Causes of Pregnancy Loss 24May21

Transcript

• 00:00This is Harvey Clyman from the Yale
• 00:03University School of Medicine.
• 00:05I'd like to 1st express my sincerest
• 00:08condolences to any mother or family
• 00:11who has suffered pregnancy loss.
• 00:13Today I'm going to be talking about
• 00:16causes of unexplained pregnancy
• 00:18loss and hopefully ways to prevent
• 00:20them in the future when possible.
• 00:23I'd like to start off by sharing
• 00:25the story of one of my patients.
• 00:28MMM at the time was a 25 year old
• 00:31who is 36 weeks and four days.
• 00:33When she went to see her doctor,
• 00:36her blood pressure was a little
• 00:38elevated at 142 / 83 and they said
• 00:40you need to watch out for certain
• 00:42things that might indicate that you
• 00:45might be developing preeclampsia.
• 00:47They told her what those things were and
• 00:49a few days later at 37 weeks and two days.
• 00:53She actually did develop
• 00:54those signs and symptoms.
• 00:56She had headaches,
• 00:57visual spots and adima for a day.
• 00:59She came back to her doctors office and her
• 01:02blood pressure was elevated at 135 / 98,
• 01:05so they asked her to go to
• 01:07labor and delivery.
• 01:08By the time she got there,
• 01:10her blood pressure had actually gone down,
• 01:12but they still looked at her urine to
• 01:15see if there was protein in her urine.
• 01:18That's a test for preeclampsia and they
• 01:20also did something called a non stress test,
• 01:23NST.
• 01:23What is an NST and NST is basically
• 01:26looking at the fetal heart rate
• 01:28on the top panel here and also
• 01:30the contractions of the uterus at
• 01:33the same time every time there's
• 01:35a contraction of the uterus and
• 01:37I'm showing you one right here.
• 01:39There should be an elevation in the
• 01:41fetal heart rate and if that happens
• 01:44then it's red is a normal NST and she
• 01:47had a normal NST so she was sent home.
• 01:51She complained of decreased fetal
• 01:53movement at 38 weeks and three days,
• 01:55so she came back to labor and delivery.
• 01:58They did another NST.
• 01:59It was normal.
• 02:00They sent her home but they said
• 02:02why don't you come back in about
• 02:05a week and let's just make sure
• 02:07everything is OK so she did.
• 02:09She came back exactly a week
• 02:11later at 39 weeks and three days.
• 02:13They did another NST and it was normal.
• 02:16Then they sent her home.
• 02:19Unfortunately,
• 02:19the next day at 39 weeks and four days,
• 02:23she had no fetal movement.
• 02:25She presented to labor and
• 02:27delivery with a stillbirth.
• 02:29This is a horrible, tragic event for anybody.
• 02:33One of the first questions
• 02:34is a mother always has is.
• 02:36Why did my baby die?
• 02:38And then the next question always
• 02:40seems to be,
• 02:41is it my fault?
• 02:42I just want to say right now it's not
• 02:45the mothers fault for this to happen.
• 02:48Where can we get the answer?
• 02:50Does it have something to do with my body?
• 02:53She might be thinking might have
• 02:56something to do with the uterus?
• 02:58Maybe there was something wrong with my baby.
• 03:01And what I'd like to share
• 03:03with you is that
• 03:04the answer is usually always
• 03:06found in looking at the placenta.
• 03:08Now let me tell you a little
• 03:10bit about the placenta.
• 03:11A lot of people don't understand
• 03:13that the placenta is part of
• 03:15the baby part of the fetus,
• 03:17so here's a diagram of a fetus
• 03:19connected to its placenta,
• 03:20and you can think of the placenta
• 03:23is like the roots of the tree.
• 03:25So when we look at a tree above ground,
• 03:28we see the tree trunk,
• 03:29the branches and the leaves,
• 03:31but underground there is as much
• 03:33of a tree in the root system
• 03:36as there is above ground.
• 03:37And the same thing is true in pregnancy.
• 03:40The placenta is part of the fetus.
• 03:43Biologically, genetically,
• 03:44physiologically, the fetus pumps
• 03:46blood through its umbilical cord,
• 03:49into its placenta,
• 03:50where it gets all the nutrients.
