The D&C

A little dark humor: "I survived my D&C and all I have to show for it is some lousy mesh panties."

Making miscarriage a crime

I present for your horrified review, legislation actually being proposed here in Tennessee:

SB 1065 by Marrero B (HB 0890 by Hackworth)

AN ACT to amend Tennessee Code Annotated, Title 68, relative to testing for certain substances in pregnant women.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF TENNESSEE:
SECTION 1.Tennessee Code Annotated, Title 68, Chapter 5, is amended by adding Section 2 of this act as a new part thereto.

SECTION 2.
(a) The general assembly declares that, as a matter of public policy of this state and in
the interest of public health, pregnant women who abuse alcohol and drugs pose a risk to their unborn children. Pregnant women who meet certain criteria, as determined by the department, through rules and regulations duly promulgated in accordance with the provisions of the Uniform Administrative Procedures Act, compiled in title 4, chapter 5, shall be tested for alcohol and drugs in order to encourage them to seek immediate treatment for an alcohol-related or drug-related problem.

(b) If the department levies a fee or charge for the cost of testing, it shall use the same billing and collection methods normally used by independent private laboratories. Any fee shall be waived for patients who are unable to pay.

(c) The department, in promulgating rules to implement this act, shall consider the following as indications of the necessity for alcohol or drug testing:
(1) No prenatal care;
(2) Late prenatal care after twenty-four (24) weeks gestation;
(3) Incomplete prenatal care;
(4) Abruptio placentae;
(5) Intrauterine fetal death;
(6) Preterm labor of no obvious cause;
(7) Intrauterine growth retardation of no obvious cause;
(8) Previously known alcohol or drug abuse; or
(9) Unexplained congenital anomalies.

(d) The commissioner of health is authorized to adopt rules, using criteria established by the United States department of health and human services as guidelines for modeling the drug and alcohol testing program pursuant to this act, concerning, but not limited to:
(1) Standards for licensing drug and alcohol testing laboratories and suspension and revocation of the licenses;
(2) Body specimens and minimum specimen amounts that are appropriate for drug or alcohol testing;
(3) Methods of analysis and procedures to ensure reliable drug or alcohol testing results, including the use of breathalyzers and standards for initial tests and confirmation tests;
(4) Minimum cut-off detection levels for alcohol, each drug or metabolites of the drug for the purposes of determining a positive test result;
(5) Chain-of-custody procedures to ensure proper identification, labeling and handling of specimens tested; and
(6) Retention, storage and transportation procedures to ensure reliable results on confirmation tests and retests.

(e) Prior to acting on the proposed rules to implement this chapter, the commissioner shall submit the proposed rules to the house health and human resources and the senate general welfare committees of the general assembly for their review and comment. The committees shall have forty-five (45) days to review the proposed rules and transmit any comment it may have to the commissioner.

(f) Any woman who tests positive for alcohol or drugs on a test administered pursuant to this chapter shall be referred to treatment for an alcohol-related or drug-related problem. Every physician, surgeon or other person permitted by law to attend a pregnant woman during gestation shall report each woman who refuses to seek treatment for an alcohol-related or drug-related problem or who misses two (2) or more appointments to the department of children's services. Such reports shall be in a manner specified by the department, either by contacting a local representative of the department or by utilizing the department's centralized intake procedure, where applicable.

(g) A health care provider who makes a report of alcohol or drug abuse, as required by subsection (f), shall not be liable in any civil or criminal action that is based solely upon such report.

(h) Nothing in this section shall be construed to confer any immunity upon a health care provider for a criminal or civil action arising out of the treatment of a woman about whom the report of alcohol or drug abuse was made.

(i) All information, interviews, reports, statements, memoranda and drug or alcohol test results, written or otherwise, received by the covered employer through a drug or alcohol testing program are confidential communications and may not be used or received in evidence, obtained in discovery or disclosed in any public or private proceedings, except in accordance with this section.

