was again positive then would be more thinking that you had the antiphospholipid syndrome and we test for thyroid with our adventure tests and possibly for thyroid antibodies now just tested here we test someone's ovarian reserve so it's sort of an account of how many eggs they may have in their ovary so that would usually be an anti-mullerian hormone test or a day 2 FSH test or an antral follicle count and sometimes they may be additional tests depending on what the history's told us so if we're really the patient's got a history of lots of clots in their legs or in their lungs we might be doing a full thrombophilia screen or if someone's got not be discharged from their breasts and headaches or visual problems you might be thinking more seriously about checking for a prolactin I know with a blood test and a skin now I've listed on the right-hand side a whole of other tests that are not routine but I use my some practitioners and so it's things like checking for natural killers not us and in Demetrio biopsies and rarest of trumbo philias so again you might see that or have been asked to have those tested but like say they're not particularly routine I'm certainly not and the clinics and I've worked in so how do we manage recurrent pregnancy loss well it's a really frustrating area to work in and like you say it's just because the cords we often find no obvious cause for why people are miscarrying and there's very few evidence-based treatments the choice of treatment really depends on whether we've found any underlying cause of the recurrent pregnancy loss so I'll talk a little bit now about what some of the treatments might be if you had a particular cause for your for your miscarriages so if you had a genetic abnormality so say you had a translocation which are not uncommon in your choices depending on your particular translocation we always seem to to the geneticists who would be able to give you a greater more specific risk for your particular genetic problem but it might be things like doing something called pre-implantation genetic diagnosis so that's where we do an IVF cycle and the embryos are created and we then biopsy those embryos and test them to make sure that the embryo doesn't have that translocation so that we can hopefully been only put back a normal unaffected embryo we think of doing that then we're going to give you a better chance of pregnancy it's a very simplified view of of PGD or it might be that if we think you've got such a high chance of having an abnormal embryo using the partners sperm or eggs that are affected it might be that we say maybe you need to think about using donor sperm or donor eggs to overcome or in some cases we might just say look you still have a chance of having a normal ongoing pregnancy but you may be at risk of more miscarried or so if you keep trying even if you have another few miscarriages you may still be lucky enough to have an ongoing pregnancy and live birth as I said before we get quite excited when we diagnose the antonov Leopard syndrome and that's because we actually have a proven treatment that's of benefit and so what we do for those couples is that we treat them with anticoagulation therapy so we usually give them heparin throughout the pregnancy and that's been shown to certainly improve the life birth rate significantly so like I say we really like making that diagnosis because we could say here's a treatment for you but they're only probably maybe 10% if anything of the couples that we see fall into that category unfortunately it came if there's an anatomical abnormality and it's correctable surgically we will try and correct it so if someone's gotten adhesions inside the uterus so they've got a polyp or until you try fibroid and pinching on the cavity we'd try and surgically remove that because by normalizing the care that team would be hopeful that they'll be able to then have an ongoing pregnancy I mean it applies also for if someone's got a uterine set and we try and research that now sometimes it's not possible to correct them you know some people have had multiple surgeries trying to remove symptoms or fibroids and it's just far too difficult or it can't be done or it causes more problems with scarring and things and so in those cases it may be that you need a surrogate which is where another woman carries the pregnancy for you so again that's a pretty big step and certainly wouldn't be our first choice of treatment but in some cases that seems to be a treatment option for some woman if someone's got an incompetent cervix where the cervix opens before the pregnancy is ready to get fully developed it's possible to put a stitch around that cervix intricate that closed until the child's of a sufficient age to be born so again that's a specific treatment for a specific problem so if someone has unexplained recurrent pregnancy loss in there aren't people tried all sorts of treatments to try and improve the outcomes they've given them things like heparin and aspirin and beta HCG and all sorts of hormone treatments and none of those have been proven to work there's been really good studies so we know that giving it quick Seine and aspirin to woman with recurrent pregnancy loss does not work so we're just an alphabet but we do know that it seems to be that if you're off a woman's in that situation support and a designated clinic then that can be really helpful and so I've just said here and over just over half of couples we don't find any obvious chords and so for them we're really trying to optimize their lifestyle factors as much as possible and so definitely stopping smoking