Pregnancy Loss with Sasha Hakman MD

Fertility Dietitians

In this episode, we are honoring pregnancy and infant loss awareness month. Caitlin and Sophia are digging in deep about this topic with OBGYN and Reproductive Endocrinologist Sasha Hackman, MD. While we know this may seem like a downer, this is purely to inform all of you about statistics, where pregnancy loss is most common, and how we can try to stop this from happening. We all realize most people don’t feel comfortable talking about this, but if this has happened to you, this is NOTHING to be ashamed about.  This is something that happens frequently. You are not alone, you do not need to keep your feelings to yourself, and you are not a failure. In this episode we are trying to educate more people to know how to approach situations like these, become more informed about miscarriages, to open up the conversation and how to hold space for someone who has gone through a pregnancy or infant loss.

Sasha starts talking about how women in early pregnancy can tell the difference between normal discharge or if they are having a pregnancy loss. She says that unfortunately, sometimes a miscarriage can be completely asymptomatic so many women do not find out until they go in for an ultrasound. Some symptoms do include cramping, vaginal bleeding, spotting, low back/ pelvic pain, and sometimes more. The symptoms are very nonspecific and can lead to stress especially with a woman who has had a miscarriage in the past. Truth be told, spotting is not necessarily normal when pregnant, but it is common. If you are having bleeding or spotting, there is a really good chance it is completely benign and will still lead to a healthy pregnancy! Additionally, discharge can be very normal and does not indicate a miscarriage at all. 

We had a question about what normal HCG values would be for women before their first ultrasound, around 4-6 weeks pregnant. Sasha explained how HCG should be doubled, or at least increased, after the first few days. Sometimes women only see a 20% increase and will still have a healthy pregnancy. However, the typical minimum cut off where they are absolutely confident about a healthy pregnancy is 53% or more. 

Sasha dives into telling us what the main cause is for early pregnancy loss. She say by far, the main cause is genetic abnormality. With technology now, they can do something called a “Microarrye Test” that doesn’t require them to culture a tissue, but instead, they can ID small, little deletions rather than chromosomal duplications or lack of entire chromosome. They have distinguished that at least 75% of pregnancy losses are because of chromosomal abnormality. This is practically nature’s way of removing and absorbing pregnancy that eventually would not result in a relatively healthy child. That being said it doesn’t make this loss any easier.

We asked if someone has experienced early pregnancy loss, what would be the medical model of care, when should they do extra testing, and do they have to experience multiple pregnancy losses before going through diagnostics. Sasha said that technically, there should be 2-3x more losses before you start evaluation. However, it is all patient orientated. If a patient wants to get tested after one loss, that’s great. If a patient has had over 3x miscarriages, doesn’t want any tests done at all, and still wants to try to get pregnant again on their own, then that is totally fine, it’s her autonomy. She describes her role as a reproductive endocrinologist and how they see pregnancy as a very sacred thing that doesn’t come easy to many people. They understand that one loss is too many and they want to see how they can prevent another loss. In this case, they will always do a workup for their patients. This mentality is how they (and us as dietitians) are trying to handle medicine now. They are trying to shift away from paternalistic mentality where the doctors just give recommendations based on past evidence. She says everyone’s body is different, so this “old school” way of thinking needs to get thrown out the window. It should always be about the patient and what they want. Catering to their needs can make a world of difference. 

Frequency of pregnancy loss, you ask. Well, Sasha gives us a very descriptive answer on what is really going on in terms of how many miscarriages are happening. Even though this is a “loaded question”, the general number of pregnancy losses would be 12-15% of clinically recognized pregnancies (pregnancies actually recognized by an ultrasound). However, if you were to actually count, a lot of the miscarriages happen before that first ultrasound or before the couple even knows they are pregnant. If you were to combine the clinically recognized pregnancy losses with the clinically unrecognized losses, the incidence rate would be around 30-60%. This HUGE range depends on multiple factors such as age and pregnancy history. 

If under 30 years, and you have already had a live birth and/ or abortion your changes of miscarriage is LOW at a 4-6%. Generally, if you are under 30 years of age, your chances are only 7-15%.

If 35-39 years old, your risk is about 30% and if you are over 40 years, your risk is about 35-50%.

If you have a history of pregnancy loss your risk for reoccurrence is about 25%. With each miscarriage, the risk will go up slightly and will usually plateau at 50%. Yes, this seems high, but there is STILL a substantial chance of a live birth!

Sasha also says that there is not really a difference in natural conception, IUI, or IVF in terms of miscarriages. Pregnancy loss really just depends on medical and pregnancy history, and age. And unfortunately, age is the biggest prognostic factor and is NOT a modifiable one (say what?!). 

Some other reasons why someone might miscarry other than genetic factors is Asherman’s syndrome, developmental abnormalities, translocation of chromosomes, and well as other disorders. Asherman’s syndrome is when some women develop scar tissue within their uterus which can be caused by a history of abortion or miscarriages and need a DNC or any other type of instrumentation of the uterus. This can increase risk of scar tissue, poor vascularization, and the risk of miscarriage. Probably the developmental abnormality of the uterus that increases the risk of miscarriages the most is called a septum. With this septum, there is not enough vascularization to support a pregnancy, which can easily be fixed by removing the septum, the procedure being minimally evasive, and a patient can go home after. Although not as common, the translocation in one of the parent’s chromosome, meaning two pieces of chromosomes switch in both parents’, causes chromosomal abnormalities which can lead to a miscarriage or having a child with a developmental disability. IVF with genetic testing is a good option for parents having this issue. Clotting disorders, endocrine disorders (poorly controlled diabetes), thyroid disease, luteal phase deficiency, PCOS, and age can also increase the risk of a pregnancy loss. These are known things that will increase risk before going into a pregnancy so Sasha always want to tell these patients to not get pregnant until they can optimize their conditions first so they can decrease risk of miscarriage in the future.