• 03:53Oxygen food energy gives up its
• 03:56waste product through the placenta.
• 03:59The fetus is completely dependent
• 04:01on its survival by the placenta.
• 04:04You can see that the placenta does sort
• 04:07of look like a root system in this diagram.
• 04:10The fetus would be up here connected to
• 04:12its placenta through its inbuilt record.
• 04:15The blood vessels branch through the
• 04:17top part of the placenta and dive
• 04:20down to form the root system here.
• 04:23The muscle layer of mom the uterus is here.
• 04:26The lining of the uterus is here
• 04:28and Mom sends her blood into the
• 04:31placenta into something called the
• 04:33interval of space an the fingers
• 04:36basically of the placenta will be
• 04:38like you putting your hand in a
• 04:40bucket of water is how the nutrients
• 04:43from mom's blood to the fetal
• 04:45circulation exchanges through these
• 04:47fingers or the root system so the
• 04:50placenta is absolutely critical for.
• 04:53Supporting a fetus during pregnancy.
• 04:55So when we looked at placentas
• 04:59of unexplained pregnancy loss
• 05:02between 4 and 43 weeks.
• 05:05We were able to find the answer
• 05:07to these pregnancy losses in the
• 05:10majority of cases by looking at
• 05:12the placenta in great detail.
• 05:14Now we usually divide up the
• 05:17names of pregnancy losses,
• 05:18the different types based on the gestational
• 05:22age and of the 1262 cases we looked at.
• 05:25We first looked at the cases
• 05:28that were less than 20 weeks.
• 05:30We call those miscarriages.
• 05:32Miscarriage is in our country.
• 05:34There are about 1,000,000 a year.
• 05:38And we examined 878 of these and these,
• 05:41as I said before,
• 05:43were previously unexplained.
• 05:44They had been looked at other places,
• 05:46but they still couldn't
• 05:47figure out the answer,
• 05:49so they sent them to me and my
• 05:52laboratory at Yale to try to figure out
• 05:55why these pregnancy loss is a curd.
• 05:57When we examine the plus centers,
• 06:00we found that basically 86% of the
• 06:04cases had abnormal development,
• 06:06something genetically abnormal with them.
• 06:08Here the blue part of the pie chart here,
• 06:13Anna much smaller fraction,
• 06:15about 2%, had clotting disorders,
• 06:17or some immunological problem.
• 06:19The pink and the olive segments right there.
• 06:25In about 12% of the cases,
• 06:26the green part of the pie,
• 06:28we actually couldn't figure out the
• 06:31exact answer for why the loss had a curd.
• 06:35When we looked at pregnancies,
• 06:37that losses occur at or greater than
• 06:4020 weeks, we call those stillbirths.
• 06:43And we examined a number of those.
• 06:46Let me just define a still birth
• 06:48in terms of the frequency.
• 06:51It occurs about 25,000 a year in our country,
• 06:54or six per thousand in the United States.
• 06:57We looked at 384 still birth placentas
• 07:00that were previously unexplained.
• 07:02And when we examine the placentas in detail,
• 07:05we were able to get the answer
• 07:08in about 99% of the time.
• 07:10And you can see the pie chart on the left.
• 07:14The different percentages.
• 07:15Here's the key of what the
• 07:17different causes were,
• 07:18and I'd like to walk through
• 07:21the different causes of what we
• 07:23found in these pregnancy losses.
• 07:25The most frequent cause of still
• 07:28birth was a small placenta,
• 07:30131 cases or exactly a third at 33 point 3%.
• 07:34So this is the most common cause
• 07:37of still birth. A small placenta.
• 07:39Why are placenta small?
• 07:41We looked at the details of the
• 07:44different causes for these small
• 07:46placentas and this is shown on this
• 07:49chart and you can see that still the
• 07:52majority are due to this blue shading area.
• 07:56Which is due to a genetic abnormality
• 07:59that was the most frequent cause.
• 08:02The next most frequent was decreased
• 08:05maternal blood flow into the
• 08:07placenta itself and then maternal
• 08:10immunological rejection.
• 08:11Where the mother's immune system actually
• 08:13views the placenta as foreign an attacks it,
• 08:16and then a small percentage of
• 08:18the time the green band.
