Heparin Sodium 5000Iu Injection

Miscarriage Facts-

A miscarriage is defined as a pregnancy that ends before the 24th week. One in five pregnancies end this way.

The cause of a miscarriage is often not identified, but if it occurs during the first trimester it’s usually due to problems with the foetus, such as a chromosomal abnormality. This is unlikely to recur and doesn’t mean there is any problem with the mother or father’s chromosomes.

• If a miscarriage happens during the second trimester (between weeks 14 and 26), it may be the result of an infection, a long-term health problem in the mother, food poisoning or a problem with the womb or cervix.
• A woman will be referred for investigations if she has recurrent miscarriages (three or more in a row). About 1 in 100 women experience recurrent miscarriages and more than 60% of these women go on to have a successful pregnancy.
• Women could be told from the beginning of pregnancy if they are at high risk of miscarriage or premature birth thanks to a highly accurate new tests.
• Leading scientists have described as “very exciting” a breakthrough technique which can detect serious complications months in advance, giving doctors the chance to intervene and save lives.
• It means that being told the likelihood of a devastating event could soon become a routine part of a doctor confirming a woman is pregnant.
• Miscarriage charities welcomed the new technique.
• Obstetricians can currently provide expecting mothers little or no warning of premature birth, miscarriage or preeclampsia, a life-threatening blood pressure disorder which kills up to 1,000 babies a year.
• But researchers have now identified a handful of molecules unlocking the fundamental biology of these conditions, which are present long before any symptoms arise.
• Scientists have so far devoted largely unsuccessful efforts to searching for blood biomarkers from the placenta.
• However, the team at the Laboratory of Premature Medicine and Immunology in San Francisco turned their attention to the placental bed, the thick mucous membrane that lines the uterus during pregnancy.
• Their discovery of 30 molecules relating to gene expression will enable newly pregnant women to undergo to a simple blood test able to determine their risk.
• Britain has one of the highest rates of premature birth in Europe, with roughly one in nine babies born before 37 weeks gestation.
• If doctors are aware a woman is at high risk of early delivery they can monitor her more closely and potentially use hormone drugs to delay the date of birth.
• While there little that can be done to prevent miscarriage, the test can help women prepare for the eventuality.
• By contrast, preeclampsia can be monitored and better managed the earlier it is detected.
• Around three per cent of pregnant women suffer the condition where blood pressure is raised to levels that threaten both mother and child.
• The only cure is to deliver the baby, meaning doctors can sometimes be forced to induce dangerously premature births.
• Tim Child, assistant professor of obstetrics and gynaecology at Oxford University, said the new research was “very promising” and described the statistical relationship between the discovery of blood biomarkers in patients in the study and their subsequent complications as “very, very strong”.
• Presented at the American Association of Reproductive Medicine annual congress in Texas, the four combined studies involved 160 births.
• Searching for microRNA in blood immune cells, the team were able to predict miscarriage and late preeclampsia with around 90 per cent accuracy and premature birth before 34 weeks with around 89 per cent accuracy.
• Premature birth between 34 and 38 weeks was predicted with 92 per cent accuracy.
• Professor Simon Fishel, an IVF pioneer and founder of Care Fertility, said a warning highlighting blood flow problems in the placental bed, potential treatments include blood thinning drugs such as heparin
• “Specialist obstetricians have means to help manage such disorders and early recognition of these complications is vital.
• “Further support and evidence for this biomarker could indeed be an important tool in the management of these high risk pregnancies.”
• He added that to be ‘forewarned is forearmed’ when dealing with pregnancy complications.
• Specialist obstetricians have means to help manage such disorders and early recognition of these complications is vital.
• Further support and evidence for this biomarker could indeed be an important tool in the management of these high risk pregnancies.’
• “Our combined analysis supports the idea that the Great Obstetrical Syndromes have a common biological origin early in the first trimester that can be detected throughout the first trimester using peripheral blood cell microRNA,” the researchers said.
• Roughly one in four pregnancies end in miscarriage, although this reduces to one in six pregnancies where the mother knows she is pregnant.
• Around 80 per cent occur in the first 12 weeks’ gestation.
• Barbara Hepworth-Jones, Vice Chair of the Miscarriage Association, said: “This is very welcome news.
• “Much research is still needed before we fully understand the causes of pregnancy complications including miscarriage, and can then look for treatments.
• “But this holds real hope for the future.”
• A recent study found that giving aspirin to women at high risk of pre-eclampsia could reduce their chance of preterm pre-eclampsia by 60 per cent.

