In the news, sadly Michelle Duggar has miscarried her twentieth child in the second trimester.
Miscarriage is far more likely than most people believe, but the vast majority of miscarriages occur before the second trimester. As the Duggars age, however, there are increasing risks of fetal abnormality. It will be interesting to see if the Duggars request fetal autopsy and whether they publicize it.
In medical advances, Ms. Duggar might benefit from alpha-fetoprotein monitoring, which correlates to fetal health and pre-eclampsia risks. She will, of course, keep trying.
Here is some data on the miscarriage rates and risks.
J Obstet Gynaecol Can. 2011 Nov;33(11):1165-75.
Advanced reproductive age and fertility
Liu K, Case A.
Objective: To improve awareness of the natural age-related decline in female and male fertility with respect to natural fertility and assisted reproductive technologies (ART) and provide recommendations for their management, and to review investigations in the assessment of ovarian aging. Options: This guideline reviews options for the assessment of ovarian reserve and fertility treatments using ART with women of advanced reproductive age presenting with infertility. Outcomes: The outcomes measured are the predictive value of ovarian reserve testing and pregnancy rates with natural and assisted fertility. Evidence: Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in June 2010, using appropriate key words (ovarian aging, ovarian reserve, advanced maternal age, advanced paternal age, ART). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated into the guideline to December 2010. Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table). Benefits, harms, and costs: Primary and specialist health care providers and women will be better informed about ovarian aging and the age-related decline in natural fertility and about options for assisted reproductive technology. Recommendations 1. Women in their 20s and 30s should be counselled about the age-related risk of infertility when other reproductive health issues, such as sexual health or contraception, are addressed as part of their primary well-woman care. Reproductive-age women should be aware that natural fertility and assisted reproductive technology success (except with egg donation) is significantly lower for women in their late 30s and 40s. (II-2A) 2. Because of the decline in fertility and the increased time to conception that occurs after the age of 35, women > 35 years of age should be referred for infertility work-up after 6 months of trying to conceive. (III-B) 3. Ovarian reserve testing may be considered for women ≥ 35 years of age or for women < 35 years of age with risk factors for decreased ovarian reserve, such as a single ovary, previous ovarian surgery, poor response to follicle-stimulating hormone, previous exposure to chemotherapy or radiation, or unexplained infertility. (III-B) 4. Ovarian reserve testing prior to assisted reproductive technology treatment may be used for counselling but has a poor predictive value for non-pregnancy and should be used to exclude women from treatment only if levels are significantly abnormal. (II-2A) 5. Pregnancy rates for controlled ovarian hyperstimulation are low for women > 40 years of age. Women > 40 years should consider IVF if they do not conceive within 1 to 2 cycles of controlled ovarian hyperstimulation. (II-2B) 6. The only effective treatment for ovarian aging is oocyte donation. A woman with decreased ovarian reserve should be offered oocyte donation as an option, as pregnancy rates associated with this treatment are significantly higher than those associated with controlled ovarian hyperstimulation or in vitro fertilization with a woman’s own eggs. (II-2B) 7. Women should be informed that the risk of spontaneous pregnancy loss and chromosomal abnormalities increases with age. Women should be counselled about and offered appropriate prenatal screening once pregnancy is established. (II-2A) 8. Pre-conception counselling regarding the risks of pregnancy with advanced maternal age, promotion of optimal health and weight, and screening for concurrent medical conditions such as hypertension and diabetes should be considered for women > age 40. (III-B) 9. Advanced paternal age appears to be associated with an increased risk of spontaneous abortion and increased frequency of some autosomal dominant conditions, autism spectrum disorders, and schizophrenia. Men > age 40 and their partners should be counselled about these potential risks when they are seeking pregnancy, although the risks remain small. (II-2C).
Fetal Diagn Ther. 2009;25(2):186-91. Epub 2009 Apr 7.
Fetal pathology in second-trimester miscarriages.
Joó JG, Beke A, Berkes E, Papp Z, Rigó J Jr, Papp C.
First Department of Obstetrics and Gynaecology, Faculty of General Medicine, Semmelweis University, Budapest, Hungary. email@example.com
We aimed to analyze, based upon autopsy, the main characteristics of miscarriages in the second trimester.
We have processed the results of fetopathological investigations of 544 aborted fetuses resulting from 486 second-trimester miscarriages.
Malformation could be identified in 13.05% of all cases. In almost one third of the patients there was a positive history. In the cases having a malformation, expressed dominance of male fetuses could be observed. Among the fetopathologically identified malformations, 49 were isolated. The most common was the single umbilical artery (22.4%). In 1.3% of the cases a chromosome aberration was verified.
Miscarriage in pregnancies complicated by a malformation occurs approximately 3 weeks earlier than in cases without a confirmed malformation. There is practically no difference between affected and unaffected miscarriages as far as the cumulative ratio of positive history is concerned. A single umbilical artery alone predisposes to miscarriage, while in association with other malformations it may result from chromosome aberration.
Copyright (c) 2009 S. Karger AG, Basel.
Acta Med Iran. 2010 Jul-Aug;48(4):234-8.
The association between second-trimester maternal serum alpha-fetoprotein in 14-22 weeks and adverse pregnancy outcome.
Dehghani-Firouzabadi R, Tayebi N, Ghasemi N, Tahmasbi Z.
Department of Obstetrics & Gynecology, Research and Clinical Center for Infertility, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
Aim of this study is to determine the risk of adverse pregnancy outcome by maternal serum alpha-fetoprotein (MSAFP) level. We followed 295 pregnant women from MSAFP screening in the 14th to 22th week of gestation until the end of pregnancy and information on pregnancy outcome have been recorded in questionnaires. Of 295 pregnant women, 270 had term labor and 25 had preterm labor. The frequencies of pregnancy outcomes were as following: 3 (1.01%) stillbirths, 25 (8.47%) preterm labor, and 10 (3.4%) preterm rupture of membranous (PROM), 15 (5.1%) pre-eclampsia, 23 (7.8%) oligohydramnious, and 1 (0.33%) miscarriage. The mean of preterm labor was significantly associated with the higher level of MSAFP (P = 0.021). The mean was 55.1 ng/cc in preterm labor and 41.1 ng/cc in term labor. Also, second trimester MSAFP levels were higher in women with pre-eclampsia (P < 0.001). The significant association was found between higher level of MSAFP with oligohydramnious (P < 0.001) and low birth weight (P < 0.001). Pregnancies with an elevated MSAFP level are associated with adverse obstetric outcomes and need more prenatal care.
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