(j) Laboratories, medical review officers, employee assistance programs, drug or alcohol rehabilitation programs and their agents who receive or have access to information concerning drug or alcohol test results shall keep all information confidential. Release of the information under any other circumstance is authorized solely pursuant to a written consent form signed voluntarily by the person tested, unless the release is compelled by a hearing officer or a court of competent jurisdiction pursuant to an appeal taken under this section, relevant to a legal claim asserted by the employee or is deemed appropriate by a professional or occupational licensing board in a related disciplinary proceeding. The consent form must contain, at a minimum:
(1) The name of the person who is authorized to obtain the information;
(2) The purpose of the disclosure;
(3) The precise information to be disclosed;
(4) The duration of the consent; and
(5) The signature of the person authorizing release of the information.

(k) Information on drug or alcohol test results for tests administered pursuant to this act shall not be released or used in any criminal proceeding against the woman who was subject to the test. Information released contrary to this section is inadmissible as evidence in the criminal proceeding.

SECTION 3. For the purpose of promulgating rules and regulations, this act shall take effect upon becoming a law, the public welfare requiring it. For all other purposes this act shall take effect January 1, 2010, the public welfare requiring it.


I read this with my mouth hanging open in shock. Unbelievable.

So if this law is enacted, it means that any woman who suffers a miscarriage, stillbirth, or other serious pregnancy complications, or who gives birth to a disabled child, will face state-mandated drug testing.

I really can't frame my own response to this vile legislation any better than fellow Tennessee blogger Aunt B already did, so I'll just quote her here:


But here's the best part. If your pregnancy just isn't going right-the placenta comes open or the fetus dies or you go into labor early for no discernible reason, or the fetus isn't growing fast enough, or the fetus has congenital anomalies-and let me remind you these are all things that just happen during pregnancies; things go wrong, for no reason, all the time-the State wants to drug test you.

And let's say that they do. Let's say that you start to miscarry. You have spotting and cramping and it's pretty obvious and inevitable what's going on. Maybe you have a bottle of wine to help you through. You've just done into labor early for no discernible reason and your fetus is dead for no discernible reason and when they drug test you, they're going to find that you've been drinking.

What do you think is going to come of that?

This is what I mean when I say that the reproductive rights fight is going to be had on the bodies of women who miscarry. And these legislators, Hackworth and Marrero are Democrats. These are the folks who are supposed to be on the side of women and they want to give the State the right to start sniffing around if your pregnancy doesn't go right?

This bill opens the door to the State blaming women who miscarry for those miscarriages. Shoot, it doesn't just open the door. It opens the door and escorts the State right in.

They cannot make it illegal, still, thank god, for you to be pregnant in your own way. They cannot legally require you to go to the doctor. They cannot hold you legally responsible for the death of your fetus.

But they want to. And so this is an end run around that. If you won't do what they want you to do, they will drug test you and force you into treatment if they don't like what they've found. In other words, you will be punished for, in the case of imbibing alcohol, something that is perfectly legal. Something most doctors will tell you is fine on occassion when you are pregnant.

In other words, the precident they're setting is that, once you are pregnant, your body is not your own. You no longer know what's best for you. Your doctor no longer knows what's best for you. You are not allowed to not realize you're pregnant. You're not allowed to be afraid. You're not allowed to be too poor to go to the doctor. You have to do what the State tells you to do while you're pregant, because, while you're pregnant, your body is not your own.

And here's the other thing. Can we just not beat around the bush about the subtext here? It's no coincidence that Memphis has an infant mortality rate so depressingly high that it might as well be a hundred years ago over there and that Marrero is bringing the bill. You cannot be a human being with a soul and look at what's going on in Memphis, or shoot, in neighborhoods here in Nashville, and not have your heart come right out sobbing into your hands.

But treating women like, once they're pregnant, the State needs to control them is vile. It just is. There's no way around it and wanting to protect babies doesn't make it okay to assume that the problem lies solely with the mothers.

