controversies in management of recurrent miscarriage aboubakr elnashar
TRANSCRIPT
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Controversies in
management of
Recurrent
miscarriage
Aboubakr Elnashar Benha university Hospital
ABOUBAKR ELNASHAR
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CONTENT CONTROVERSIES
1.DEFINITION
2.MANAGEMENT OF POSSIBLE CAUSES
3.MANAGEMENT OF DOUTFUL CAUSES
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1. DEFINE
3 Consecutive miscarriages (ESHRE, 2006; RCOG, 2011)
2 Consecutive miscarriages (ASRM, 2012)
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2. MANAGEMENT OF POSSIBLE CAUSES
I. Anatomic:10% 1. Congenital uterine malformation.
2. Submucous fibroid
3. Cervical incompetence
4. Severe IU synechiae
II. Endocrine: 5% 1.Uncontrolled DM
2. Clinical and sub clinical thyroid
disorders.
III. Atiphospholipid antibody syndrome
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IV. Inherited Thrombophilic Defects:2nd TRM (RCOG,
2011)
1. Factor V Leiden mutation
2. Prothrombin gene mutation
3. Protein s deficiency
V. Genetic: 25%
1. Parental chromosomal abnormalities
2–5% of couples with RM
2. Embryonic chromosomal abnormalities
30–57% of further
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ASRM
(2012)
RCOG
(2011)
ESHRE
(2006)
HSG
3DUS
MRI
2DUS
3DUS,
Hysteroscopy,
Laparoscopy
SIS and/or
HSG
Hysteroscopy
Laparoscopy
1.
Anatomical
TSH, PRL
No: T3, TPOAb
No TFT, HA1C 2.
Endocrine
LA, aCL (G&M),
aβGI
LAC and
aGL(G&/orM)
LAC and aCL 3.
APS
No 2nd TRM:
factor V, factor II gene
mutation
Protein S. def
RCT req 4.
Thrombophil
ia
karyotype of
abortus
Parental
karyotype
If above normal:
karyotype of
abortus:abnormal:
Parental karyotype
Parental
karyotype after 2
miscarriages
5.
Genetic
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ASRM(2012) RCOG(2011) ESHRE(2006)
RCT req RCT req
Cx cerclage if ……
Uterine septum, s m
fibroid, severe IU
adhesions
Cx incomptence
Eltroxin;TSH:2.5
Dopamin ag
P: some benefit
RCT required
GnRha: No
Met: RCT req
RCT req
Hypothyroidism
Hyperprolactinaemia
LPD
PCOS
low-dose aspirin
plus heparin
low-dose aspirin plus
heparin
RCT req APS
No Heparin:
1st TRM:RCT req
2nd TRM: yes
RCT req
RCT req
Thrombophilias
Hyperhomocysteinaemia
No No RCT req Alloimmune
IVF/PGD: No IVF/PGD: No Genetic
TCL: yes TLC: yes
IVF/PGS, Aspirin,
Heparin: No
HCG: RCT req
TLC
health
advices
Unexplained
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3. MANAGEMENT DOUBTFUL CAUSES
I. ANATOMIC
RVF, Mild IU adhesions, Subserous fibroid: Not related to RM (ASRM,2012)
Arcuate Uterus
1.0% to 16%. [SugiuraOgasawara et al, 211] Chan et al, 2011 MA
: 2nd TRM, PTL, F malpresentation
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Jayaprakasan et al, 2011:
Women who are referred for ART
Arcuate uterus (11.8%) not associated with a
reduction in PR or increase in miscarriage
Further evidence is needed to recommend
hysteroscopic surgery in arcuate uterus [SugiuraOgasawara et al, 2011] (Evidence level II).
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II. ENDOCRINE
Thyroid peroxidase (TPO) antibodies
Controversial [Chen et al, 2011; Thangaratinam et al, 2012].
not linked to RM (Yan et al, 2012}
Linked to RM. [Abbassi , 2011, Twig et al, 2012]
Euthyroid women with high TPO antibody [Negr et al, 2006, RCT].
Eltroxin (50 mcg daily):
decreased
miscarriage rate (13.8 to 3.5%)
PTL (22,4 to 7%).
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TPO antibody screening is not recommended (Evidence level II).
Until strong evidence is available, thyroxine tt is
not recommended in raised thyroid antibody with
normal thyroid function tests (Evidence level III).
Aim: TSH < 2.5 mU/L.
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PCOS
linked to an increased risk of RM
Mechanism: unclear
Not a cause
1. Elevated LH (>10 IU/l): suppression of
endogenous LH release before conception: did
not improve LBR.
