Amanda (Host): This is BayCare HealthChat. I'm Amanda Wilde, and I'm joined by OB-GYN, Dr. Carlos Lamoutte. We're talking about a condition called recurring pregnancy loss. Dr. Lamoutte, thank you for being here to help us understand the condition and causes and treatment of recurring pregnancy loss. Thank you so much for being here.

Carlos Lamoutte, MD: You are most welcome, Amanda. Glad to be here. If I may start with a bit of background. Approximately 10% of clinically recognized pregnancies end up with early pregnancy loss, that which we define as less than 12 weeks. And, know that 80% of the pregnancy losses occur in that first trimester.

When we're talking about recurrent pregnancy loss, we are referring to more than two first trimester losses, and those are the patients that I focus on and we're going to be focusing on today.

Amanda (Host): Okay, good, because I was going to ask you about the medical definition of recurring pregnancy loss. So, it is two or more losses in the first trimester.

Carlos Lamoutte, MD: Correct.

Amanda (Host): And what causes recurring pregnancy loss? It must be heartbreaking.

Carlos Lamoutte, MD: It is, it is. I've been doing this for 31 years and it's one of the toughest things that patients go through. So just to give you a little bit of background, also regarding risk factors. So we know that advanced maternal age, which we define as greater than 35 years of age, is one of the main risk factors and previous losses, history of previous first trimester loss.

But then there are other risk factors that we won't have time to get into, but conditions such as polycystic ovarian syndrome [PCOS], history of infertility, and so on. Those are all risk factors. And if we look at the frequency by age that pregnancy losses occur at when you have the younger moms between age 20 and 30, anywhere from nine to 17% end up in first trimester miscarriages, that bumps up to 20%at age 35, it bumps up to 40% of pregnancies end up miscarrying at age 40. And then after age 45, up to 80% of patients end up miscarrying. And so, you know, it is a devastating thing, but I am here to bring hope to those patients because a lot of the causes can be helped and can be reversed and can be addressed so that they can end up with a successful pregnancy.

So I tell my patients that there are four areas that we focus on, really three. The fourth one, if they are interested, I check it, but three out of the four main causes can be addressed. And so I try to focus on those.

The first one is a condition called thrombophilia. And in particular a condition called antiphospholipid antibody syndrome. It's been shown to be linked to recurrent pregnancy losses. And there's a whole other slew of defects in the coagulation cascade that if the patient has, they have more propensity to forming blood clots and those can lead to first trimester recurring miscarriages.

Amanda (Host): Is that what thrombophilia is?

Carlos Lamoutte, MD: That's what thrombophilia is. So clot loving, in other words, thrombo is clot and philia is loving. So these are basically defects in the coagulation cascade that lead to more clotting than normal and they've been linked to recurrent pregnancy losses. The second cause is uterine anomalies.

By the way, the thrombophilia can be ruled out with blood tests. The uterine anomalies, think of anything that can distort the inside of the endometrium, which is the inside of the uterus, of the womb, that may prevent proper implantation of that baby, and those can lead to recurring  miscarriages.

So I'm talking about large endometrial polyps. Things like submucosal uterine fibroids, and those are things that can be corrected with a hysteroscopic  surgery. Basically putting a camera inside the cavity and removing the polyp or removing fibroid.

The third area that we look at is defects in the post-ovulatory hormonal phase called the luteal phase. So these luteal phase defects are cases where the mom does not produce enough of a hormone called progesterone, and they're commonly seen in those conditions, such as polycystic ovarian syndrome. Then the fourth area is going to be genetic predisposition of one or both of the parents that can lead to anomalies. That one brings a little bit more angst to the couple. It is checked with genetic testing. That one, there's not a lot you can do, but those are the causes that we look at.

Amanda (Host): Do they sort of come together? Like if you have a genetic anomaly, you might also have uterine abnormalities?

Carlos Lamoutte, MD: That's a great question. Sometimes yes. So sometimes if the mom has had certain so-called mullerian anomaly. So, although that's more of an anatomical issue in the mom, but when they were in utero, in their mom at the embryological stage in the development of the uterus, if they develop something called a septate uterus or a uterine didelphys or bicornuate uterus, those could deform the endometrium and those can lead to recurrent miscarriages. Some can be corrected. The septate uterus, which is almost like a heart shaped uterus, can be surgically corrected. The bicornuate uterus and the uterine didelphys those usually in very extreme cases cannot be surgically corrected as easily.