or using any recreational drugs reducing alcohol and caffeine people are often you know really consumed they're going to give up everything you know but a coffee but actually it seems to be if you drink more than two cups of coffee or the caffeine equivalent of that that's when your miscarriage risk starts to increase so you can still have a cup of coffee every so often but just not more than two cups a day being a healthy weight and in the healthy being me my weight range would be really helpful as well and so by doing keep making attention to those lifestyle factors we know that your chance for the subsequent pregnancy is at least seventy to seventy-five percent so even though you've hit three miscarriages your chance of an ongoing pregnancy Nick's son is still really high so it's really important to keep that in mind and and keep trying like I say when we come when if someone comes to our princey loss clinic we offer them sort of supportive care and monitor early pregnancy monitoring and I think when you've had lots of miscarriages it's really nice to be able to be seen by clinic that understands a bit watching what are you going through and also you know knows how to manage you a bit more appropriately so like I say we monitor you by doing and quite frequent beta HCG blood tests if you want that and then we start scanning you come about six weeks and you to do that weekly so that we can see that the baby's growing appropriately now some people don't miss really want that degree of intervention or monitoring and that's fine it's a very individual choice but if someone would like that then that is available to them and your you might ask for monitoring it's not going to stop me from miscarrying and you're right it's not but at least we're monitoring you we can give you a much earlier indication of this pregnancy is likely to be ongoing or if it's likely to be miscarrying there's nothing worse than getting to 12 weeks thinking the pregnancy is going along beautifully and then finding out that actually you know maybe died at six weeks and you know all your symptoms have disappeared sort of thing so at least it's better this way if you find out actually at five weeks things weren't looking so great the princi hormone levels weren't rising appropriately and so you can sort of prepare yourself a little bit more what the outcome might be so I'm just going to go to them yep so this the next few slides have just been put in by our counsellors saying that you know couples who are experiencing recurrent princey loss require a lot of even thing and understanding it's a real loss of hopes and dreams you know as soon as you're pregnant you have planned that child's life that you sort of mapped it out you know exactly when you're gonna be giving birth and all the rest of it and so when you miscarry and it's a really real loss but often one that's not necessarily recognised by you know friends or family members because nothing they can actually see and remember that experience of miscarriage is unique so women will have very different physical emotional spiritual experiences and no one weighs the right sort of experience and all these feelings of sadness and disappointment devastation all those are all very real and there's nothing to be ashamed of fulfilling those I guess the frustration or the difficulty can sometimes come and when you and your partner may have different ways of experiencing out or having different feelings and it can sort of you know separate you a little bit at that time so I guess since it's being aware that your partner may experience different feelings and may express themselves differently as well so it's really important to you know give yourself permission and give yourself time to grieve you know don't expect to just be over at next month you know there's no set time period just because your friend you know bounced back in a month doesn't mean that you necessarily will do that so you shouldn't sort of put expectations around when you should feel better it's often a common response to want to get pregnant straight away and be pregnant again and that's fine and there's no physical harm in doing that well I guess you also need to be prepared you know for if it is a miscarriage again oh you give me resilient enough to be able to deal with they're looking at their time and so sometimes it's quite nice to be able to sort of acknowledge your loss and you know the ceremony or some more running a leisure or taking a photograph you know something it's just sort of symbolize it and also you can't remember it in a more sort of positive way and it's good idea to you know tell people if you want their support or if you don't want their support now people are wanting to help but it's very hard sometimes to know exactly what help will be useful to you how counselors always available if people wish to talk to them so it's always you know feel free to make contact with them or with other people especially with fertility indeed they've got great resource groups and contact groups theater to help and sometimes if you if you do the plan like it's good sometimes to come along and have a chat to your doctor about what they think your chances are and maybe what your goals could be going forward and if there are any particular treatments you should try or whether you know you should just continue doing everything you've been doing it at once and imitate you know take time for yourself to rest and recover and you know get into a routines and things because it gives you some sort of control as well

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