If Marrero makes a medical decision I don't like, should I have the right to force her to take a drug test, make sure she hasn't been drinking too much?

The sad truth is that pregnancies end for all kinds of reasons. Some women can go their whole pregancies not even knowing they're pregnant, drinking and drugging it up, and their kids come out with no ill-effects. Many, many women in this State try their hardest to do the right thing every step of the way-doctor visits, vitamins, no alcohol use, etc.-and they still lose their pregnancies. They still have babies who are too sick to make it through the year. It's not anyone's fault. It just happens. And I know my fair share of women in that situation and they all blame themselves at some level. Adding to their suffering by having the state step in and act like they're to blame is cruel.

Yes, it's okay to talk about your miscarriage

I love this perspective:

I don't think women have always known the other women in their life who've had miscarriages. In fact, when I told a friend at the beginning of the last pregnancy that I was pregnant she replied "Well, I guess I'm old fashioned; I didn't tell people until week 13." And I responded "Why? If I had a miscarriage, I'd tell you to!"

Am I supposed to be ashamed if I have a miscarriage? It it because we're discussing something that is vaguely associated with my nether regions that I'm not supposed to tell a soul that I'm pregnant until I'm showing? Helloo!!! WORLD!!!! Get past Queen Victoria and stop blaming the mother for everything that happens!!!

I do understand the awkwardness of having to explain to someone after the fact that you are no longer pregnant. I was thinking of inventing a button that says "I'm not pregnant anymore, but I'm OK!" But if I had kept my pie hole shut, I'd never been able to talk to my friends this weekend who needed a shoulder, some information, and a "sister's" about what they were going through.

So there. I'm not going to shut up. Not that I ever could.

But then, one of the commenters below that post makes an equally valid point, and one I can very much relate to:

well, after five miscarriages (and no babies) i feel like i have a much different perspective on when to tell. I always told, at least my close family and friends, but with this last pregnancy, i just found i couldn't anymore. You're getting a bit high-handed, i think, in dismissing the reasons not to tell. that decision often has nothing to do with any victorian mores, or even shame, often it's pure terror of even putting voice to something you know is so completely fragile. it's so very private. plus, after five of them, i just couldn't handle all the pity. and honestly, i think most people just don't know what to say anymore. false positivity never did it for me. so, yes, having support is essential, but sometimes you need to come to terms with what's happening (or might happen) before shouting it to the world.

Secondary infertility: one of the weirdest experiences of my life

How I am feeling lately:

I also realized this week that my current evening medication regimen, designed to potentially get and keep me pregnant, looks rather like the pill intake of a very elderly woman suffering from numerous and serious chronic diseases. It’s THAT many pills and supplements. And then there is all the drawing of blood and ultrasounding of innards and karyotyping of chromosomes that comes with this experience. It’s something, let me tell you.

A great resource for educating yourself on miscarriage

In my opinion, the best information currently available online regarding miscarriage is the Healthline "Fruit of the Womb" blog authored by Dr. Kenneth Trofatter. Dr. Trofatter has blogged very extensively over the past several years on the topics of miscarriage and recurrent pregnancy loss. His blog is searchable, so you can easily find any specific topics you are looking for, and be sure to read all the comments below each post, because they are filled with patient comments, and very specific and informative responses from Dr. Trofatter. He must commit a tremendous amount of time to this blogging, and I'll tell you, I am a fan. I wish he were located in my neck of the woods (he used to be), because I'd definitely be calling for a new patient appointment.

Thrombophilias, miscarriage and bloodthinners - a research review

If you have suffered one or more miscarriages, and are trying to figure out whether or not you may need blood thinners (heparin or lovenox) next time you get pregnant, here is some data to ponder (and share with your doctor):

[Treatment with enoxaparin (“Lovenox”) adapted to the fertility programs in women with recurrent abortion and
thrombophilia]
Sarto A, Rocha M, Geller M, Capmany C, Martinez M, Quintans C, Donaldson M, Pasqualini RS.