Pregnancy gives a woman completeness by turning her into mother from a simple woman. It is the thing which makes the couple parents, the dream which they nurture right time from their marriage. Of course there are many couple s who are not fortunate enough to achieve pregnancy and they are usually termed infertile and we have discussed it in separate post. But there are other couple s who may or may not (as this is the usual case) find difficult to conceive but the pregnancy does not continue to the age of viability. Age of viability means the age, when a baby born can survive. Thanks to the improvement in neonatal care by leaps and bounds and availability of NICU which made it possible to survive even a baby born at 22 weeks. For example last month we delivered a baby at 28 weeks of pregnancy, who is fine now. But if the baby is 'born' before 20 weeks, it is called MISCARRIAGE. This is because these babies who weigh less than 500 gram cannot survive outside the uterus. It is seen that 10-15% couples who conceive successfully may not be able to carry pregnancy beyond 20 weeks. Thus the miscarriage rate for a single pregnancy is 10-15%. But in most of the time this mishap does not recur in future. We call it 'sporadic miscarriage' and often the cause is not known. But almost 1% of the couples who wamt to get pregnant may suffer from repeated miscarriage. That means the unfortunate events can repeat. These are called 'RECURRENT MISCARRIAGE' or 'REPEATED PREGNANCY LOSS *RPL).

CAUSES

So, what's the reason for RPL which is equally frustrating for the patients as well as the doctors? First of all let me honestly confess that in most of the cases the cause is not known (50-60%) and this is called 'UNEXPLAINED RPL'. Again we have to admit that despite tremendous advancement in science, the knowledge behind RPL is limited. Many theories and causes have ben proposed but most of them could not withstand the taste of time. That means if a problem is found in husband or wife, we are not certain whether the treatment of that problem will prevent future miscarriage. This should be explained properly to the couples to have realistic expectations and avoid unnecessary frustration s in future. Only factors which are definitely associated with RPL are only two- anti-phospholipid antibody syndrome (APS) and chromosomal problem of either of the couples. Detection and treatment of these problems are often rewarding as after treatment pregnancy continuation rate us very high. The other causes have been proposed but as mentioned above the link between RPL and these causes are not yet very clear and need further scientific research. Please remember according to the timing, RPL may be divided into two categories- the 1st trimester RPL (occurring before 12 weeks in each pregnancy) or second trimester RPL (12-20 weeks in each pregnancy).

4-5% cases may be due to genetic or chromosomal problem of the couples. These problems can affect the egg (ovum) and/or the sperms. Even if the couples are normal, the baby may have abnormal chromosome.It is blessing that a genetically abnormal baby is miscarried by the nature, otherwise if it survives there is high chance that it may be mentally or physically handicapped. The reason may be increased age of the mother (above 35 years especially), exposure of mother to some environmental pollutants or sometimes increased age of the father (the latter is controversial). The diagnosis is done by chromosomal analysis of the couple by Karyotyping or FISH from blood samples. If the baby has been miscarried, it may be rational to send the tissue of the baby for chromosomal analysis to find iut the cause. The treatment option in next pregnancy in such cases is genetic counseling by an expert and in most cases unfortunately ine option remains- that us IVF and PGD (pre implantation genetic diagnosis) where only genetically tested normal embryos are transferred by IVF ('test tube baby').