• 08:20Right here we couldn't actually
• 08:22find the answer.
• 08:23So still in the majority of cases we were
• 08:26able to do it almost 99% of the time.
• 08:31Now what is the definition of
• 08:33a small placenta?
• 08:34The usual definition is a placenta
• 08:37that's less than a 10th percentile.
• 08:39So if you look at the whole
• 08:42population of all the placentas
• 08:44born at any gestational age,
• 08:46you can make a bell shaped curve
• 08:49as shown in this next figure.
• 08:51The pink bell shaped curve is the
• 08:54normal distribution of weights of
• 08:56placentas at different gestational ages.
• 08:58And this is actually a standard
• 09:01deviation chart.
• 09:02With zero being the exact average and
• 09:05that's why the peak is right here and then.
• 09:08The numbers either below or above are
• 09:11standard deviations above and below that.
• 09:13And just for reference,
• 09:15the dotted lines,
• 09:16the dashed lines I should say are
• 09:19representing the 90th percentile
• 09:21here and the 10th percentile here.
• 09:23So normally when you look at
• 09:26a normal distribution,
• 09:2710% of the cases should be below
• 09:30the 10th percentile and 10%.
• 09:32Should be above the 90th percentile.
• 09:35But in our series we found that we
• 09:39had vastly more very small placentas.
• 09:42And some of these placentas were 345
• 09:46standard deviations below the mean.
• 09:49In percentiles of point 1.01 or .001.
• 09:52These were extremely small.
• 09:56How many excessive cases did we
• 09:58have below the expected frequency?
• 10:00Well,
• 10:01in our series 47 cases were extremely small,
• 10:04as represented by this area.
• 10:07And there were also cases of
• 10:10stillbirths that had sent us that
• 10:12were significantly too large.
• 10:14So although the most common
• 10:16is a small placenta,
• 10:18there were certainly cases with
• 10:20the centers that were very large,
• 10:22probably again because of
• 10:24being genetically abnormal.
• 10:26Now, in addition to small placentas we
• 10:29had other causes we found for still birth.
• 10:33The next most common was abnormal development
• 10:36or a genetic abnormality at about 30%.
• 10:39And this is represented by
• 10:41abnormal infoldings of the cross
• 10:44sections of the fingers.
• 10:45The root system of the placenta,
• 10:48and the identification of something
• 10:50that's called a trophoblast inclusion.
• 10:53And these are labeled right here
• 10:55as T trophoblasts inclusion,
• 10:57so that's about a 30% of the
• 11:00time we found that as the cause.
• 11:03The next most common cause after
• 11:06that record accidents at almost 15%.
• 11:09Now,
• 11:10court accents are very unfortunate
• 11:12because they're unexpected.
• 11:13Usually everything else is perfectly fine,
• 11:16except that a loop of the cord gets kinked.
• 11:19There might be a not the cord
• 11:22might wrap around the neck or
• 11:25some other body part of the fetus,
• 11:28and these are very unpredictable
• 11:30and very sad and tragic.
• 11:32Of course,
• 11:33the only thing good about accord accident
• 11:36is that it usually doesn't recur.
• 11:39The small placentas and the genetic
• 11:41causes that I just mentioned.
• 11:43Have a higher frequency of reccuring
• 11:45so it's much more important to
• 11:47try to prevent those if we can.
• 11:49For court accidents.
• 11:50I tell most of the families
• 11:52that this is something that is
• 11:54of course a terrible tragedy,
• 11:56but it is not likely to occur again.
• 11:58It's a chance event.
• 12:02The next most common cause of
• 12:05stillbirths are infections at about 6%.
• 12:08Why are there infections and
• 12:10pregnancy in the 1st place?
• 12:12Well,
• 12:12there always bacteria that live in
• 12:14the vagina and sometimes maybe there's
• 12:17something wrong with the cervix in
• 12:20terms of how tightly it's closed.
• 12:22Maybe the mucus plug has passed.
• 12:24Or maybe there's just bacteria in
• 12:26the vagina that are more virulent,
• 12:29stronger than usual. In whatever case.
• 12:31If these bacteria get through the cervix,
• 12:34break through the membrane,
• 12:36they start growing in the amniotic fluid.
