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Vaginal
Birth After Cesarean
The birth of a new baby is a time of wonderful emotions.
Whether by vaginal or cesarean delivery, childbirth
is a process of significant physical changes for a
woman, and it carries some risk. In most cases, women
and newborns come through childbirth without complications,
but it helps to anticipate some of the problems that
can occur.
Cesarean Section: The Facts
Cesarean deliveries are surgical procedures through
the abdominal wall of the mother. An incision is made
in the skin and continues through many layers until
the uterus is reached. An incision is then made through
the muscles of the uterus for the delivery of the baby,
the placenta or afterbirth and the membranes that surround
the baby’s sac. Cesarean sections tend to be
associated with a slightly higher risk to the mother
than vaginal delivery. It is major surgery and carries
a risk of such complications as infection, bleeding
and injury to the bladder and intestines that are located
near the uterus. A woman usually stays in the hospital
longer after a cesarean section (3 - 4 days) than after
a vaginal delivery (usually 2 days) because of the
recovery process.
Recently, there has been a great deal of attention
focused on the rate of cesarean section deliveries
as compared to vaginal deliveries. The rate of cesarean
delivery rose from 5% in the early 1970s to 20.8% in
the 1990s. Although there is no consensus as to what
is a healthy and safe rate of cesarean sections, many
believe the rate of cesarean deliveries in the United
States is too high. Physicians, hospitals and insurance
companies have looked for ways to reduce cesarean section
rates while keeping risks to mothers and babies low.
Recently these efforts have been focused on reducing
the rates of repeat cesarean sections though Vaginal
Birth After Cesarean (VBAC).
VBAC: What You Should Know
It used to be the practice of obstetricians that when
a woman had one cesarean section, she must deliver
all subsequent babies by cesarean section. This rule, “once
a cesarean, always a cesarean,” was deemed necessary
until the past several decades. Advances in obstetrical
practice, such as monitoring of the baby during labor
and improvements in anesthesia, made it possible to
evaluate the safety of VBAC. Hundreds of studies have
examined the risks and benefits of attempted VBAC.
Most studies indicate that when a woman attempts VBAC,
there is a 60 to 80% chance she will successfully delivery
her baby by vaginal delivery. The success rate depends
on the reason for the first cesarean section. When
the first cesarean section was performed because the
labor did not progress normally, for example the cervix
did not dilate or the fetus did not descend through
the birth canal, the chance of a successful VBAC is
50 to 70%. The success rate is higher for women who
had their first cesarean section for other reasons,
such as breech presentation.
Who Should Consider VBAC?
VBAC is not safe for everyone. For a woman to consider
VBAC, she needs to know what type of incision was made
in her uterus. The incision in the skin is not necessarily
made in the same direction as the inner incision that
was made to open the uterus. Usually the incision on
the uterus is made across, like the bikini cut on the
skin. This transverse incision cuts across fewer of
the muscle fibers of the uterus and allows for ber
healing than a “vertical” sear or “up
and down” scar. VBAC is safe for women who have
had one or two low transverse incisions but women who
have had a “vertical” uterine incision
are not VBAC candidates.
Similarly, VBAC may not be considered safe for women
who have had fibroid tumors removed or other uterine
surgery. A woman’s obstetrician should also consider
whether the woman’s pelvis is too small to allow
the fetus through. Other VBAC requirements, as outlined
by the American College of Obstetricians and Gynecologists,
are that a physician must be immediately available
throughout the active part of labor. In addition, the
hospital should have anesthesia and other personnel
available to perform a cesarean section if needed.
There are other women for whom VBAC may be safe but
there is not enough information to know with certainty.
These include women for whom the type of uterine scar
is unknown, women with more than two prior low transverse
cesarean sections, women with twin gestations and women
carrying a large fetus. Also, if a woman does not wish
to try a VBAC she has the right to have an elective
cesarean delivery.
