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| William Matzner, MD., Simi Valley, CA |
Miscarriages can be prevented: Overview by Dr. William Matzner
Dr. William Matzner provides an overview on preventing miscarriage.
An unexpected miscarriage can shatter dreams. Two more can be devastating. But now there is hope, and a solution. One in every 200 couples are too genetically similar to achieve successful pregnancy. And usually, they don't know it. That's why early detection is vital. Without intervention, the painful pattern of miscarriage occurs again and again.
Introduction
One in two hundred couples will experience two or more consecutive miscarriages. There are five reasons for miscarriage which have been identified: (1) Infection; (2) Anatomy abnormal; (3) Progesterone level low; (4) Chromosome abnormal; (5) Immune mechanisms. There may also be unknown or undiagnosed reasons and some women have multiple reasons for miscarriages. Your obstetrician will test for most other causes of pregnancy loss.
Immune Systems
Advances in immunology, the study of the body's defense systems, enable us to understand how during pregnancy, the mother's immune system is altered so that the fetus is not rejected by her body and allows the fetus to grow.
The immune system is comprised of white blood cells, also known as leukocytes, which make a variety of antibodies . Some of the antibodies protect us and others are harmful to our bodies. Some of the antibodies that are important to the reproductive system are: Blocking (protective) antibodies, Antiphospholipid antibodies, and Antinuclear antibodies.
When the immune system is the cause of miscarriage, the chances of mother having a successful pregnancy without treatment after 3 miscarriages is 30%, after 4 miscarriages 25%, and after 5 miscarriages 5%. With proper treatment, overall success is 80%!
Blocking Antibodies
Early in pregnancy, the mother's immune system receives signals from the tiny fetus. Many of the signals are hormonal, but others come directly from genetic messages that the father has contributed. Some of the messages involve the tissue type, also known as the human leukocyte antigens (HLA) are the white blood cell (leukocyte) type. HLA are expressed on white blood cells. They are unique to each individual and allow the body to identify anything foreign to it such as infections, cancers, transplanted organs and fetuses. One half of the fetus's HLA type is contributed by mother and the other half by father. When a woman becomes pregnant, her body's immune system usually recognizes the father's HLA as different from her own, and the white blood cells in her uterus produce protective, blocking antibodies. These antibodies coat the baby's cells and protect the fetus from mother's killer cells (figure 1).
If father's HLA is too similar to mother's, her cells may
not recognize differences that are vital to the production of blocking
antibodies.
Women who have successful pregnancies and have no history of miscarriages normally, have high levels of blocking antibodies even in the non pregnant state vs women who miscarry and whose levels tend to be low even when pregnant.
Through HLA tissue typing we can identify couples who look too much "alike" In addition we can measure the ability of a couple's cells to respond to each other i.e. level of blocking antibodies, using sophisticated equipment which combine computers and laser (cell flow cytometry).
Treatment involves immunizing mother with concentrates of father's white blood cells so that the HLA signal is amplified. When blocking levels are elevated, prior to conception, the rate of successful term pregnancy is approximately 80%.
The risk associated with white blood cell immunization is the possible transmission of infectious agents that the father's blood may be harboring. This can be avoided by testing his blood for any significant infections. Very uncommonly, there can be a local skin infection caused by bacteria on mother's own skin. This is easily treated.
Antiphospholipid Antibodies
Phospholipid molecules are normal components of all cell membranes. Some also have glue like properties and allow cells to fuse (as you will see later). Antibodies to phospholipid molecules can, therefore, cause problems. Specifically, they can damage the inside of the blood vessel wall. This allows blood cells to stick to the site f the injury and cause blood clots (figure 3 & 4).
With each pregnancy loss, there is a 10% chance that the mother will develop an antibody to a phospholipid molecule (figure 2).
Most women with antiphospholipid antibodies are not sick. However, some have underlying autoimmune tendencies and should be appropriately evaluated. Women with underlying autoimmune diseases may have antiphospholipid antibodies even before they ever become pregnant.
The treatment for antiphospholipid antibodies involves the use of low dose (baby) aspirin and a blood thinner called Heparin. Heparin is a very large molecule and is unable to cross the placenta. Aspirin is able to cross the placenta but the dose used is so small that the fetus is unaffected. The effectiveness of treatment is mush greater when the medication, if indicated, is started prior to conception and continued throughout the pregnancy. All medication, if indicated should be discussed with one's physician.
Antinuclear Antibodies
The nucleus is the "brain" of the cell. It contains the information that regulates the function of the cell. Some people have antibodies to different nuclear components. What causes these antibodies to be made is currently under investigation but there appears to be a genetic susceptibility which may be reflected by the HLA tissue type (refer back to the section on blocking antibodies).
The disease that we typically associate with antinuclear antibodies is Systemic Lupus Erythematosus (SLE). The miscarriage rate in SLE patients is much higher than that of the general population. Although most women who suffer recurrent miscarriages do not have clinical signs of SLE, many exhibit autoimmune phenomena which is similar to that seen in SLE patients. The placentas in these women are inflamed and weakened.
The treatment for this problem is Prednisone, a corticosteroid, which suppresses the inflammatory process and stabilizes the cell. Prednisone does not pass through the placenta easily and is also broken down by enzymes in the placenta so that the fetus is exposed to only trace amounts. Additionally, the body produces the equivalent of 8 mg per day of this corticosteroid. When indicated, Prednisone should be started prior to conception.
As the body is dynamic, antibody levels may change over time. This is illustrated in the figure below. Most people have no antinuclear antibodies all of the time (A,B). Many women who miscarry have borderline (C,D,E) or abnormal levels of antinuclear antibodies (F,G) (figure 5).
Patients who develop new autoantibodies like antinuclear and antiphospholipid antibodies during pregnancy have a more guarded prognosis.
About William L.
Matzner, M.D., PhD, FACP
Dr.
William Matzner works in the area of healthcare economics consulting at
Healthcare Analytics, LLC, in California. He graduated Phi Beta Kappa from
Stanford University. He received his M.D. with Honors from Baylor College of
Medicine. In 1988, he was the Solomon Scholar for Resident Research at Cedar
Sinai Medical Center. Dr. Matzner subsequently was awarded a PhD in Neuro
Economics from Claremont Graduate University. He is board certified in Internal
Medicine and Palliative Medicine. He has researched and published extensively
on the issue of reproduction and immunology in medical literature. He has been
in private practice since 1989, specializing in Reproductive Immunology and
Internal medicine.
Website: https://drwilliammatzner.com
Consulting Website: https://healthcareanalytics.biz
William Matzner, MD (Simi Valley, California), has been practicing medicine since 1989, Internal Medicine and Reproductive Immunology. M.D. with Honors from Baylor College of Medicine.