• 12:39And unfortunately,
• 12:40the fetus then is exposed to this infection,
• 12:43and it's something like septic shock.
• 12:46Basically, for the fetus,
• 12:47the sad and difficult part about
• 12:50infections like this are that
• 12:52the space within the uterus is
• 12:55actually not inside of the mother.
• 12:57It doesn't seem logical,
• 12:59but because there's a continuous line.
• 13:01Basically you can take a catheter and
• 13:04go from outside of the woman's body
• 13:07through the vagina, through the cervix.
• 13:10Into the uterine cavity.
• 13:12Infections that are inside of the
• 13:15amniotic fluid here do not trigger
• 13:17in the mother any reaction until the
• 13:20infection has been there for many days.
• 13:22So for several days at least,
• 13:25the fetus can be exposed to this
• 13:27infection and can cause severe
• 13:29damage and even death.
• 13:31And in our case 6% of stillbirths were
• 13:34associated with these sorts of infections.
• 13:37The next most common cause is abruption,
• 13:40which is the fancy name for saying a
• 13:43separation of the placenta from the uterus.
• 13:46This happened about 4% of the time.
• 13:50And you can see different diagrams,
• 13:52some abruption's or separations occur right
• 13:54at the edge of the placenta shown here.
• 13:57And although it's dramatic because
• 13:59there's blood that comes out and
• 14:02can come out of the woman's body,
• 14:04it actually luckily doesn't cause a
• 14:06serious problem for the fetus because the
• 14:09placenta is mostly attached to the uterus.
• 14:12If this separation gets larger up to 50%,
• 14:15this can cause serious damage to a fetus.
• 14:18And if the placenta completely
• 14:20separates as shown here.
• 14:22That usually unfortunately leads to the
• 14:24death of the fetus or a still birth.
• 14:27So that's a serious cause happens
• 14:294% of the time.
• 14:31One of the rare causes,
• 14:33but again so tragic because no one
• 14:35really knows that this is happening,
• 14:37is what's called a fetal bleed.
• 14:40Sometimes it's called a maternal
• 14:42fetal hemorrhage.
• 14:43Basically what it is is that the blood
• 14:46in the umbilical cord travels into the
• 14:49placenta and at some point there's a
• 14:52rupture of the circulation so that blood
• 14:55can either leak out the side of the placenta,
• 14:58blood can leak into the amniotic fluid,
• 15:01or most commonly, as exemplified by #3.
• 15:04Here, there's a rupture of one of
• 15:07the vessels within the placenta.
• 15:09One of the fetal vessels in the placenta.
• 15:12And the fetal blood actually goes
• 15:15out into the maternal circulation,
• 15:17and there's really no way to detect this
• 15:20unless you're really looking for it.
• 15:22This is usually something that is unexpected.
• 15:25The only thing that the mother notices that
• 15:28maybe there's some decreased fetal movement,
• 15:31and then there's no fetal movement,
• 15:33and then a still birth is diagnosed.
• 15:36This is, of course a very tragic case.
• 15:39Again, this does not recur very often,
• 15:42so this is usually what we
• 15:45call sporadic event.
• 15:46So those are the different
• 15:48causes of still birth.
• 15:50What happened with them?
• 15:51Let's go back to my patient.
• 15:53Well,
• 15:54in this case the placenta of her fetus,
• 15:57her babies will sent to remember the
• 16:00pool center belongs to the baby,
• 16:02not the mother was less than
• 16:04the 1st percentile.
• 16:05You can see it plotted right here,
• 16:08so it was very small.
• 16:09The reason it was small in this case is
• 16:12there is decreased maternal blood flow to
• 16:15the placenta leading to increased fibrin.
• 16:18Calcification of the fire and actually
• 16:20death of parts of the placenta,
• 16:23so that's obviously an unfortunate outcome,
• 16:25and in her case there were some
• 16:28elevation in blood pressure,
• 16:29but not enough to alert people
• 16:32that this was a problem.
• 16:34And of course they weren't
• 16:36looking at the placenta,
• 16:37so they didn't realize that it was small.
• 16:40So why didn't the OB know
• 16:43that double center was small?
• 16:45Well, there it's a complicated answer,
• 16:47but for the most part.