While the benefits of a successful VBAC include a
shorter stay in the hospital with a lower risk of infection,
excessive bleeding or blood transfusions, the risks
associated with VBAC can be significant. For women
undergoing a VBAC, there is a small but real risk that
the uterine scar will open during labor, called uterine
rupture. A uterine rupture can be life threatening
to both mother and baby.
The risk of rupture is small, ranging from 0.2 - 1.5%
of women attempting VBAC, but because of its possible
severe consequences, uterine rupture must be considered
in the decision. Uterine rupture can result in the
need for hysterectomy, blood transfusions, injury to
the intestines or bladder during surgery and infections
of both mother and baby.
How should a woman approach a decision concerning
VBAC? First, she should find out what type of incision
was made at the time of her first cesarean delivery.
She should discuss with her physician whether there
are any medical reasons that preclude her from attempting
VBAC and consider the decision with her provider. Whether
the decision is for a VBAC or a repeat cesarean section,
it is most important that a woman make the decision
in an informed environment and that she is comfortable
with her choice. Regardless of how the delivery occurs,
in all likelihood mother and baby will make the transition
to their new life without significant complications
but with plenty of joy and excitement.
For information on VBAC classes, call (973)
322-5360.
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James
L. Breen M.D., Internationally-Recognized Physician,
Retires as Chairman of the Department of Obstetrics
and Gynecology, While Continuing As An Outstanding
Physician
 Over
thirty years ago, James L. Breen , M.D., came to Saint
Barnabas Medical Center as Chairman of the Department
of Obstetrics and Gynecology, ushering in a new era
of greatness in obstetrical and gynecologic care for
women. Though he now retires from that role, Dr. Breen’s
legacy of excellence continues.
Guided by Dr. Breen’s vision, the Saint Barnabas
Obstetrical Service has become the largest in New Jersey
with over 7,000 deliveries last year. Today, the outstanding
reputation of the three sub-specialty divisions—Gynecologic
Oncology & Reconstructive Pelvic Surgery; Maternal-Fetal
Medicine; and The Institute of Reproductive Medicine
and Science-- has attracted national attention and
ensured the finest, most state-of-the-art medical care
for New Jersey women.
An internationally-recognized physician, Dr. Breen
has dedicated his life to improving the health of women.
Through his many roles, including Chairman of his department,
attending physician in gynecologic oncology and reconstructive
pelvic surgery, leading researcher, lecturer and clinical
professor, Dr. Breen has raised the standard for women’s
health care and chartered new frontiers in medicine.
His efforts have garnered him the most prestigious
awards in his field. In 1998, he received the Distinguished
Surgeon Award from the Society of Gynecologic Surgeons
(SGS) as a physician who has “contributed immeasurably
to this specialty.” He has held leadership roles
and received major awards from the national societies
in his field, including presidency of the American
College of Obstetricians and Gynecologists (ACOG) 1983-84;
Distinguished Service Award (ACOG) 1994; American Cancer
Society’s Man of the Year for 1987; Board of
Governors, American College of Surgeons, 1991 to the
present; and Award for Meritorious Service, American
Medical Association.
In 1995, he was chosen to receive the NJ Governor’s
Clara Barton Medical Service Award, the highest honor
the State of New Jersey can bestow on a person, for
his outstanding medical care of women.
Dr. Breen’s passion for medicine and warm, sensitive
manner toward patients and peers have made him one
Saint Barnabas’ most beloved and respected physicians.
His long-standing vision has become the cornerstone
of The Department of Obstetrics and Gynecology and
his compassionate presence has inspired generations
of patients, families and colleagues. Always the learned,
patient teacher, Dr. Breen will continue to share his
experience as an emeritus educator for Saint Barnabas’ residents.
In addition, he will continue to treat patients in
his hospital-based gynecologic oncology & pelvic
reconstructive surgery practice.