Acquired and inherited thrombophilia are associated with recurrent pregnancy loss (RPL). Antithrombotic therapy could restore hemostatic balance and improve early placentation and gestational outcome. We evaluated the efficacy of enoxaparin adapted to the fertility program for prevention of pregnancy loss in 35 women (W) with early RPL and thrombophilia. Previous to the diagnosis of thrombophilia, they had had a total of 105 gestations of which 89 (85%) ended in early pregnancy loss. After diagnosis of thrombophilia, 35 subsequent pregnancies were treated with enoxaparin. In 5 cases assisted reproductive techniques were necessary to achieve pregnancy due to couple infertility. In 17 W who had had at least one preclinical pregnancy loss, enoxaparin (20 mg/d/s.c.) was started previous to conception and adapted to the fertility program. All the women continued with the gestational regime. Eighteen W with only clinical pregnancy loss started enoxaparin (20 mg twice per day s.c.) after biochemical pregnancy diagnosis. During gestations heparin dose was adjusted with anti Xa test, maintaining a range between 0.3 at 0.6 u/ml. With antithrombotic therapy, 30/35 (85%) of the pregnancies ended in live birth versus 16/105 (15%) of the pregnancies without treatment (p < 0.001).

--

American Journal Of Reproductive Immunology
Volume 49 Issue 2 Page 90 - February 2003

Successful Pregnancy with Low Molecular Weight Heparin in Two Women with Recurrent Miscarriage of Unknown Etiology

Yoshihiro Miyashita, Masako Waguri, Isao Nakanishi, Noriyuki Suehara, and Tomio Fujita

We report here two cases of recurrent miscarriages that were successfully treated with continuous intravenous administration of low molecular weight heparin (LMWH). One patient experienced 11 spontaneous abortions, and the other eight abortions. Previous treatments including prednisone, aspirin and mononuclear-cell immunization were all unsuccessful. They were negative for anticardiolipin antibodies and lupus anticoagulant, and had no inherited thrombophilic disorder. Intravenous administration of LMWH, 4800 units of dalteparin, was started as soon as the conception was confirmed, and was continued until 34 weeks of gestation. They were delivered of live born infants.

--

Clin Appl Thromb Hemost. 2005 Jan;11(1):1-13.
Recurrent miscarriage syndrome and infertility due to blood coagulation protein/platelet defects: a review and update.

Bick RL, Hoppensteadt D.

University of Texas Southwestern Medical Center, Dallas, Texas 75231, USA. rbick@thrombosis.com

Three-hundred fifty-one women were referred for thrombosis and hemostasis evaluation after suffering recurrent miscarriages. All patients were referred by a high-risk obstetrician or reproductive medicine specialist after anatomic, hormonal or chromosomal defects had been ruled out. These patients were assessed over a three year period. The mean patient age at referral was 34 years and the mean number of miscarriages was 2.9 (2-9). All patients underwent a thorough evaluation for thrombophilia and, when indicated, a hemorrhagic disorder. Of the 351 patients, 29 (8%) had no defect. Of the remaining 322 patients, 7 (2%) had a bleeding disorder: 3 with platelet dysfunction, 1 with Factor XIII deficiency, 3 with von Willebrand's and 3 with Osler-Weber-Rendu. The remainder of the patients had a thrombophilia as follows: 195 (60%) had antiphospholipid syndrome, 64 (20%) had Sticky Platelet Syndrome, 38 (12%) had MTHFR mutation, 23 (7.1%) had PAI-1 polymorphism, 12 (3.7%) had Protein S deficiency, 12 (3.7%) had Factor V Leiden, 3 (1%), had AT deficiency, 3 (1%) had Heparin-Cofactor II deficiency, 3 (1%) had TPA deficiency, and 6 (2%) had Protein C deficiency. There were a total of 364 defects found in the 312 patients harboring thrombophilia; thus, several harbored two and a few harbored three separate defects. All patients with thrombophilia were treated with preconception ASA at 81 mg/day with the immediate post-conception addition of heparin or LMW heparin (Dalteparin). Both ASA and heparin/LMW heparin were used to term. The first 120 patients were treated with unfractionated heparin at 5,000 U every 24 hours, subcutaneously and the last 192 have been treated with Dalteparin at 5,000 U/day subcutaneously. The patients with MTHFR were also treated with folate at 5 mg/day + pyridoxine at 50 mg/day. All patients were carefully monitored with CBC and platelet counts, anti-Xa levels, frequent ultrasounds and physical exams. Only 2 of the thrombophilia patients suffered another miscarriage; all others had a normal term delivery. There were no pregnancy-related thromboses, no delivery complications and no episodes of post-partum thrombosis. The only bleeding consisted of 1-4 cm bruises at injection sites. No episodes of thrombocytopenia (HIT) were noted. In our experience, thrombophilia is a common cause of recurrent miscarriage and all patients with no anatomical, hormonal or chromosomal defect should be evaluated for thrombophilia or a bleeding disorder. The success rate of normal term delivery in these 312 patients was 94% using ASA + heparin or Dalteparin. In addition, side effects of therapy were minimal.

