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Pregnancy Bliss | Reproductive Health Hub

Polycystic ovaries and miscarriage

Question:  Hi Dr, I was diagnosed with PCOS. Underwent treatment for ovulation during July. Within a month I was pregnant.  Had light brownish spotting last week. Gestation Age by my dates 13 weeks, 4 days. Went for a a scan and found the baby's growth corresponded to only 8 weeks 1 day and henceforth a missed miscarriage. My scan report showed " Uterus normal. No cyst/mass. Trophoblastic reaction is inhomogeneous. Yolk Sac mildly irregular (2.5x2.7x2.9). Foetal growth - 1.63 cm. No cardiac activity/movement."

It was the worst trauma in our life. Had performed D/C and doctor said that the placental and foetal tissues were strong that they could not be easily expelled from the body and also the  Trophoblastic reaction being inhomogeneous will not indicate genetic problem. Hence it might be oxygen deficiency for the foetus and hormonal supplements could have sustained the pregnancy.  I have few queries:

1) What is meant by Trophoblastic reaction? And in my case, is it true that this indicates there were no genetic defects?

2) Will inducing Progesterone hormonal injections and taking proper rest and sleep in future pregnancy reduce the risk of (missed)miscarriage.

3)How should I make my body normal (the diet, the supplements, the essential factors) and have a healthy pregnancy in future and avoid miscarriage? Thanks for your time and patience. Regards. D.B. (USA)

Answer: Pregnancy loss can be extremely traumatic as your case demonstrates. Let’s look at your situation: you have been found to have Polycystic Ovarian Syndrome (PCOS). As it happens, you conceived quite quickly after the diagnosis was made. You have not said if you had been trying for a long time or not. In any case, if your conception was spontaneous, that augurs well for the future. I am sure you are now aware that PCOS manifests itself to varying degrees. When severe, there can be real issues with fertility in general but the main problems tend to be erratic conception and subsequent difficulty in conceiving. The other fertility issue is a significantly increased risk of miscarriage. Without the full picture of your PCOS, it is not possible for me to give you individualised assessment of the potential impact of PCOS in your quest for a successful pregnancy. Factors such as your body weight, pattern of your periods, presence and degree of insulin resistance etc. are all important. As a general statement, it is appropriate for me to say that, if you are or can get your weight to as close to the ideal as possible (BMI of 25-29), that is a major part of the battle won.

Going next to your specific questions: Trophoblastic reaction is a description of the appearance of the developing tissue and membranes which will lead to the formation of placenta and amniotic sac. In a developing early pregnancy, this appears smooth and regular (homogeneous). With a failing or failed pregnancy as is the case with a missed miscarriage, this might appear inhomogeneous. I am completely at a loss to explain how the appearance of inhomogeneous trophoblastic reaction was somehow equated to absence of possible genetic defects. There is simply no relationship. You can only give this sort of reassurance by doing proper laboratory (cytogenetic) tests. Unfortunately, with an early miscarriage, this is not always possible. I am not prepared to comment on the other theories put forward by your doctor as possible explanations for your miscarriage. Suffice to say, it is simply not possible to prove any of those one way or another.

Using Progesterone hormone injections has not been shown to be of benefit for a naturally conceived pregnancy (as opposed to IVF). They certainly wont do any harm but it will be misleading to present it as a panacea. If you feel you are overworked to an extent of getting stressed, rest and adequate sleep will be a good idea. What you shouldn’t do is to force yourself to rest. That is of no value and could be counter-productive.

Regarding general measures you should take to minimise risk of another miscarriage, I would refer you back to my earlier suggestions. Ensure normal body weight if at all possible, if there is insulin resistance, get medication for this and in general, maintain a healthy lifestyle. My best wishes.

Swine flu vaccine in pregnancy

Question:  I am 24 weeks pregnant. Should I have the swine flu vaccine and is it safe? How much has it been tested? (Ireland)

Answer: We have answered this question a few times now, reflecting on the prevailing anxiety around this subject. There is strong evidence that the injectable swine flu vaccine is safe for everybody including pregnant women. You should also be aware that pregnant women as well as toddlers have been shown to be the most at risk population groups with potentially lethal outcome following an infection. There is really a strong case for the vaccine during pregnancy but the decision, ultimately, has got to be yours.

Early infant feeding pattern and weight gain

Question:  My daughter in law gave birth 2 weeks ago and seemed to be getting along fine with breast feeding. However the baby is not gaining weight and has lost 10oz and she is feeding her formula as well as breast milk on the advise of the midwife. Any advice on what we can do please as she is distraught and feels like a failure. Thank you. C.P. (UK)

Answer: This can be a tricky question to answer remotely. It is certainly the case that all babies lose weight after the birth and, on average, regain their birth weight by the end of the first week.

Bottle-fed babies tend to do this faster than breast-fed ones mainly because of the higher fluid retention and a different fat content of the formula. Overall, in the first month, an infant will be expected to gain about 450-800 grams in weight, averaging 112.5 to 200 grams per week (4 to 7 ounces) Most of this weight is gained in the last two weeks of the month. If this baby appears contented, despite the apparent lack of weight gain at this very early stage, I would not worry about it. As a general rule, babies that are fed on demand, including during the night, tend to show better weight gain patterns than those where feeding is regimented.  I am sure the midwife had a valid reason to advise mixed feeding (rather than the recommended exclusive breast) so I wouldn’t want to question that without being on the ground.

Fetal and sac measurements

Question:  I recently had an ultrasound done. From the ultrasound measurement by the baby that I am 6½ weeks along but from the measurements of the yolk sac I was 7 weeks along. Is that normal or a bad sign? D. (USA)

Answer: It is very unlikely that the second measurement you had was that of a ‘yolk sac’. The size of this is never used to estimate gestation. I suspect it was the gestational sac or ‘amniotic sac’. This is the sac within which the baby is floating. Coming back to the essence of your question, the answer is almost certainly No; it is not a bad sign. Even at this early stage, the measurements obtained have an inherent error of about 2 - 3 days. A difference of half a week in those measurements falls well within that margin of error. I think you can relax. My best wishes.

gestational sac and yolk sac

Gestational sac

Yolk sac

A scan image showing a gestational sac where the baby is found (this one is empty). At the right periphery is the distinct ring-like structure which is the yolk sac.