Anatomical factors are responsible for 12-15% if RPL, in most cases the second trimester RPL. The most common cause is 'CERVICAL INCOMPETENCE'. The cervix is the mouth of the uterus which should remain closed in pregnancy to support pregnancy and should only open during delivery. But in some cases it xan open prematurely leading to miscarriage. Usually this causes apparently painless miscarriage. In many women fibroid is found as a tumour of uterus. Whether fibroids cause RPL is again very controversial among the scientists and doctors. In some women who had repeated abortion or surgery to uterus and even tuberculosis (TB) there may be adhesion (binding together) between the walks of uterus. This is called Asherman Syndrome which causes scanty or absent periods and RPL. In few women there may be Congenital Anomaly of the uterus- that is yhere is some abnormalities inside uterus from birth. Thesr xan sometimes caus RPL, although controversial. These anatomical problems are diagnosed by proper examination, some tests like HSG (hystero salpingogram), SSG (sono salpingogram), 3D ultrasonography (USG), MRI, hysteroscopy and/or laparoscopy, depending on the women and test results. The treatment should be dobe cautiously as treatment may not always prevent RPL. For cervical incompetence usually we put stitch in the cervix in pregnancy or sometimes before pregnancy. Operation xan be done, before pregnancy for fibroids, Asherman and congenital anomalies.

In many cases (more than 70%) cases hormonal problems may be there and these may cause both 1st and 2nd trimester RPL. However whether treatment us beneficial or not, is again controversial. The commonest pattern is Luteal Phase Deficiency (LPD) due to deficiency of hormone progesterone. PCOS (Polycystic Ovaries) is also asdociated with RPL. The other causes are uncontrolled diabetes, thyroid problems, high prolactin and high testosterone, high insulin and low ovarian reserve. As mentioned earlier, it is not clear whether they all need testing and treatment but usually tests advised for these are blood for progesterone, TSH, Prolactin, FSH, LH, AMH, Insulin, Testosterone, sugar, HbA1C etc. Treatment is usually progesterone supplement along with correction of hormonal imbalance. It is to be mentioned that these patients need high dose of thyroid drugs (TSH normal for other people may be considered abnormal for RPL) and more tight control of blood sugar in diabetes.

In 60-70% cases the cause Thrombolphilia, that is tendency to thrombosis or blood clotting. The most common is  anti phospholipid antibofy syndrome (APS) which nay or may not be associated with thrombosis in other sites but can cause thrombosis if blood supply to the baby and thus causes stopage of its heart and miscarriage. Although more common in the Western World, some Hereditary Thrombolphilia may be found in other family members and commonly cause miscarriage and thrombosis. Deficiency of folic acid and vitamin B12 rarely xan cause thrombosis and RPL. The APS testing is often successful, so as the treatment with aspirin and heparin injection throughout pregnancy. With this 80% women can expect full term pregnancy. Folic acid and B12 vitamin supplement is commonly given to RPL patients. Whether testing for hereditary thrombophilia is needed in our country ir not is controversial. But treatment is like APS- that is aspirin and heparin injection.

Diseases of mother like diabetes, epilepsy, liver or kidney diseases, SLE etc can cause miscarriage. Exposure of mother to harmful substances like environmental pollution, radiation, chemotherapy and some toxic drugs, smoking, alcohol, cocaine, cannabis etc are alse responsible but the latter usually cause sporadic miscarriage rather than RPL. So these drugs should be stopped and replaced by safer drugs anf the diseases mudt be treated properly. Even exposure of father to some drugs can cause RPL. Again some abnormalities of sperms may cause RPL. So, semen analysis of the husband is usually done as a test for RPL.

The most controversial topic for RPL is the infections. But itbis the fact proved by scientific studies that only infection in current pregnancy causes miscarriage. So infection is a cause of sporadic miscarriage, not RPL. In the past TORCH testing was very much popular but nowadays it is obsolete test and there is no scientific ground for tests or treatment of TORCH. Only test we recommend is rubella testing. If rubella IgG is negative that means you may get infection in pregnancy so we advice to take rubella vaccine and avoid pregnancy for one month. On the other hand, rubella IgG positive neans you are already imune and thus you can never get rubella. So vaccine is not useful in those cases. If any genital infection is found in husband or wife, both if them should be tested and treated aggressively.