--

Acta Obstet Gynecol Scand. 2000 Aug;79(8):655-9.
Birth outcomes in pregnant women treated with low-molecular-weight heparin.

Sorensen HT, Johnson SP, Larsen H, Pederson L, Nielsen GL, Moller M

The Danish Epidemiology Science Center at the Department of Medicine V, Aarhus University Hospital.

BACKGROUND: Pregnancy and puerperium are associated with an increased risk of venous thromboembolism. Low-molecular-weight heparin is the anticoagulant of choice in pregnant women because, unlike warfarin, it does not cross the placenta. However, there are limited data on the risk of adverse birth outcomes following use of low-molecular-weight heparin in pregnancy. PATIENTS AND METHODS: We performed a population-based cohort study to examine the safety of low-molecular-weight heparin use in pregnancy using data from the Pharmacoepidemiological Prescription Database, The Danish Medical Birth Registry and the Regional Hospital Discharge Registry in North Jutland County, Denmark. The birth outcomes in a cohort of 66 pregnant women treated with low-molecular-weight heparin between 1991-98 were compared with the birth outcomes of 17,259 pregnant women who did not receive any prescriptive drugs during pregnancy. RESULTS: No increased risk of malformations, low birth weight or stillbirth was found. However, an increased risk of pre-term delivery was found (odds ratio: 2.11, 95%, confidence interval: 0.96-4.65), which could reflect inherited thrombophilia as an indication of low-molecular-weight heparin. CONCLUSION: We have provided additional evidence of the safety of low-molecular-weight heparin use in pregnancy.

--

Fertil Steril. 2005 Sep;84(3):770-3.
Effects of enoxaparin on late pregnancy complications and neonatal outcome in women with recurrent pregnancy loss and thrombophilia: results from the Live-Enox study.
Brenner B, Ellis M, Yarom I, Yohai D, Samueloff A, Live-Enox Investigators

Rambam Medical Center, Haifa, Israel. b_brenner@rambam.health.gov.il

Women with thrombophilia and a history of recurrent pregnancy loss have poor pregnancy outcomes. Prophylaxis with enoxaparin 40 mg/day or 80 mg/day resulted in favorable gestational and neonatal outcomes.

PMID: 16169422 [PubMed - in process]

The other type of "two week wait"

For those of us who have experienced recurrent pregnancy loss, the "two week wait" doesn't end when we get the positive pregnancy test. In fact, that's just the beginning of the very worst kind of wait - waiting to miscarry ...or to make it through the first trimester.

It's an agonizing experience. You can't allow yourself to become too invested or hopeful, but it's hard to remain completely detached. You don't get to really enjoy being a pregnant woman, but you have to observe all of the restrictive rules of pregnancy (no caffeine, alcohol, etc).

