Question: Dear Doctor,

I am 36 years old. I miscarried my first child in November 2006. It was a missed miscarriage. We saw the heartbeat at around 8 to 9 weeks, which was missing in the 12th week scan. Had a D&C after that...

Following that, I conceived in XXXXXXX 2007 and was immediately put on SUSTEN 100 mg and IM PROLUTON injection 250 mg weekly every 10 days for nearly 16 weeks. I delivered a healthy girl baby in March 2008 via c-section as my water bag burst and my baby's head was unengaged.

I conceived again in November 2010 and had a similar missed miscarriage in January 2011. Underwent D&C,

Before planning for a second child this year, I underwent a master health check up in XXXXXXX 2014 and the reports said that my sugar, BP and thyroid levels are normal. I also did a general check up with a gynaecologist who asked me take a few tests to understand the reason for miscarriage. LUPUS ANTICOAGULANT, CARDIOLIPIN ANTIBODY-IgG and IgM, APA-IgG and IgM antibody to Phospholipid. All the results are NORMAL and NEGATIVE.

I am NOW pregnant. 6 weeks. My LMP is 8th September 2014. My gynaecologist has asked me to wait to take SUSTEN tablets till my first scan. She also says that she does NOT believe in Proluton injections sustaining the pregnancy but she will give me shots if I prefer as I had them when I delivered my first child and it does not cause any harm. She has also told me that she will put me on ECOSPRIN 75 mg tablets (once a day) from the time the heart beat is seen till 34 weeks to ensure blood circulation to the foetus.

Now my questions are

1)     Is it ok to avoid IM PROLUTON injections as my gynae says it’s not of much use? Will SUSTEN 100 mg capsules taken orally twice a day enough? I am yet to start on it. My scan is due this week.

2)     Is it safe of take ECOSPRIN tablet for such a long period of time? What will be its side effects?

3)     Is there any possibility of me having a normal delivery this time given my history and reason for C-Section? My daughter is now 6.5 years.

Thanks and Regards
XXXX

Dear Doctor,

Thank you for the appreciation :-) Though I know how busy doctors are, was eagerly awaiting your reply. Thank you so so much for responding in such detail and that too in the wee hours of the morning.

I have 3 more questions doctor...

1) Is dydrogesterone tablets to be taken instead of 'susten' or along with it? I shall also check about this with my gynae and which tablet to take, as suggested by you.

2) I feel bloated and constipated after taking 'susten' capsules. Does 'susten' cause that? Is there any side effects of taking 'susten'?

3) Regarding ECOSPRIN tablets, I understand its action and use in case of ANTI-PHOSPHOLIPID syndrome. But, in my case doctor, my blood test reports show NEGATIVE Cardiolipin antibodies- IgG and IgM and also antibodies to PHOSPHOLIPID is NEGATIVE. The LUPUS Anticoagulant value is also normal. I also do not have any blood clotting issues or circulatory issues or Blood pressure. So, in my case, is it really NECESSARY to take this tablet doctor. I have attached the lab reports for your reference. My gynae had advised this, just in case...

Awaiting your reply.

Thanks and Regards

XXXX

Thank you so much doctor for the detailed responses! I shall let you know once I take a scan and update you

Thanks for the diwali wishes too and hoping you had a great Diwali :-)

Regards
XXXXXXX

Dear Doctor,

I am 36 years old. I miscarried my first child in November 2006. It was a missed miscarriage. We saw the heartbeat at around 8 to 9 weeks, which was missing in the 12th week scan. Had a D&C after that...

Following that, I conceived in XXXXXXX 2007 and was immediately put on SUSTEN 100 mg and IM PROLUTON injection 250 mg weekly every 10 days for nearly 16 weeks. I delivered a healthy girl baby in March 2008 via c-section as my water bag burst and my baby's head was unengaged.

I conceived again in November 2010 and had a similar missed miscarriage in January 2011. Underwent D&C,

Before planning for a second child this year, I underwent a master health check up in XXXXXXX 2014 and the reports said that my sugar, BP and thyroid levels are normal. I also did a general check up with a gynaecologist who asked me take a few tests to understand the reason for miscarriage. LUPUS ANTICOAGULANT, CARDIOLIPIN ANTIBODY-IgG and IgM, APA-IgG and IgM antibody to Phospholipid. All the results are NORMAL and NEGATIVE.

I am NOW pregnant. 6 weeks. My LMP is 8th September 2014. My gynaecologist has asked me to wait to take SUSTEN tablets till my first scan. She also says that she does NOT believe in Proluton injections sustaining the pregnancy but she will give me shots if I prefer as I had them when I delivered my first child and it does not cause any harm. She has also told me that she will put me on ECOSPRIN 75 mg tablets (once a day) from the time the heart beat is seen till 34 weeks to ensure blood circulation to the foetus.

Now my questions are

1)     Is it ok to avoid IM PROLUTON injections as my gynae says it’s not of much use? Will SUSTEN 100 mg capsules taken orally twice a day enough? I am yet to start on it. My scan is due this week.

2)     Is it safe of take ECOSPRIN tablet for such a long period of time? What will be its side effects?

3)     Is there any possibility of me having a normal delivery this time given my history and reason for C-Section? My daughter is now 6.5 years.



Hi XXXX,
I loved the intelligent way you related your history and the precise way of asking questions. Excuse this slight delay in answering your query. Was terrifically busy.
Here we are:
1. Proluton is the injectible form of the hormone Progesterone whereas micronized Progesterone (Susten) is the oral form to be taken by mouth or vaginally. Both, however, are progesterone type preparations. It really is no point in taking both. Susten in doses of 100 mg twice a day would be enough.