TESTS REQUIRED

First of all we ned to know when we should advise tests. Assuming that most cases of miscarriages are SPORADIC, we usually di not advise investigation after single miscarriage unless the couple insists or there is some reason by the doctor to suspect some abnormalities that might cause future miscarriage. In the past testing was started after 3 miscarriages. But nowadays we do not want to give the couple, especially the woman a third trauma. So we usually advise tests after 2nd miscarriage. The tests usually start with checking for chromosome of the baby. It is followed by chromosome analysis of both the partners along with proper history taking and physical examination. Semen analysis us fone for the husband. The wife is advised ultrasonography, routine blood, thyroid testing, testing for APS and blood group. These are tests usually dine everywhere. Further tests are done depending on the results if initial tests ans0d especially if no cause us found after initial tests. It should be mentioned to the couples that the 2nd group if tests often do not have scientific grounds and are done only on benefit of doubt. They may not change the management plan. TORCH test is not done in modern era.

TREATMENT

The basic treatment is support if the couples, reducing stress as stress can be responsible for RPL. When a cause is found this should be treated. While an optimistic approach should be taken with expectations for normal pregnancy in future but this should be based on scientific and realistic approach to avoid future frustration. The treatment may not be 100% effective and most treatment may not have scientific base but are usually not harmful. Treatment may not guarantee a successful future pregnancy but a positive attitude is necessary. This is called TENDER LOVING CARE (TLC where proper support and discussion can help more than explanation if mere statistics. Treatment should be continued both before and after pregnancy confirmation, as mentioned above. This isbto be mentioned thst even after 6th miscarriage, the chance that future pregnancy will be normal is more than 50%. So, the message should be not to give up hope.

If you have some kinds of heart or blood vessel disease, or if you have poor blood flow to your brain, your doctor may recommend that you take a blood thinner. Blood thinners reduce the risk of heart attack and stroke by reducing the formation of blood clots in your arteries and veins. You may also take a blood thinner if you have

• An abnormal heart rhythm called atrial fibrillation
• Heart valve surgery
• Congenital heart defects

There are two main types of blood thinners. Anticoagulants, such as heparin or warfarin (also called Coumadin), work on chemical reactions in your body to lengthen the time it takes to form a blood clot. Antiplatelet drugs, such as aspirin, prevent blood cells called platelets from clumping together to form a clot.

When you take a blood thinner, follow directions carefully. Make sure that your health care provider knows all of the medicines and supplements you are using.

What is recurrent miscarriage?

If you have three or more miscarriages in a row, doctors call it recurrent miscarriage. If you have experienced recurrent miscarriage, your GP or midwife will refer you to a gynaecologist. Your gynaecologist will try to identify the reason for your losses.

Having miscarriage after miscarriage may leave you feeling utterly drained of hope. At times, it may be hard to keep trusting in the future. This experience affects every aspect of a woman’s life from her mental and emotional health to her physical health and social well-being. 

If you can, try to draw comfort from the fact that most women who experience recurrent losses do go on to have a baby. This is especially the case if tests can find no reason for the losses. Six out of 10 women who have had three miscarriages will go on to have a baby in their next pregnancy.

Treatment of Recurrent Pregnancy Loss

Treatment for anatomic abnormalities of the uterus involves surgical restoration through removal of local lesions such as fibroids, scar tissue and endometrial polyps or timely insertion of a cervical cerclage (a stitch placed around the neck of the weakened cervix) or the excision of a uterine septum when indicated.

A thin endometrial lining has been shown to correlate with compromised pregnancy outcome. Often times this will be associated with reduced resistance to blood flow to the endometrium. Such decreased blood flow to the uterus can be improved through treatment with sildenafil (Viagra), Terbutaline and possibly aspirin.

Sildenafil (Viagra) Therapy Viagra has been used successfully to increase uterine blood flow. However, to be effective it must be administered starting as soon as the period stops up until the day of ovulation and it must be administered vaginally (not orally). Viagra in the form of vaginal suppositories given in the dosage of 25 mg four times a day has been shown to increase uterine blood flow as well as thickness of the uterine lining. To date, we have seen significant improvement of the thickness of the uterine lining in about 70% of women treated. Successful pregnancy resulted in 42% of women who responded to the Viagra. It should be remembered that most of these women had previously experienced repeated IVF failures

Terbutaline this is a medication that relaxes the muscle in the uterine wall and so permits improved hormone delivery to the endometrium. The use of Terbutaline will often cause an increase in heart rate. It should not be prescribed to women who have irregular heart beats (arrhythmias), and women who have decreased cardiac reserve.

