Ranked among the top gynecology programs by U.S. News & World Report
Published: Sept. 26, 2008
Updated: Sept. 8, 2010
When couples learn they are pregnant, this can be the most wonderful news of their lives -- but there are many expectations that form immediately.
Couples have often invested tremendous time and resources to achieve that positive pregnancy test. A topic that is not discussed adequately is pregnancy loss.
A positive pregnancy test means that fertilization and cell division has occurred. It does not mean the embryo has had normal implantation or development.
The hormone tested for in a pregnancy test is human chorionic gonadotropin (HCG). The earliest time from fertilization to a reliable pregnancy test is approximately seven days (roughly equal to cycle day 21 for unmonitored cycles).
Because women in treatment cycles take supplemental HCG up to six days after insemination or transfer, the test must be delayed to avoid a false positive value. Our clinic generally tests at 14 to 18 days after transfer or insemination.
Currently we are not testing controlled ovarian hyperstimulation (COH) patients that have had a menses unless specifically requested. Delaying the testing also allows for the HCG level to rise prior to testing.
Home pregnancy tests are considered qualitative (positive or negative) while the quantitative beta-HCG (QBHCG) gives a specific number. There is not a specific number that can reliably predict pregnancy outcome, though there are ranges of numbers that can raise concern.
Once a positive result has been reported, patients come back in 48 hours for a repeat value. QHCG levels are expected to roughly double over a 48-hour period.
During this time the pregnancy is too small to be seen on ultrasound so an appropriately rising QHCG correlates well with an ongoing pregnancy. There is not a way to predict normal outcomes or to determine if the pregnancy is an ectopic pregnancy at this point in testing.
The next step is to schedule an ultrasound. The ultrasound appointment is scheduled around five weeks after transfer or insemination, which is equivalent to seven weeks gestation. This additional two weeks is added to correspond to the obstetric practice of dating pregnancies from the last menstrual period. The ultrasound normally shows a fetus with heart activity, tiny limb buds, and a yolk sac.
After confirmation of fetal cardiac activity, the risk of an undesired event drops off appreciably. From here, your care will be transferred to your obstetrics provider.
Using a combination of the dating, pregnancy testing, and ultrasound, the physician will make recommendations in the event the tests are abnormal. Abnormalities can occur with testing in a pregnancy that turns out to be normal. Your specific situation and results will be discussed.
In women who are not aware they are pregnant, the pregnancy loss rate can be as high as 30 to 50 percent. Once a woman discovers she is pregnant, this risk drops appreciably.
Some estimates of pregnancy loss are as high as 20 to 30 percent, though the true incidence is likely more around 15 percent. There is another significant milestone based on older data: women reaching 12 weeks are at an estimated 5 percent risk of pregnancy loss.
The takeaway point is that there are a significant number of miscarriages that occur. While this is not "normal" it is not unexpected. Our best advice with early pregnancy testing is cautious optimism.
Pregnancy loss can be discovered in several ways. As mentioned above, abnormal labs may be an indicator of an interruption of a normal pregnancy. Some patients come in for their seven-week ultrasound to discover there is a problem.
One of the most common presentations for miscarriage is vaginal bleeding and uterine cramping. Not all patients with cramping and bleeding will have a bad outcome.
First trimester bleeding is a common occurrence that can be due to many factors. Bleeding before the QHCG values are drawn will be followed by QHCG testing.
If the bleeding occurs between the QHCG values and the seven-week ultrasound there are several factors to consider.
The risk of ectopic pregnancy needs to be contemplated. A single repeat QHCG value is not of use because it does not indicate if the hormone is going up or down (it will have continued to rise after the last test and will be significantly higher even if the pregnancy is not continuing as desired).
An early ultrasound may reveal an intrauterine sac but again will not help in determining the outcome of the pregnancy. QHCG and ultrasound can be combined to help look for ectopic pregnancies.
Unfortunately there are no immediate therapeutic options for treating early pregnancy loss at this stage.
Significant pain should be considered an emergency and the clinic, or physician covering emergency calls, should be contacted immediately.
When vaginal bleeding or cramping occurs it is not necessary to restrict you to bed rest, and sitting with your feet up in the air will not prevent a bad outcome. Your activities are independent of the outcome though our advice is to do only those activities with which you are comfortable.
Again, self-blame can be a significant burden and you should avoid doing activities which may increase these feelings in the event of a bad outcome.
Causes for miscarriages are numerous. Not knowing the exact cause of the pregnancy loss may be one of the most frustrating aspects. Due to the high occurrence of pregnancy loss there have developed many "wives tales" and opinionated explanations.
The foremost thing a couple must come to terms with is that there is nothing they have done to cause this to happen.
Activities, actions, thoughts, and household chemicals are not associated with pregnancy loss. Women in particular may feel guilt and scrutinize themselves looking for an explanation for the pregnancy loss.
One of the most common causes for early pregnancy loss is a chromosomal abnormality within the fetus. This is rarely an inherited problem and occurs spontaneously. Testing for these spontaneous abnormalities offers no useful information about future pregnancies and is most often not performed.
Uterine septum and leiomyoma can also contribute to pregnancy loss. Significant defects are most often detected on HSG or ultrasound.
A large portion of miscarriages fall into the "unknown" category. Explanations for this unknown group may exist but the testing and treatments are often extensive and not useful.
Testing is often offered to patients with recurrent pregnancy losses, but again, finding treatable results is uncommon.
If an early pregnancy does have a bad outcome there are several options. If the tissue has already left the uterus, often no further therapy is needed, though follow-up testing may be performed to document the decline of the QBHCG.
When the tissue remains in the uterus this is termed a missed abortion. Patients not experiencing much discomfort may wish to allow nature to take its course. The tissue will often pass within several weeks but exact predictions are not possible. Women choosing this option may experience continued bleeding and increased cramping when the time comes.
A dilation and curettage (D&C) can be scheduled as another option. The procedure involves using instruments to remove the pregnancy tissue. Having a scheduled date is often reassuring to patients.
Risks primarily include damage to the uterus and infection, but other risks do exist. Patients electing to wait may also set a time limit or schedule a D&C if desired.
Many patients are anxious to enter another treatment cycle. Emotional recovery is an important aspect of pregnancy loss and couples are encouraged to wait until they have the proper recovery time before continuing.
Elevated QHCG levels will prevent normal menstruation. Several months may elapse before a woman is physically ready to attempt pregnancy again.
To prevent the risk of starting a treatment cycle too soon, at least two menses are suggested. The clinic staff and physicians will help you with the details while taking your best interests into account.
Due to the significant risk of an undesired pregnancy outcome, some women may experience more than one miscarriage after another.
The risk of miscarriage after a previous one is considered about 1 percent more likely than someone not having a previous miscarriage. Three consecutive pregnancy losses are considered recurrent spontaneous pregnancy losses. Testing may be offered but correctable findings are uncommon.
Many therapies have been attempted to reduce this risk. Among them are: progesterone, heparin, immunoglobulins, and folate. While many of these therapies are not harmful they have not been conclusively proven useful.
Progesterone supplementation is used generally to about 10 weeks gestation. At that time the placenta takes over progesterone production and the pregnancy is no longer dependent on the corpus luteum.
Heparin is used with several blood disorders that may predispose to pregnancy loss. Heparin itself carries small risks of its own.
Another therapy involves the use of immunoglobulins. This therapy is controversial and is currently considered experimental.
Just because someone with a history of recurrent pregnancy loss becomes pregnant, this pregnancy can not be automatically attributed to the therapy.
If you are having problems with recurrent pregnancy loss these therapies can be discussed with your physician who can provide you with the current information and recommendations
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