There are countless women whose lives are far healthier
and happier because of the efforts of this wonderful
man. James L. Breen, M.D., has lived
a life of sincere, unyielding service to others and
has fulfilled the greatest promise the field of medicine
has to offer.
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Chlamydia:
The Stealth Destroyer ofWomen's Reproductive Health
The most common sexually transmitted
disease in the United States today is chlamydia, with
three to four million new cases occurring each year.
The highest rates of the infection are in 15- to 19-year-old
adolescents, yet the consequences of chlamydia often
do not become apparent until teens reach adulthood
and attempt to become pregnant. Pelvic Inflammatory
Disease (PID), a serious complication of the chlamydia
infection, is as a leading cause of infertility among
women of childbearing age.
The detection and treatment of this disease
is of significant importance to female gynecological
care because of the serious consequences of untreated
infection. Treatment is made more difficult because
the majority of chlamydia infections in women are without
symptoms until devastating complications appear. According
to the Centers for Disease Control, about 75% of infected
women have no symptoms and do not know they have the
infection. Men with chlamydia are usually symptomatic
in at least 70% of the cases.
Diseases caused by this organism have
been known to affect women since antiquity; however,
it was not until the 20th century that the chlamydia-specific
organism was identified. Chlamydia is a type of bacteria,
but also exhibits properties of a virus. Left untreated,
chlamydia can permanently damage the reproductive organs
and cause a variety of diseases in the newborn, including
blindness, conjunctivitis and pneumonia. Without treatment,
an estimated one third of women with chlamydia will
develop PID and about 20 percent of these women will
become infertile. PID causes scarring of the fallopian
tubes, which can also lead to ectopic or tubal pregnancy.
The Spread of Chlamydia and the
Symptoms
Chlamydia is transmitted through unprotected
vaginal and anal intercourse. It can also be spread
from a woman to her baby during birth and be transmitted
in donor sperm samples used for artificial insemination.
The usual incubation period (development of an infection
from the first point of entry to the appearance of
first symptoms) is one to two weeks after exposure.
However, since chlamydia is often a symptom-less condition,
the damage frequently takes place undetected. It is
also not uncommon to be infected multiple times.
When symptoms of chlamydia are present,
they are similar to those of gonorrhea. For men, symptoms
include burning with urination, discharge from the
end of the penis, tenderness in the testicles and lower
abdomen. Women may experience unusual vaginal discharge,
urinary burning and increased frequency, abdominal
or pelvic pain and bleeding after sexual intercourse.
Aside from total abstinence, a monogamous
sexual relationship with a healthy partner is the best
way to avoid any sexually transmitted disease. The
risk of becoming infected with chlamydia increases
when individuals have more than one partner or engage
in risky behaviors such as sex without a barrier-type
contraceptive (condom).
Diagnosis and Treatment
To make a diagnosis, the physician needs
a detailed sexual history from his or her patient.
Then, a test is performed using a cotton swab on an
infected site such as the penis, cervix, urethra or
anus. If a woman’s Pap smear comes back showing
signs of severe inflammation, she must be checked for
chlamydia, as well as other sexually transmitted diseases.
Some physicians suggest that patients
with two or more of the following risk factors be tested
for chlamydia: 24 years of age or less, intercourse
with a new partner within the two preceding months,
exam revealing a suspect cervical discharge, bleeding
caused by swabbing the cervix, or use of no contraception
or a non-barrier method.
At least 90 percent of all chlamydia
infections could be detected if this screening process
was followed.
There has been major progress in the
treatment of chlamydia with antibiotics over the past
few years. When suspected or confirmed, the treatment
of choice is doxycycline 100 MG twice a day or tetracycline
500 MG four times a day for seven days. In place of
tetracyclines, erythromycin 500 MG can be taken four
times a day for seven days. It is also imperative that
exposed sexual partners be treated.
Keep in mind that because of the silent
nature of this disease, it is impossible to know if
chlamydia has been contracted unless a medical screening
is performed. Physicians must always be aware that
chlamydia may be present in their patients and should
seek it out before it can cause harm.