That's a condition [the bicornuate uterus] where the uterus typically in embryo, form, in the embryological stage forms by merging two horns, if you would. And then the division between the two horns kind of dissolves in utero and then they form the cavity. I find that in patients with bicornuate uterus, usually one of the two horns, if you would, one of the cavities is almost normal.

So if they get pregnant on that side, they usually can carry, have a little bit more risk of preterm labor and things like that, but they can, so I never discourage the moms that have bicornuate uterus from trying.

Amanda (Host): Well, that brings us to treatment. Can you describe the treatment? Should we do that by the four areas that you laid out?

Carlos Lamoutte, MD: Absolutely. So for the moms that have the thrombophilia, in particular, the antiphospholipid antibody syndrome, the literature shows that if you put them on a blood thinner, that's injectable because the oral blood thinners are not safe in pregnancy. But heparin is, and low molecular weight heparin is also safe.

So if you give them a daily injection of this blood thinner called, either heparin or Lovenox, which would be the low molecular weight heparin, those babies, typically will not miscarry and you would continue the injection up until maybe 24 hours before they deliver. In patients that have uterine anomalies, there are surgeries that we can perform and typically fairly straightforward surgeries.

For example, hysteroscopy polypectomy, which would be a camera that goes through the cervix into the uterus and removes the polyp or hysteroscopic  myomectomy, which is where you put the camera and through the camera, there's a gadget that can shave off the fibroid. That's in case the fibroid is in the cavity, deforming the cavity. So those can be corrected in that fashion.

The third area, the luteal phase defect. We treat with progesterone.Now, there was recently in 2024, a Scandinavian meta-analysis. So this was a study that looked at like 12 studies altogether, and they found favorable evidence that supplementing progesterone likely helps to prevent the recurrent miscarriages.

In my practice, I use a lot of progesterone, and I've seen a lot of moms that kept having miscarriages. We check their luteal phase. They do have a progesterone deficiency. We put them on progesterone and they end up caring to term. For the genetic anomalies, like I said, not a lot you can do there, but those are the treatments that we implement.

Amanda (Host): And what is your rate of success? I don't really mean numbers, but how do you know when the treatment is working?

Carlos Lamoutte, MD: That's a great question. So I typically will follow these patients closely and I usually tell them that if they make it past 12 weeks, cause remember the recurrent pregnancy losses are defined as more than two, but in the first trimester. We usually say if you make it to past 12, 14 weeks, we can breathe a sigh of relief and feel that the baby should do well. I also involve, because I'm in a small town, so I have a great maternal fetal medicine group accessible in our sister hospital in Tampa, and I get them involved. They do serial ultrasounds just to make sure that they can monitor the pregnancy as it progresses. Those level two ultrasounds begin typically between 18 and 22 weeks. So I have maternal fetal medicine involved in a lot of these patients, and they do extremely well.

Amanda (Host): So many people who have experienced recurring pregnancy loss can go on to carry a baby to term.

Carlos Lamoutte, MD: Absolutely. And I always look at the cup as half full, not as half empty. And so, my goal is with  this presentation that we're doing today, this is the same talk I give to my patients and  I give them hope and a lot of them they can carry. And I have had many, many patients that have suffered from recurrent pregnancy losses and we typically try to find the causes and they do well.

There was an old recommendation to begin baby Aspirin. That's another treatment that I did not mention, but that's also been shown to be helpful. I believe the study was in the New England Journal of Medicine. That was a study maybe from 20 years ago, and that's been one of my practices too.

Amanda (Host): Thank you so much for leading us through understanding recurring pregnancy loss and your success with treating it.

Carlos Lamoutte, MD: You are very welcome. These are one of the things I'm very passionate about and thank you for the opportunity.

Amanda (Host): That was OB-GYN Dr. Carlos Lamouette with BayCare Medical Group. And this wraps up this episode of BayCare HealthChat. Head on over to our website at BayCare.org for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all other BayCare podcasts.

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