• 16:49It's because the focus of most
• 16:51of obstetrics and maternal
• 16:53fetal medicine is on the fetus.
• 16:55Why is that? Well,
• 16:56because everybody is waiting for the baby.
• 16:58That's what everybody is paying attention to.
• 17:01But what I'd like to share with you is
• 17:03not knowing the size of the placenta is
• 17:06like driving a car without a gas gauge.
• 17:09How does a car run just before it
• 17:12runs out of gas perfectly normally,
• 17:14and then it runs out of gas in the car stops?
• 17:18That's what happens when the
• 17:20placenta is too small.
• 17:22So the question is,
• 17:23can we actually measure the size of the
• 17:26placenta and it turns out we can now do that.
• 17:30There's a method called estimated placental
• 17:32volume that can look at a cross section
• 17:35through ultrasound of the placenta
• 17:37represented by this Red Crescent here.
• 17:40And I actually got the help of my father
• 17:42who is an engineer and a mathematician,
• 17:45and I said to my father, Dad,
• 17:48if I give you the width measurement
• 17:50here of this cross section,
• 17:52the height and the thickness.
• 17:53Can you create the equation to figure
• 17:56out the volume of this 3 dimensional
• 17:59placenta and he did that and it turns
• 18:01out it's actually easy to do and
• 18:03I'm going to show you an example of
• 18:06measuring and IPTV on this ultrasound.
• 18:08This is from a normal patient.
• 18:10At 18 weeks.
• 18:12And here is the placenta right
• 18:14here in cross section.
• 18:16The amniotic fluid and the fetus.
• 18:18So if you take this picture and draw
• 18:21the width measurement from the tip to
• 18:24the tip and then if you find the apex
• 18:27which is right here the top part of the
• 18:30placenta and draw the line down to the base.
• 18:33Here the width make sure it's 90 degrees.
• 18:36That's the height.
• 18:37Then start at the same apex point.
• 18:40Draw the line down through
• 18:41the same height line.
• 18:43But stop at the bottom of the placenta here.
• 18:46That's the thickness.
• 18:47If you take those three numbers and stick
• 18:50it in the equation that my father created,
• 18:53you get the estimated placental volume.
• 18:55In this case,
• 18:56it's 251 cubic centimeters.
• 18:58Well, the first thing we need to do is
• 19:00see if this equation actually worked.
• 19:03How did we do that?
• 19:05Well,
• 19:05with the help of one of my fellows at Yale,
• 19:09we looked at 29 patients between
• 19:1129 weeks and almost 41 weeks.
• 19:13And measure the estimated placental
• 19:15volume right before delivery.
• 19:16The placenta the baby was delivered.
• 19:19The placenta was delivered.
• 19:20We clamp the cord and then weighed the
• 19:23placenta and we compared the actual
• 19:25weight to what we thought the weight
• 19:28was by estimated will center volume and
• 19:31found that there is a very good correlation.
• 19:34And this is the paper that we published,
• 19:36and I'm proud to say my
• 19:38father is a coauthor on that.
• 19:40Well,
• 19:40just do proving that the equation works
• 19:43is not really good enough clinically.
• 19:45The next thing we needed to do is actually
• 19:48create what are called normative curves.
• 19:51What's the normal value at
• 19:52different gestational ages?
• 19:53So the first study we did,
• 19:56we looked at 366 patients
• 19:57between 11 and almost 39 weeks.
• 20:00Here's a plot of those patient results here,
• 20:03and the red line on the top is
• 20:05the 90th percentile. The bottom is
• 20:08the 10th percentile and the green.
• 20:10Is the 50th percentile.
• 20:12We also did a study like this at Cornell,
• 20:17a different institution with completely
• 20:19different people in patients,
• 20:20446 patients developed the
• 20:22same normative curves.
• 20:23They looked actually quite similar
• 20:25and finally a study that we just
• 20:28finished and haven't published yet.
• 20:31I had one of my Yale medical
• 20:33students go to Senegal for a year.
• 20:36She collected an amazing amount,
• 20:391003 patients between 5 and 42
• 20:41weeks and these are her data.
• 20:44Point plotted.