For a referral to a Saint Barnabas OB/GYN,
please call 1-888-SBMC-DOC.
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Focus
on Female Sexual Dysfunction
Until recently, little research or attention had been
focused on female sexual function. As a result, knowledge
and understanding of the anatomy and physiology of
the female sexual response is limited. Recently, with
the advances in male erectile dysfunction, the study
of female sexual dysfunction has begun to evolve, particularly
with the advent of Viagra®. Future advances in
the evaluation and treatment of female sexual problems
are forthcoming.
Female sexual dysfunction appears to be age related
and in a recent study in the New England Journal of
Medicine evaluating couples with sexual dysfunction,
it was revealed that 63% of women studied had arousal
or orgasmic dysfunction. Similar to male sexual dysfunction,
the prevalence of female sexual dysfunction has been
shown to increase with age and be associated with vascular
risk factors. Post menopausal women and women with
a history of vascular risk factors have been shown
to have significantly more complaints of self-reported
female vaginal and clitoral dysfunction.
What is Female Sexual Dysfunction?
When we talk about female sexual dysfunction, we can
describe it as a hypoactive (underactive) sexual desire
disorder characterized by the persistence or absence
of sexual fantasies, thoughts and receptivity to sexual
activity.
A second characteristic is sexual arousal disorder,
in which there is persistent or recurrent inability
to obtain or maintain sufficient sexual excitement,
causing personal distress. It may be experienced as
a lack of excitement or lack of genital lubrication.
Thirdly, there is orgasmic disorder, characterized
by persistent or recurrent difficulty, delay or absence
of obtaining orgasm after sufficient sexual stimulation.
The fourth characteristic is sexual pain disorders
dyspareunia, which is recurrent or persistent genital
pain associated with sexual intercourse or vaginismus,
which are recurrent or persistent involuntary spasms
of the musculature around the vagina.
The Future of Treatment
It is a myth that older American women no longer have
sexual desire and cease sexual activity. As long as
there is a loving sexual partner available for sexual
activity, older couples may continue sex as long as
physical health remains intact.
The reality is that more than 50% of women may be
without a sexual partner by age 65 while only 14% of
65-year-old men may have lost their spouse. This means
that many women who desire to continue their sexual
activity are without a partner.
The future for the treatment of female sexual dysfunction
is very promising. There are several specific treatment
modalities that are either already accepted or in a
development phase.
Apomorphine is an old medication originally used as
an emetic (to cause vomiting). This drug has an essential,
enhancing effect on the portion of the brain stem,
allowing sexual stimulation to increase central sexual
function. In women, this drug appears to improve sexual
desire.
At this time, Apomorphine Stage III trials are occurring
in men and further testing and exploration would be
necessary for use with females. Since sexual desire
problems represent 1/3 of all sexual problems in females,
this medication may play a role in women who have diminished
sexual desires since it increases central sexual stimulation.
Testosterone is the most commonly used drug for the
treatment of sexual dysfunction in females. It appears
to work best in those women who have diminished sexual
desire.
An extremely low dose, 1/10 of the dose that the male
takes, is all that is necessary for its positive sexual
effects on women. Creams, patches and combinations
with estrogens and progestational agents are being
developed.
Viagra® has revolutionized male sexual dysfunction
with approximately 78% of men responding to the medication.
Preliminary results from European trials on women have
not been divulged and North American trials on Viagra® for
women are soon to begin.
The drug is being used in female sexual dysfunction.
Women with vaginal lubrication difficulties, poor vaginal
engorgement and arousal problems appear to be the best
candidates for this potent oral drug. Rapid-acting
forms and long-acting forms are also being developed.
Vasomax is a new sexual drug for men to be introduced
in the United States. It is a rapid release form of
Phentolamine®, an agent that increases blood flow
to the organs of the body including the pelvic organs.
