Case of the month Aug '08: Episode #3
Click here for episode 1
Irene and Harold continue their consultation appointment. They are here for help regarding their repeated miscarriages.
The fourth pregnancy occurred towards the end of their second year of marriage. Ironically, instead of being happy with her positive pregnancy test, Irene was terrified. She immediately made an appointment with her OB. This was a new doctor and not the one who cared for her during the first three miscarriages. Her insurance had changed and she was also wanted to switch doctors for personal reasons.
Her hCG test was positive and in the 400’s range. Her OB checked her levels again two days later and it was in the 600’s range. Two days after that, it was about 1000. By now, Irene was an expert on how to monitor an early pregnancy and her memory sure was excellent. She had her first ultrasound five days later. A 6mm sac was seen in the uterus. No fetus nor yolk sac were seen, but I agreed that this was acceptable at this stage. Irene continued her story. Her hCG level was about double of the previous test, but that was five days ago. Meanwhile, she was on complete bedrest and scared to do anything.
Then the bleeding began. She went to the emergency room. The ultrasound was unchanged. There was still a sac, but it hadn’t grown and there was still no yolk sac seen. The bleeding increased and her hCG levels dropped. She just had her fourth pregnancy loss. After Irene courageously told me the whole story, I handed her a box of tissue and took over the conversation.
ME: First of all, I thank you for sharing this with me. I realize it’s not easy to have to talk about such a painful three years. I’ll start by telling you that at this point, given your age and your situation, the odds still indicate that it’s much more likely that you will have a healthy baby eventually. You might find that hard to believe, but even patients with seven or eight miscarriages have gone on to have babies. Hopefully, over time, you will be able to believe me more, but I do understand if you are doubtful.
IRENE nods.
ME: With four miscarriages, there is a likelihood that there is a reason, something that is making your chance of miscarriage higher than the normal 15-20% that other women have. I’m going to start by telling you five major categories of problems that we have to consider. We will then decided which ones to pursue first.
IRENE excuses herself while she removes a notepad from her handbag. It is not uncommon for patients to play “medical student” and take notes while I explain things, so this action did not surprise me.
ME: One area of problem we have to consider is ANATOMICAL. Is there something wrong with your uterus that is giving pregnancies a difficult time to implant? Something like a small fibroid or polyp. We may or may not do some testing right away to see if this is the case. The second thing we have to consider is a GENETIC reason. I know you have had some testing in this area, but we’ll discuss if we should do any further testing at this point. A third category that I consider together are IMMUNE AND BLOOD CLOTTING issues. The fourth category consists of INFECTIOUS causes and the fifth would be HORMONAL issues. We are going to explore these one by one and choose which order we will test.
IRENE begins to smile with hope.
ME: The order of testing will depend on several factors, including how much the test costs, how invasive the testing is, how likely it is for us to find an abnormal result and finally, how likely we can intervene and change things in case we do find something wrong.
IRENE: This is so different and reassuring to hear. I feel like we finally have a clear direction and pathway to go.
Click here for episode 4