• 20:45And what's interesting,
• 20:46if you superimpose all this
• 20:48data in one plot right here,
• 20:51you see that the data is almost
• 20:53identical in these three locations.
• 20:55Whether it's Yale, Cornell,
• 20:57or Senegal.
• 20:57Now this is the master equation
• 21:00that explains the relationship
• 21:01between the estimated placental
• 21:03volume and just stational age,
• 21:05and you can see that it's a
• 21:07very good fit of this data.
• 21:09If you put that equation
• 21:11into an ultrasound machine,
• 21:13you can figure out the EV.
• 21:15With the ultrasound machine,
• 21:17this is actually in bear to us period
• 21:20who is my yell MFM fellow who is the
• 21:23first author of our first paper and
• 21:25this is a picture of him literally
• 21:27doing the first PPV ever done.
• 21:30This was done in 2008 and here's
• 21:32the actual picture and in this
• 21:34case we put the equation into the
• 21:36ultrasound machine and you can
• 21:38see it calculated the EP fee for
• 21:41us now because the equation is
• 21:42not in all ultrasound machines.
• 21:45We decided that we would make a free app.
• 21:48That people could use named
• 21:50it after my father,
• 21:51Merwins calculator is very easy to use.
• 21:54It's free in the Apple App
• 21:56Store and you basically put in
• 21:58the measurements of the width,
• 22:00height and the thickness.
• 22:01The patients name the number of
• 22:03weeks and days pregnant she is.
• 22:05It calculates the volume and the percentile.
• 22:08If you flip the phone on the side,
• 22:11it makes the graph bigger and
• 22:13it's easy to see.
• 22:14For example in this case at
• 22:1619 weeks in two days.
• 22:18At the placenta is in the 2nd percentile,
• 22:21so that would be quite
• 22:23concerning at that point.
• 22:25Now,
• 22:25because people were asking us
• 22:27to also make an Android app,
• 22:30we were very lucky to have Michael
• 22:32Frederick who works at Google and
• 22:35unfortunately was a loss dad himself.
• 22:37He was kind enough to make the same app
• 22:40merwins calculator in the Android App Store.
• 22:43So now you can get it on either App Store.
• 22:48So in summary,
• 22:50when we looked at the different
• 22:52causes of still birth,
• 22:53we found that the number one
• 22:55cause was a small placenta.
• 22:58We now have a way to actually
• 23:00identify these cases and prevent
• 23:02stillbirths from happening.
• 23:04And I want to point out that when we
• 23:06looked at just 3rd trimester stillbirths
• 23:09so remember stillbirths are defined
• 23:12as 20 weeks to term.
• 23:13If we looked at the 3rd trimester,
• 23:16which is the last 13 weeks of pregnancy,
• 23:1936% of those cases were
• 23:20due to a small placenta,
• 23:22now only about 16 where the genetic
• 23:25and the next big cause actually after
• 23:27a small placenta or cord accidents.
• 23:30Given that this is such a
• 23:32big chunk of the pie here.
• 23:34I think it's very important for
• 23:36people to consider doing estimated
• 23:38full center volumes during pregnancy.
• 23:40One of the questions is when should
• 23:43this be done and I want to show you a
• 23:46cautionary story about one of my other
• 23:49patients of what happened to her.
• 23:51Unfortunately,
• 23:51she had a stillbirth literally
• 23:53right before her due date,
• 23:55and no one knew why it happened,
• 23:57but I was asked to consult on this case,
• 24:01and I determined that the cause again in
• 24:04this case was due to a very small placenta.
• 24:07Now they had not done estimated
• 24:09placental volume ultrasound
• 24:11measurements in this case,
• 24:12but they had done a series of
• 24:14ultrasounds and I asked to look at
• 24:17them and even though they weren't
• 24:19planning on the EP V to be measured.
• 24:22I retrospectively went back and
• 24:24looked at them and calculated the
• 24:27EP VIS and I've plotted them in
• 24:30these blue pentagons right here.
• 24:32You can see that at 20 weeks it was
• 24:35basically normal and then a few weeks
• 24:38later it was a little above the 10th
• 24:41percentile but basically between 20
• 24:44weeks and let's say 34 or five and 40 weeks.
• 24:48The placenta barely grew.
• 24:50It really just stop growing.