It will work similar to Viagra® in the sense of
improving vaginal engorgement, lubrication and probably
arousal.
Finally, topical medications are being studied which
have the potential to increase blood flow, sexual lubrication
and desire all by simple topical applications. Clinical
trials are beginning in men and will probably begin
in women in a short time.
Hopefully, research in the area of female sexual dysfunction
will shed more light on the causes of this condition
and bring hope to the millions of women who are looking
for answers.
For a referral to a Saint Barnabas Medical Center
physician, please call 1-888-SBMC-DOC.
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Catch
A Rising Star in the Maternity Center at Saint
Barnabas
The birth of a child is, without question, one of
life’s most wondrous experiences. Each year more
families choose to have their babies at Saint Barnabas
Medical Center than at any other hospital in New Jersey.
The largest obstetrical service in northern New Jersey,
Saint Barnabas had nearly 7,000 deliveries in 1998
alone. These parents appreciate the thorough, compassionate
and technologically advanced care offered in the Department
of Obstetrics/Gynecology.
Now, parents of babies born at Saint Barnabas are
invited to celebrate the birth of their little one
by placing a star, personalized with baby’s name
and birthdate, on a new “A Star is Born” Wall
on the Maternity Unit. All proceeds benefit Maternal
Child Services and the unique amenities provided to
new moms, such as special dinners for new parents,
the televised Newborn Channel on baby care and postpartum
topics, the specialized Women’s Resource Library
and “info buggy.”
What is the “A Star is Born” Wall?
The Saint Barnabas “A Star is Born” Wall
will be a new display on the Maternity Unit that celebrates
the births of babies born at Saint Barnabas and recognizes
the families’ financial support of the Medical
Center. Proud families may place star-shaped plaques
on the Wall to celebrate the births of their, and our, “shining
stars.”
Who may reserve a star?
Stars may be reserved by the parents, grandparents,
friends and loved ones of any child born at Saint Barnabas
at any time.
What do the stars look like?
The star-shaped plaques are silver in color and will
be engraved with babies’ names and birthdates.
Stars are available in three sizes:
- Large Stars: $1,000 -
May list one or two child(ren)’s names
and birthdate(s) depending on name length
- Medium Stars: $500 -
May list one or two child(ren)’s names
and birthdate(s) depending on name length
- Small Stars: $200 -
May list one child’s name and birthdate
Where will the Wall be located?
The “A Star is Born” Wall will be displayed
on the Saint Barnabas Maternity Unit. Families will
receive an announcement of their star’s “arrival,” and
are invited to “star-gaze” at any time
during visiting hours.
For Further Information
For more information about the “A Star is Born” Wall,
or about supporting Maternal Child Services at Saint
Barnabas, please contact the Saint Barnabas Medical
Center Foundation at 973-322-4338. For more information
about Maternal Child Services, please call the Department
of Obstetrics/Gynecology at 973-322-5282 or the Women’s
Health/Parent Education Center at 973-322-5360.
Your support will help us to continue to meet the
needs of the growing number of families who depend
on us.
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Progesterone
and the Breast Cancer Connection
The issue of hormone replacement therapy causes a
dilemma for many women following the onset of menopause.
The benefits of replacement can be great: prevention
of bone loss, hot flashes, night sweats and mood swings,
and possibly a lower risk of heart disease and Alzheimer’s
disease. Many women, however, opt not to take hormone
replacement because of the potential risk of breast
cancer. This potential risk is poorly understood because
hormone replacement therapy involves not only one drug,
but also usually two. Progesterone is usually given
in addition to estrogen because it helps to protect
the uterus from endometrial cancer. Most studies in
the past have focused on estrogen’s affect on
breast cancer, but recently the role of progesterone
has been questioned as well.