Aspirin this is an antiprostaglandin that improves blood flow to the endometrium. It is administered at a dosage of 81mg orally, daily from the beginning of the cycle until ovulation.

Selective Immunotherapy Using Intralipid, heparin, aspirin and corticosteroid

Many causes of pregnancy loss or failure can be treated with immunotherapy comprising combinations of aspirin and heparin and corticosteroids (dexamethasone or prednisone) and Intralipid (IL) to regulate increased level of Natural Killer Cell Activation (NKa). Achievement of optimal success with Intralipid/corticosteroid therapy requires that the treatment be initiated well before ovulation takes place (about 7-14 days prior to anticipated implantation). Given the fact that only 10-15% of natural cycles (with or without the use of insemination and/or fertility drugs) will result in a pregnancy, it follows that repeated administration of Intralipid will be required in most cases before a pregnancy will occur. IVF achieves pregnancy rates that are often 2-3 times higher. This often makes IVF a treatment of choice in cases of immunologic recurrent pregnancy loss.

Role of IVF

Preimplantation genetic diagnosis (PGD) a procedure whereby the embryo can be tested for genetic or structural chromosomal abnormalities requires the use of IVF to select the best embryo(s) for transfer to the uterus. In cases of structural chromosomal (translocations) egg or sperm donation is often another option worth considering.

In those cases where due to intractable anatomical or alloimmune dysfunction IVF repeatedly is unsuccessful or is not an option, Gestational Surrogacy might represent the only recourse other than adoption.
If a couple with Recurrent Pregnancy Loss is open to all of the diagnostic and treatment options referred to above, a live birth rate of 70% – 80% is ultimately achievable.

One of the most severe forms of pain is the pain that a woman experiences during the process of childbirth. On a scale of 1 to 10, with 10 being the most severe, it is believed to be 8 to 10. In the earlier days, a number of women would die during childbirth and survival was considered as a second lease of life. This belief has however, changed with the advancements in medical science. The delivery has now become an almost painless procedure.

How it works: The pelvis and the lower limbs receive nerve supply through the nerves coming out of the spinal cord. A strong anesthetic is injected into the lower back to numb the pelvis and down below. This ensures that the mother is comfortable and awake during the whole procedure and is able to see the child being delivered but has reduced pain in the lower half of the body.

What are its benefits?

1. The mother has a painless delivery and is conscious and able to see the process of delivery.
2. Significant relief from the painful experience of childbirth. The pain induces secretion of stress hormones in the mother, which adversely affects both the mother and the child.
3. Blood pressure is better controlled using this procedure.
4. Additional instruments can be used during the delivery if required without the need for additional anesthesia.
5. If required, the procedure can be converted to a cesarean section too, by adding an epidural catheter.
6. The duration of childbirth has been significantly decreased.
7. Suitable for patients who have preeclampsia and heart disease

It has some disadvantages too

There are minor complications, including:

1. This can develop after the painless delivery and the onset and intensity vary from one individual to another
2. Post-procedure headache
3. Pain at the site of injection
4. Difficulty during urination
5. The normal pushing effect by the woman is reduced due to the numbness and so vacuum may be used or delivery may have to be converted to a cesarean one.
6. In rare cases, there could also be a sudden drop in the blood pressure

Certain indications

In the following cases, the doctor would advise the mother to go for a painless delivery

1. Medical conditions like preeclampsia, high BP, or other heart conditions
2. Subsequent births after having had a cesarean section (VBAC – vaginal birth after cesarean)
3. People who have previously had prolonged or complicated labor, a painless delivery is easy on both the mother and the child

When it should be best avoided

In some cases, like the ones listed below, the painless delivery should be avoided

1. Women with bleeding disorders.
2. Women who are on blood thinners like aspirin, heparin, etc.
3. Women who have had prior low back surgeries
4. Women with neurological conditions

A detailed discussion with your gynecologist is the best way to identify, if this would work for you.