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Re: children in delivery roomFrom: Suzanne S. Powell, ICCE, CD (suzannep@mindspring.com)Wed Feb 10 22:17:38 1999
Received: from swan.prod.itd.earthlink.net (swan.prod.itd.earthlink.net [207.217.120.123]) by talk.obgyn.net (8.8.8/8.8.8) with ESMTP id XAA07558 for <ob-gyn-l@obgyn.net>; Wed, 10 Feb 1999 23:17:37 -0600 Received: from 38.30.22.164 (ipb164.baltimore10.md.pub-ip.psi.net [38.30.22.164]) by swan.prod.itd.earthlink.net (8.8.7/8.8.5) with SMTP id VAA27100; Wed, 10 Feb 1999 21:45:46 -0800 (PST) Message-ID: <36C26F1F.57C1@earthlink.net> Date: Thu, 11 Feb 1999 00:48:26 -0500 From: "Rafael Haciski, MD" <haciski@earthlink.net> Reply-To: haciski@earthlink.net X-Mailer: Mozilla 3.01-C-NSCP (Macintosh; U; PPC) MIME-Version: 1.0 To: ob-gyn-l@obgyn.net CC: Multiple recipients of list <ob-gyn-l@talk.obgyn.net> Subject: Re: Recurrent first trimester pregnancy losses References: <36C234DB.EB097D7E@erols.com> Content-Type: text/plain; charset=iso-8859-1 Content-Transfer-Encoding: 8bit No, I do not think Heparin is of value, although it won't hurt. However, I would focus on Progesterone supplementation, and make sure that the serum levels are adequate (at least >15, preferabley above 20) and continue that suplementation through at least 12th week. Upon stopping I would measure serum prog. ~3 days after stopping, and again 3 days later to make sure there is no precipitous drop, and that the levels remain stable. You did not mention the route of supplementation, which may have a bearing on how effective it is. A prog. of 6 ng/ml is perilously close to being unrescuable - we certainly do not fully understand the mechanics of this, but it has been shown that when prog. drops to 5 or below, that pregnancy can not be retained, even with supplementation. Should she miscarry again, I would obtain the aborted tissue for karyotyping – we know that a large number of abortuses have chromosomal anomalies, nevertheless, it would be interesting to see if it was the same anomaly recurring, which would suggest a repetitive problem making us re-look at the parental genetics. Afterwards I would evaluate the ovulatory factor meticulously, and if there is a problem with ovulation being late, endometrial biopsies out of phase, hypothyroidism, elevated PRL, etc., I would initiate apropriate ovulation induction, making sure after achieving normal ovulation (by BBTC) that the previously abnormal parameters (timing, prog. levels, endometrial biopsies) have all been normalized - this is critical. Of course appropriate thyroid replacement needs to be monitored with TSH, and PRL suppression (if needed) with PRL levels. I personally feel that looking carefully into the ovulation process is where the biggest improvements may be achieved. Of interest is also the semen analysis, as well as cervical (and seminal) cultures for mycoplasma, ureaplasma, and chlamydia. Should be checked and treated before she tries again. If all is normal, I would support her emotionally, and without an identifiable defect, she should succeed, eventually. Of interest is the question of whether to offer her a genetic CVS or amnio to r/o a continuing genetic problem in the fetus (don't know the answer to that, so I would offer it). Good luck.
-- Rafael Haciski, MD FACOG Gynecology & Infertility Assoc. Baltimore MD http://www.ivf-md.com
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