Understanding Cancer
Cancers start from a mistake in the genetic material
that is contained within a cell. Sometimes a mistake
can occur when a cell is injured by a toxin, but it
can also occur by chance when a cell divides to make
a new cell. Cell division must occur for people to
stay alive, however outside influences may cause cells
to divide more rapidly than normal, thus theoretically
allowing more chances for mistakes to occur. It is
like rolling dice; the more often you roll the greater
the chance that you will eventually lose.
Hormones influence our breast tissue by regulating
cell growth. Division of breast cells is necessary
to become adult women and to nurse our infants. Estrogen
causes breast cells to multiply. Progesterone’s
effects, however, are not so clear, and there are multiple
current theories about how it works.
One theory suggests that progesterone protects the
breast in a similar fashion to how it protects the
uterus. A second theory speculates that it does not
influence the cell division rate at all. Finally, a
third suggests that it might actually increase estrogen’s
effects on cell growth, since during the menstrual
cycle breast tissue divides the most when both estrogen
and progesterone levels are high. The wide divergence
in the opinions shows that, even within the scientific
community, the actions of progesterone in breast tissue
are still highly speculative. Furthermore, hormonal
research studies are most often done using cells that
are not actually in a living patient. What happens
in an actual person may be very different, and progesterone
taken as a pill after menopause may not work the same
as the progesterone that is naturally in our body.
Examining Hormone Replacement Studies
All of our studies on hormone replacement to date
are observational studies. An observational study takes
existing data from the environment and tries to analyze
it. The scientists have no idea why some of the women
in the study took hormones and others did not, and
therefore there is no guarantee that the groups were
really the same. This type of study cannot prove cause
and effect.
The actual human studies on progesterone in post-menopausal
replacement therapy, therefore, are limited. One study
tried to look at the issue by comparing three groups:
post-menopausal women who never used hormones; women
who used estrogen alone; and women who used both estrogen
and progesterone together. The study found that with
long-term use, estrogen increased breast cancer risk,
but that the addition of progesterone had no affect
on estrogen’s actions.
The largest study combined all the existing data from
previous studies (including the one just discussed)
on post-menopausal hormone use. While this accounted
for data from over 150,000 women, only 12% of these
women had used progesterone, so that no conclusion
could be reached about progesterone’s influence
on the breast.
Recent Study Causes Concern About
Progesterone
A recent study was just published that is causing
concern about progesterone since it has received substantial
press coverage. This study also compared those women
who never used hormones to those who just used estrogen
and those who used both hormones. In this study, estrogen
with progesterone was associated with more risk than
estrogen alone, but only in very lean women. In addition
to being an observational study, the overall design
of this study has other problems as well. The number
of women who took combined therapy is still so small
that the results obtained may not be significant. The
majority of the information on hormone use was obtained
from questionnaires filled out by the participants,
and may, therefore, contain inaccuracies. Finally,
as in almost all the other studies, the majority of
the women were white, giving us very little information
on minorities. This study suggests a very important
area for future research but leaves considerable uncertainties.
Unfortunately, many women are taking this rather weak
data as absolute proof that progesterone therapy will
cause them significant harm. The media reports about
new studies, but neither discusses them in light of
old studies nor addresses any problems with the research
that may make scientists hesitant about the results.
Each new study that is discussed is often portrayed
as the best and as having provided the most definitive
answer. In actuality, new studies are just one layer
of our ongoing search for the truth.
Finally, there is one randomized study that is being
done on hormone replacement.
It is called the Women’s Health Initiative and
menopausal women who participate are given either a
placebo or hormone replacement.
In this type of study the scientists control the groups
so any differences will be due to the hormones. Unfortunately,
this study began before the questions on progesterone
arose and is, therefore, unlikely to give us any answers
pertaining to progesterone.