Chemical pregnancy versus miscarriage? Sasha explains that a chemical pregnancy is an actual pregnancy with the presence of HCG, but there is nothing in the ultrasound to show sac is being formed. On the other end, there is something called a “blighted ovum” meaning that there is a gestational sac present but no embryo present. Both of these conditions are considered spontaneous abortions. Again, with all of these conditions, whatever they may present as, women should not be ashamed with themselves because IT IS NOT THEIR FAULT. 

Does obesity increase risk of miscarriage? Sasha tells us that studies have shown that once you are in the range of obesity it definitely increases the risk. There is a huge correlation there. Sometimes even very mild weight loss, even 5% of total body weight, will show improved outcomes in pregnancies. This is when it is important to remind women it is not just the weight that matters, it is their overall lifestyle. Being dietitians, we had a few things to say in regard to obesity and pregnancy. We want to tell our listeners that if you are a woman of a larger body size are not eating things that are helpful for fertility, that it is possible to change the way you are eating into a way that DOES support fertility. This will make your fertility completely transformed but your body size does not have to change. This is why the “just lose weight” statement from doctors is not realistic or the issue, we need to talk about how to change the diet and lifestyle with the nutrients that are going to support a healthy baby. Sometimes this will result in a natural weight loss. What we want is to get your hormones under control, blood sugar more regulated, thyroid supported, digestion under control, and stress and inflammation reduced. Sometimes body size will change and sometimes body size will not. Your chances of having a healthy pregnancy will be dramatically increased but it will not always impact your body size.  

Let’s say you are experiencing a loss in pregnancy. What can you expect in terms of medical intervention, managing it on your own, and how long should you wait before seeking medical care? The best practices are giving the women the option between 3 interventions.

  1. Do nothing. Sit and wait to see if your body will take care of it on its own. Advantage: is there is minimal risk. Downside: if it doesn’t happen right away, you may be waiting several weeks to actually complete the miscarriage and even then, it might not happen, and intervention would be needed. 
  2. Medical intervention would involve medication like Misoprostol where it can be given orally/ vaginally. Downside: cramping is really intense. Advantage: avoid having to go into surgery. Another medical intervention would be having a plastic tube inserted into the uterus which would suck everything out. Advantage: all products of conception can go for genetic testing so you can get a better answer (especially now with “microarraye” testing) which really helps with closure for patients.
  3. Surgery: if you are experiencing hemorrhaging of if you develop an infection. 

What is an ectopic pregnancy and how would someone know if they are having one? 

Ectopic pregnancy is different than a miscarriage because the embryo is actually implanted outside of the uterus. There is medication to manage an ectopic pregnancy if the woman is stable, but if unstable, then surgery would most likely be needed. You can tell if its ectopic when you go into doctor’s office and the HCG levels are fairly low compared to what is expected. Also, if the HCG levels are high, then they wouldn’t be rising as quickly as it should. The suspicions would either be a miscarriage, ectopic pregnancy, or sometimes it can even turn into healthy baby. (Wouldn’t it be nice if we could scoop up the ectopic pregnancy and plant it in healthy uterus???)

If someone has an early pregnancy loss, how long can they wait until they can start trying again? What about a further- along pregnancy loss (around 27 weeks)? Sasha says that for an early pregnancy loss the answer would be to start trying whenever you are emotionally and physically ready. Generally, she tells her patients to go for whenever they want, but it might be helpful to wait until they have their next period. For a further along pregnancy loss, also called a fetal demise, you really just want to give months for physical and emotional recovery and grieving. However, she really recommends looking into why this may have happened and if there is something specific that can be changed, then you want to work to see how you can change that and try to reduce risk for the next pregnancy. 

Sasha explains that trying to prevent a miscarriage can be tough because the majority of the time it is chromosomal. Sometimes it can be stress related, which no one knows for a fact, but why they believe in this is because there is one intervention for recurrent pregnancy loss that’s called TLC (tender love and care). This is when they will bring patients in for weekly ultrasounds (or really whenever they just want it) to reassure them that their pregnancy is still viable and ongoing. Studies have shown that the live birth rate with this intervention is significantly higher. (Wow!) There is something to be said about constant reassurance, really being there for a patient, and allowing them to get as many ultrasounds that they need. This treatment may help you if you have been through a pregnancy loss more than once and might be scared it will happen again. Reassurance that everything is okay will reduce your stress. Staying active, staying distracted, including lifestyle interventions like proper sleep, mindfulness, mediation, eating whole foods, and doing things that make you feel good, will help you enjoy your pregnancy more, as well as taking care of your mental health and your growing baby.

To end on a happy note, to any woman who has gone through a miscarriage/ recurrent loss, the chances of you holding a baby in the next pregnancy is 70%. THAT’S HUGE. Just remember that and that will help bring you back some optimism.

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