It's hard.

Entering the foreign territory of miscarriage

A columnist opens up about her miscarriage experience:

I didn’t know that this could happen to me. I thought I was too young, too healthy. I didn’t realize that up to 25 percent of confirmed pregnancies end in loss. I had never heard of a “missed miscarriage,” which is characterized by a lack of symptoms of a baby’s death. I didn’t have any clue how painful the question, “Do you have any children?” could be to hear and how hard it could be to answer.

“God needed another angel in heaven”; “At least you won’t have to care for a handicapped child”; “You still have time, and at least you know you can get pregnant”; “It happens all the time”; “This baby just wasn’t meant to be.” I’ve heard these phrases dozens of times from well-meaning friends and family, but it’s hard to take comfort in any of them. Nothing can diminish my love for my child, and my heartbreak over what is a unique loss, not a statistic.

I was shocked after we lost our baby that so many women I know shared that they, too, had had a miscarriage—or more than one. Even women who had lost their babies 20 years ago cried with me. Even women across oceans and continents shared my pain through e-mails and online forums.

But why doesn’t anyone talk about it before it happens? Why is there a veil of secrecy behind which we can only share our grief with others who have experienced the same grief? When I found out that our baby was no longer alive, I felt alone in the world. Indeed, there were people who seemed frightened of me, as if I had a contagious disease. And there were others who just never said anything about our baby at all. How was I to realize that a large percentage of women I know had suffered a similar loss? This wouldn’t have made my loss any less devastating, but I think it would have made a difference. It would have helped me to realize that I should not blame myself.

A few HCG questions

There is a whole lot of info on HCG in early pregnancy out there on the Web, but there are a few specific questions for which I cannot find answers. Perhaps some of y'all know the answers, and can reply in the comments below:

-Should HCG double every 48 hours in early pregnancy? Or is 48-72 hours considered the normal range? Online info seems to vary on this point.

-Are there any studies quantifying miscarriage risk based on HCG levels in early pregnancy?

-Does the day on which the embryo actually implants - which can vary by several days in a cycle - account for the wide variance in starting HCG #s in early pregnancy?

-Does a higher progesterone level offset a lower HCG level in quantifying miscarriage risk? Or vice versa?

All about Hughes Syndrome

An interesting article from the UK:

Hughes is a relatively new condition that is just beginning to become recognised by the wider medical community outside the specialised area of auto-immune diseases (in which the body's immune systems attacks itself). The professor first began to note the condition in the mid-Seventies when he was working in a rheumatology clinic in Jamaica. "I noticed there were a whole group of women, paralysed, and forced to use wheelchairs, with the same antibodies in their blood."

When he returned to the UK a few years later, he set up a working party to study the antibodies he had found. Very quickly, his unit had collected up hundreds of patients whose blood carried the antibodies and whose symptoms all resulted from clotting around major organs. "They weren't just suffering clots in their veins but also in their arteries which led to strokes and heart attacks."

Significantly, the clots were also found to have serious effects when they occurred at two particular organs: the placenta and the brain. In the former cases, this led to multiple and unexplained miscarriages. In the latter, they starved the brain of oxygen, leading to migraines, memory loss and what many patients simply described as 'fogginess'.

By 1983, Prof Hughes' team had gathered enough evidence for two papers to be published: one in the British Medical Journal and the other in the Lancet. For the team, this felt like a 'eureka' moment. "We were finally getting our message across. We all celebrated with a long lunch at the local Italian restaurant," says Hughes.

Gynecologists picked up the news fast; the respected royal gynaecologist Dr Anthony Kenny called it the major discovery in obstetrics in the 20th century, and it has revolutionised treatment of women with recurrent miscarriage. Where the antibodies are present, and blood thinners are given, to prevent clotting at the placenta, the rate of successful pregnancy soars from about 20 per cent to 80 per cent.