Reviewing the Facts
In conclusion, there is no solid evidence from either
recent or older studies to stop women from taking hormone
replacement therapy that includes progesterone. When
making decisions about hormone replacement therapy,
women should work with their physicians to draw up
their profile of benefits and risks. This should include
cardiovascular risks, bone density, menopausal symptoms,
body size and breast cancer risk. Breast cancer risk
can now be approximated numerically to give women a
firm basis on which to turn hormone replacement therapy
from a confusing dilemma into an educated decision.
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Understanding
Recurrent Miscarriage
Recurrent pregnancy loss is defined as
three or more consecutive spontaneous abortions (often
called miscarriages). However, more and more clinicians
have come to believe that two miscarriages should be
enough to trigger an evaluation with a physician. A
miscarriage can be psychologically stressful and many
couples who wish to be pregnant choose to have a medical
evaluation performed after a second miscarriage.
If a fetus has genetic abnormalities,
the chance for a miscarriage is greatest in the first
trimester and less in the second trimester. Up to 70%
of first-trimester losses are genetically abnormal
as compared with between 13% and 30% of second-trimester
losses. It is interesting to note that most of these
are spontaneous abnormalities in the pregnancies themselves – in
both the first and second trimesters. This means that
a genetic defect occurs either when the sperm and egg
are forming or after fertilization.
The chance of finding a chromosomal abnormality
in the parents, which could result in a miscarriage,
remains about the same in the second trimester as in
the first. The odds of a parent having a genetic abnormality
are higher when there is a family history of stillbirth
or an abnormal child.
In terms of nongenetic abnormalities – for
example, anatomic abnormalities in the mother such
as fibroids of the uterus – we would expect
a higher incidence of pregnancy loss in the second
trimester. Hormonal causes of miscarriage, such as
deficient hormone production, are thought to be much
more related to loss in the first trimester.
The overall likelihood of successful
pregnancy in patients with recurrent pregnancy loss
not explained by any of the traditionally accepted
causes is 60% to 70%. These percentages decrease with
females over age 40 and also depend on the number of
prior losses. If a woman has had a prior successful
pregnancy, the percentages increase.
Causes of Recurrent Pregnancy
Loss
Genetic Causes
The majority of miscarriages stem from
chromosomal abnormalities in the fetus. But for the
couple with recurrent miscarriages, there is also an
increased chance that one partner may have a major
chromosomal rearrangement of some sort, in the range
of 2% to 5%.
If there is a history of stillbirth or
a liveborn with a chromosomal abnormality, this incidence
increases to 10% to 20% and even higher if the couple
has had a malformed infant.
Aneuploidy (when a fetus has extra or
missing chromosomes) is a genetic cause of recurrent
miscarriage and is well known to increase with advancing
maternal age. There may be genetic causes that we do
not understand yet, including single-gene mutations
and other molecular-level abnormalities. The most common
chromosomal abnormality leading to random miscarriage
is trisomy (fetus having an extra chromosome) of which
trisomy 16 is the most frequent. Monosomy X (fetus
missing a chromosome), another common cause, is also
referred to as Turner’s Syndrome. If a patient
has had recurrent miscarriage, discussing the need
for a genetic analysis of a possible future miscarriage
is an important part of planning the next pregnancy.
Anatomic Causes
About 8% to 10% of women with recurrent
miscarriage have a uterine abnormality identified by
either hysteroscopy (X-Ray) or hysterosalpingography
(HSG) (saline ultrasound). These anatomic problems
may be congenital, such as a bicornuate or septate
uterus, or acquired, such as fibroids or uterine adhesions
from prior surgery. Women with a DES (diethylstilbestrol)
uterus have an increase in miscarriages as well as
ectopic and preterm deliveries. Another possible anatomic
cause of recurrent pregnancy loss is an incompetent
cervix.
Infectious Causes
Thus far, mycoplasmas and ureaplasmas
(two bacterias) are the only organisms for which there
is evidence of an association with first-trimester
loss, and for which there are data showing that treatment
with antibiotics probably does help. Bacterial vaginosis
may be associated with preterm birth, but there are
no data to link this with recurrent miscarriage.