Yes, in your particular case, the role of Progesterone supplementation is rather limited and may not be of much use. But since you associate a good result and outcome with the taking of Progsterone, it may be taken.

Let me point out about another natural form of Progesterone known as Dydrogesterone, has certain immunological benefits in repeat abortions. So sometimes, even in missed abortions like yours, Dydrogesterone may be of benefit. Your doctor can advise you further regarding its immunological role in pregnancy preservation, as well as doses.

2. Ecosprin 75: i generally would advice from the time of confirmation of a pregnancy till 36 weeks of pregnancy. But if your doctor has mentioned 34 weeks, i wouldn't consider it entirely wrong since i understand the thoughts of your doctor. A baby more than 34 weeks and/or more than 2.5 kgs has good survival rates. Nevertheless, i personally prefer continuing Ecosprin till about a week short of delivery or 36 weeks, whichever is later.

Ecosprin is safe to a large extent. But let me alert you that even though its such a low dose of aspirin (acetyl salicylic acid), don't take it lightly as it can cause troublesome hyper-acidity. So please take it after your meal, preferably dinner. Secondly, if continued till delivery time, it can cause clotting problems because it thins the blood leading to excessive bleeding. It is its this very action of thinning the blood that helps in cases of recurrent abortions due to Anti-Phospholipid Syndrome.
People of heart disease take low dose aspirin for years and years so taking for about 7 months during pregnancy causes no problems.
It causes no harm to unborn baby.

3. Yes, there is a possibility that you can have a normal delivery after a previous C-Section although the chances are lower than if your previous delivery was a normal birth. Attempting VBAC (Vaginal Birth After C-Section) makes the case a High Risk one and the doctor/ place of trial should both be appropriate. You should not attempt this in a low resource settings. A decision about this is usually made as the pregnancy progresses and is dependent on many factors - whether there is any history of infertility in addition to your previous abortions, presence of any medical risk factors in this pregnancy, the weight of baby, softness of the opening of the womb etc etc. The intent should be to try normal delivery which should then be modified by circumstances of the pregnancy. Don't remain fixed about it. Remain relaxed. Whatever will be will be fine.
Best wishes for you and the baby.
If there are any more queries I'll be happy to answer them for you.
Regards,
Dr Nirja Chawla







































Dear Doctor,

Thank you for the appreciation :-) Though I know how busy doctors are, was eagerly awaiting your reply. Thank you so so much for responding in such detail and that too in the wee hours of the morning.

I have 3 more questions doctor...

1) Is dydrogesterone tablets to be taken instead of 'susten' or along with it? I shall also check about this with my gynae and which tablet to take, as suggested by you.

2) I feel bloated and constipated after taking 'susten' capsules. Does 'susten' cause that? Is there any side effects of taking 'susten'?

3) Regarding ECOSPRIN tablets, I understand its action and use in case of ANTI-PHOSPHOLIPID syndrome. But, in my case doctor, my blood test reports show NEGATIVE Cardiolipin antibodies- IgG and IgM and also antibodies to PHOSPHOLIPID is negative. The LUPUS Anticoagulant value is also normal. I also do not have any blood clotting issues or circulation issues or BP. So, in my case, is it really NECESSARY to take this tablet doctor. I have attached the lab reports for your reference. My gynae advised this, just in case...

Awaiting your reply.

Thanks and Regards

Meena

Brief Answer:
Progesterone and aspirin given empirically

Detailed Answer:
Hi XXXX
1. Dydrogesterone and Susten are both progestrogens. Therefore only one of them is taken at any time - either of them; not both together just as Proluton and Susten are not required together.
2. Bloating and constipation are caused by progesterone. These are side-effects of Progesterones. They may be there even with Dydrogesterone although different salts may have variable side-effects.
3. Yes, there is no laboratory evidence of Anti-Phospholipid Syndrome in your case other than the clinical data of 2 abortions. Sometimes medicines are given empirically even though laboratory results do not support that diagnosis.
I hope this answers your queries.
Wish you all the best. Happy Diwali to you and all whom you love.
Regards.
Dr Nirja Chawla








Dear Doctor,

An update and just a final few more questions.

Yday took a scan and unfortunately the doctor said there is no development of the embryo and it seems like a blighted ovum with empty sac. Asked me to take a follow up scan next week to confirm. We feel completely crushed..... My husband so wanted a second child and my daughter is longing for a sibling. Finally, I defeated my doubts if I can manage a second child and decided to try. We were happy when I conceived in 3 months. This was supposed to be our last try. Now it’s just a busted bubble...

My Hcg levels on the 33rd day of pregnancy was 278, 34th day was 478 and 38th day was 2316.8. My progesterone level on the 38th day was 14.

1) Were my HcG levels taken in the first week after the missed periods too low? Did it not indicate viability of the foetus?

2) Should I have gone for progesterone supplements or shots from the first day of missed period when I tested positive? Would that have helped?

3) After 2 miscarriages, now a blighted ovum. what can be the reason? Both my husband and I are healthy and do not have any major problems. Why is this happening to me? Is it my age now?

4) I have tender breasts, painful to touch, bloating, mild headaches and temperature hovering around 99.5 (even today). Other than that, I do not have other classic pregnancy symptoms like nausea, morning sickness, vomiting, tiredness or hunger. Does the presence of the latter symptoms indicate more viability of the preg? Cos the only time I had vomiting for a few times was when I was preg with my daughter. All other pregnancies that ended before its time was the same with no nausea or vomiting…

5) If the next week scan shows the same result, what will be the course of action? Can the empty sac be removed via medicines or should I undergo a D&C? I have already undergone 2 D&C's and do not want it again.

6) If at all we plan to try again, how many months should we wait before we try?

Thanks so so much in advance. Your responses were so useful and informative.

Regards

XXXX XXXXXXX