2. Elevated serum T (>3 nmol/l) {Rai, 2000]
Hyperandrogenaemia: elevated FAI: RM. 3. Ovulatory PCOS: do not increase risk
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May be:
Insulin resistance: hyperinsulinaemia
independent factor of RM {Chakraborty et al, 2013].
one of the direct causes: RM. [Li et al, 2012; Hong et al, 2013]
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GnRHa
Suppress LH secretion prior to ovulation induction:
no difference in outcome
Metformin
To reduce RM: debatable.
MA: preconception metformin did not reduce RM
Small retrospective study: reductions in RM. (Glueck etal, 2001; Jakubowicz et al, 2001)
Metformin is not recommended as a tt of RM (Evidence level III).
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HYPERPROLACTINEMIA
In early pregnancy were significantly greater in
women who miscarried . [Hirahara et al, 1998].
: RM {alterations in the hypothalamic pituitary ovarian axis: impaired folliculogenesis and oocyte maturation, and/or a short luteal phase}.
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Serum prolactin (ASRM, 2012)
Normalization of prolactin levels with a
dopamine agonist : decrease in RM. [Hirahara et al, 1998, RCT].
Treatment of hyperprolactinemia associated with
RM is recommend (ASRM, 2012, Up to date, 2013)
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LUTEAL PHASE DEFECT
Short luteal phase: pregnancy loss but the
assessment and interpretation of a putative
LPD is problematic.
The use of histological and biochemical endpoints as diagnostic criteria for endometrial dating are unreliable
(Evidence level III).
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Progestagen supplementation
Cochrane Database Syst Rev. 2013 4 trials, 225 women
: statistically significant decrease in miscarriage rate
compared to placebo or no tt (Peto OR 0.39; 95% CI 0.21 to 0.72).
However, these 4 trials were of poor methodological
quality.
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III. INFECTIONS
TORCH test
not recommended (Evidence level II).
Bacterial vaginosis
Risk factor for PTL and 2nd TM [Leitich et al, 2007]
Vaginal swabs as screening tests during
pregnancy in high risk women with previous
history of 2nd TM. [Trojniel et al, 2009]
Oral clindamycin early in 2nd T: significantly reduces
rate of 2nd TM and PTL [Leitich et al, 2007] (Evidence II).
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IV. THROMBOPHILIAS
Controversial. [McNamee et al, 2012]
Methylene tetrahydrofolate mutation: Hyperhomocysteinemia,
Protein C deficiency,
Antithrombin deficiency: Not associated with RM
The evidence is conflicting on
hyperhomocysteinaemia as a risk factor for RM:
testing for MTHFR mutation is not a part of
routine evaluation for RM. (Evidence level II).
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Hyperhomocysteinemia
High dose folic acid (5 mg) and vit B12 (0.5 mg)
once daily: reduce levels of homocysteine
No evidence to support usage of 5 mg folic acid
from prepregnancy stage purely to reduce the risk
of RM (Evidence level III).
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V. ALLOIMMUNE FACTORS No clear evidence related to RM.
1. human leucocyte antigen incompatibility
between couples
2. absence of maternal leucocytotoxic antibodies
3. absence of maternal blocking antibodies.
4. altered peripheral blood NK cells
5. raised uNK cell numbers
: should not be offered routinely in the investigation
of RM. (RCOG, 2011)
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Intralipid:
Evidence does not support [Shreeve , Sadek, 2012}
Paternal cell immunization, third party donor
leukocytes, trophoblast membranes, and IV IG: Not
beneficial .[Chochrane SR, 2006]
Criticized {not dd between primary and 2nd y RM}
IVIG increased LBR in 2nd ry RM
insufficient evidence for its use in primary RM [Hutton etl, 2007, MA]
Immunotherapy should not be advised. [Porter etalm 2006] (Evidence level II)
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VI. PATERNAL CAUSES
Significant increase of RM in patients with high
DNA damage compared with those with low DNA
damage (Robinson et al, 2012, MA)
Significant association between SDF and
pregnancy loss after IVF or ICSI (Zini, 2008, MA)
85% of u RM (Maynou et al, 2012)
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Several tests are available
but no consensus:
most predictive test?
Cut off level?
DFI ≥30: male infertility
15-30: RM
≤15: fair
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Insufficient evidence (Level C) to recommend
routine SDF testing to predict pregnancy loss. (ASRM, 2013)
For diagnostic test 1. Results must be reproducible 2. Applicable to a given patient 3. Change management of patient
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Thank you ABOUBAKR ELNASHAR