Immunologic Causes
Autoimmune disease, such as antiphospholipid
syndrome, can be a cause of recurrent pregnancy loss,
though it is probably not very common and is more likely
to be a factor in fetal loss. When identified, it is
a cause that can be treated with aspirin and heparin.
The percentage of patients who have lupus
anticoagulant or increased levels of anticardiolipin
antibodies is small, probably no more then 5%. Some
women may also have a miscarriage because they are
too genetically similar to their spouse. When this
occurs, some part of the woman’s immune system
reacts inappropriately to the presence of the fetus,
causing a miscarriage.
Endocrine Causes
Spontaneous pregnancy loss related to
major endocrine disorders, such as diabetes, hyperprolactinemia
and hypothyroidism is uncommon. Corpus luteum deficiency
is thought to make conception difficult, but may also
be a possible cause of recurrent pregnancy loss. Also,
corpus luteum deficiency may be a deficiency of progesterone
secretion or a problem of endometrial development.
Suggested Laboratory Workup for
Recurrent Pregnancy Loss:
Genetic Cause:
Genetic analysis of miscarriage materials;
genetic analysis of parents.
Anatomic Cause:
Hysterosalpingography (HSG) (X-Ray) or
sonohysterography (saline ultrasound) for uterine anomalies,
adhesions and fibroids. Laparoscopy is usually not
helpful.
Infectious Cause:
Culture for T-mycoplasma
Immunologic Cause:
Tests for lupus anticoagulant and anticardiolipin
antibodies. Tests for antinuclear antibodies, antileukocyte
and antithyroid antibodies and HLA typing are not helpful.
Endocrine Cause:
Biopsy to evaluate luteal phase (second
two weeks of the menstrual cycle); possibly a Thyroid
Stimulating Hormone (TSH) test for general screening
Treatment of Recurrent Pregnancy
Loss
If a treatable condition is discovered,
treatment should be as specific as the problem; i.e.
surgery for a uterine septum, antibiotics for mycoplasma.
Corpus luteum deficiencies may be treated with oral
or vaginal progesterone or medications for ovulation
induction such as clomiphene citrate if the endometrial
biopsy shows abnormal development of the lining of
the uterus. Since more than 50% of patients may have
a “negative” work-up (no problem found),
there may be a place for treatment of these patients
with progesterone. There may be an immunologic cause
that we do not yet understand and in this case progesterone
may be beneficial. Finally, there is no evidence that “bedrest” is
of any benefit in this situation.
Recurrent miscarriage is a difficult
diagnosis and there is much controversy in the field.
Couples suffer greatly with repetitive losses. Much
remains to be learned for the medical community to
improve the counseling, diagnosis and treatment for
our patients who are confronted with this frustrating
problem.
[ top ]
Twin Moms
Each Give Birth to Twin Boys
Reprinted with permission from
the Belleville Times
 "Believe
it or not --- my twins had twins!" So says the proud
grandmother, Marie Kimble, of the most unlikely of
occurences. Marie and her husband, (Belleville) Township
Manager Raymond Kimble, are bursting with pride over
the twin births of twins to their twin daughters.
Confusing, yes, but a blessed series
of events, according to the families. The two sets
of twins were born at Saint Barnabas Medical Center,
just three weeks apart. Sean and Linda Kimble Conley
of Florham Park welcomed Sean Raymond, 5 lbs., and
Stephen Francis, 6 lbs. 1 oz., on January 16.
Less than three weeks later, on February
8, John and Lisa Kimble Gabrielle of Verona, celebrated
the arrival of John Raymond, 5 lbs. 4 oz. and Frank
Rosario, 7 lbs. 1 oz. The two sisters have followed
each other before --- as teachers. Linda is a former
School #8 teacher, while Lisa used to teach at School
#7.
Physicians estimate the chances of twin
girls giving birth to their own sets of twins as infinitesimal. |
