Perinatology Consult #1


DATE OF 08/22/2007

Patient is seen today with her husband because of 2 mid-trimester pregnancy losses. She is a 3l-year-old, gravida 4, para 2-0-2-2, woman whose first 2 pregnancies resulted in term deliveries, and her 3rd and 4th pregnancies were fetal losses at 21 and 18 weeks respectively.

Her first son was delivered in 04/2003 at 39 weeks' gestation. That pregnancy was uncomplicated until late in pregnancy when decreased fetal growth was noted. [MY NOTE: This is not correct. Slightly lagging growth was noted at 20-week ultrasound, with more markedly decreased fetal growth noted later in the pregnancy.] She had no problems with blood pressure or bleeding. A vaginal delivery resulted with delivery of a 2277 gm (5 lb.) male infant through thick meconium. Apgars were 2 and 7 at 1 and 5 minutes. Her son required admission to the NICU at the hospital where he was born. He has subsequently done well.

Her daughter delivered in 2005. No apparent complications occurred during the pregnancy. [MY NOTE: The pregnancy was complicated by pubis symphysis dysfunction, a persistent transverse lie until 38 weeks, and possible partial placental abruption during labor] She delivered vaginally at 6 lb. 3 oz. Her daughter was subsequently diagnosed as having an Atrial Septal Defect [MY NOTE: This hole in her heart closed on its own by age 3]. At the time of delivery, she was noted to have a small placenta with '2 sacs’, presumably nonfused membranes.

Her 3rd pregnancy occurred after their move here to [current state of residence] . Her pregnancy was complicated by recurrent Upper Respiratory Infections and sciatica but no other specific complaints. At 21 weeks, heart tones were not audible, then she was diagnosed as having a fetal demise. Induction of labor was undertaken here at Methodist, and she delivered a stillborn male fetus who appeared normal. Pathology report was unremarkable. [MY NOTE: The pathology report noted that the umbilical cord was hypercoiled.] The placenta was noted to be hypovascular, consistent with a prior demise. There was focal inflammation which was nonspecific. No evidence of villitis. Tissue was sent for karyotype and subsequently found to be 46XY with a pericentric inversion of chromosome 9 [inv(9)(p12ql3)], an apparently normal chromosomal variation polymorphism found in 2% of the general population. Other laboratory studies done at that time included negative factor V Leiden, negative prothrombin mutation, normal TSH 1.08, normal Alc 5.0, negative lupus anticoagulant, anticardiolipin IgM positive, IgG negative, HSG/IgG positive, IgM negative (consistent with a prior infection), CMV and “toxo'' IgG and IgM both negative, rubella immunity present, parvovirus IgG positive, IgM negative, Kleihauer-Betke negative. Blood type O Rh positive, antibody screen negative. Lastly, on gross examination, the umbilical cord was noted to have increased ''twisting.''

With the above information, I did speak on the phone with her doctor and recommended that this patient begin baby aspirin 81 mg a day with a subsequent pregnancy. She went on to become pregnant again and unfortunately had another demise at 18 weeks' gestation. Placental pathology with the 2nd loss noted an area of stenosis in the mid umbilical cord with no endothelial proliferation or thrombosis. The placenta showed no infarcts or chorioamnionitis. Chromosome studies on the placenta were 46XY.

Kleihauer-Betke was positive for 2.5 cc of fetal whole blood.

Anticardiolipin IgG, IgM, and IgA were all negative. Mostly recently, both parents have done peripheral blood karyotype. Her karyotype is 46XX with the same inversion of chromosome 9 noted in the first miscarriage. His peripheral blood karyotype is 46XY.


Significant for a large benign paratubal cyst removed in 10/2001 and the 2 deliveries as noted above.


She is on no medications.


She is allergic to Demerol, developing hives.

Is a nonsmoker.


Noncontributory. Her mother had 8 children and 3 early miscarriages. There is no family history of strokes, heart attacks, deep vein thrombosis, or pulmonary embolism. Her paternal grandfather died of cancer.

There is no family history also of hypertension, diabetes, or thyroid disease.


Blood pressure: 119/84

Pulse: 59

Height: 68 inches

Weight: 156

Exam shows a thin woman.


Repetitive 2nd trimester pregnancy loss.


I spent a total of 60 minutes with the patient and her husband, all of which was spent discussing this past history and possible causes for repetitive midtrimester pregnancy loss.

In view of their first son's distress at birth, meconium and IUGR status, one wonders about an underlying thrombophilia or placental pathology which has carried through more significantly in the last 2 pregnancies. There is no family history suggestive of thrombophilia, and certainly the tests to date do not support this diagnosis; however, I recommended that we complete the thrombophilia evaluation with an anti-z glycoprotein antibody, protein S, protein C, antithrombin III, homocysteine, and MTHFR test. In addition, uterine malformation may result in an abnormal placentation, and a sonohysterogram would be of help.

Interestingly, the patient states that she has pain on a regular basis on the right side which she attributes to possible adhesions from her peritubal cyst surgery 6 years ago. She states the months that she has pain, she never becomes pregnant, but the months that she has no pain, she attains pregnancy. This is certainly suggestive of peritubal adhesions on the right. Also, interestingly, her husband was 5 lb. at birth and was delivered at term. Certainly, an underlying genetic disorder, possibly even X-linked, could be an issue. However, there is none to my knowledge that would result in a normal outcome.

We discussed the empiric use of Lovenox in low dose, 40 mg a day, in addition to low-dose aspirin, if all of these lab studies are normal. Patient will be informed of results when available. Once she does attain a pregnancy she should seek perinatal care for her pregnancy, as close monitoring and fetal surveillance in the 3rd trimester would be warranted.