• 24:53However.
• 24:54Her baby continued to grow,
• 24:57so he was almost at the
• 24:5940th to 50th percentile,
• 25:01while his placenta remained very small
• 25:03at term and the ratio between his size,
• 25:07his weight,
• 25:08and his placental placental weight was
• 25:11about 10 or 11 to one normal is 6 to
• 25:14one a normal newborn baby should only
• 25:17be 6 times larger than its placenta.
• 25:20He was over 10 times larger,
• 25:23which is why unfortunately he died.
• 25:26In my opinion,
• 25:27if the doctors taking care of
• 25:29this patient had known that the
• 25:31percent to actually stop growing,
• 25:33they would have been more
• 25:35proactive in terms of delivering
• 25:37her before this stillbirth ikerd.
• 25:39So let me summarize what I
• 25:42think the messages here are that
• 25:44I've tried to share with you.
• 25:47Number one, it's not your fault.
• 25:49It's not your fault.
• 25:51It's extremely rare that a
• 25:53mother can do anything.
• 25:54In fact,
• 25:55there's almost nothing she can
• 25:57do to cause a pregnancy loss.
• 25:59All the causes that I've shared with
• 26:02you have nothing to do with what the
• 26:05mother has done, what she's eaten,
• 26:07how she sat down, how she drove a car,
• 26:10how tight her shoes were,
• 26:12nothing,
• 26:12there's nothing that she could have
• 26:14done to cause any of these losses.
• 26:17That's the first really important
• 26:19take home message.
• 26:20The second is it's critical to
• 26:23diagnose the cause of the loss.
• 26:25Why did it happen?
• 26:26We can't do anything about preventing
• 26:28something if we don't know
• 26:30why something happened,
• 26:32so it's critical to get the
• 26:34diagnosis and in my opinion,
• 26:36the main place for getting
• 26:38the diagnosis is the placenta.
• 26:40So if your local hospital doesn't have
• 26:42the expertise to look at that placenta,
• 26:45make sure it goes to the pathology
• 26:48department and then find a consultant,
• 26:50somebody who isn't.
• 26:51Expert in the placenta to actually
• 26:54look at that placenta to figure
• 26:56out why the loss occurred.
• 26:58Once we know the reason for
• 27:00the loss if possible.
• 27:02We're going to try to
• 27:05prevent a recurrence now.
• 27:07Not everything can be prevented.
• 27:09Obviously things like a fetal bleed
• 27:12really can't be prevented because there
• 27:16we have no control over the vasculature
• 27:19of the fetus within the placenta.
• 27:22However,
• 27:23immunological rejection clotting disorders.
• 27:26Certainly a small placenta.
• 27:27The number one preventable cause
• 27:30of still birth can be prevented
• 27:32in the case of genetics,
• 27:34we can't really prevent that,
• 27:36but at least we know in those
• 27:38cases that the highest frequency
• 27:40of recurrence risk is about 50%,
• 27:43so those families need to understand that,
• 27:45although there can't,
• 27:47they can have another loss 50% of the time.
• 27:51They can have a completely
• 27:53successful pregnancy.
• 27:54I'd like to end by acknowledging the
• 27:57people who helped me with some of the
• 28:00work that I presented here today.
• 28:02Betrix BB Thompson graduated
• 28:03from Yale College last year.
• 28:05She has been a postgraduate fellow
• 28:07in our department and help me
• 28:09with the pregnancy loss paper and
• 28:11data I just showed you.
• 28:13Parker Holtzer did the statistical
• 28:16analysis and produce these
• 28:17beautiful graphs that I showed you.
• 28:19The merwins calculator.
• 28:21Obviously my father was instrumental
• 28:23in figuring out the equations.
• 28:25My brother-in-law Matt Harper actually
• 28:28made the iPhone app John Emerson help
• 28:31with the statistical percentile calculations,
• 28:33and Michael Frederick was nice enough to make
• 28:38the Android version of Merlin's calculator.
• 28:41You can find details of the
• 28:44papers that we've published.
• 28:46The ways to get us to help you
• 28:49look at any of your pregnancy
• 28:53losses and much more.
• 28:55At our Yale website at kleimanlabs.yale.edu.
• 28:58Thank you very much.