recurrent pregnancy loss 1

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  • 1.RECURRENTPREGNANCY LOSSProf. M.C.BansalMBBS., MS., FICOG., MICOG. Founder Principal & Controller,Jhalawar Medical College & Hospital Jjalawar. MGMC & Hospital , sitapura ., Jaipur

2. INTRODUCTION The loss of pregnancy at any stage can be adevastating experience and particularsensitivity is required in assessing andcounseling couples with recurrentmiscarriage. Emotionally traumatic, similar to stillbirth orneonatal death. 3. DEFINITION 3 consecutive losses of clinically recognizedpregnancies < 20 week gestation Ectopic, molar, and biochemical pregnancies notincluded.Clinical investigation should be started after two consecutivespontaneous abortions, especially when fetal heart activity had been identifiedprior to the pregnancy losswhen the women is older than 35 yrs of agewhen the couple has had difficulty conceiving 4. RPL- SUB TYPES All pregnancy losses, no viable pregnancy Viable pregnancy followed by pregnancy losses Pregnancy losses interspersed with viablepregnancies 5. RPL-TYPES Primary recurrent pregnancy loss" refersto couples that have never had a livebirth, While Secondary RPL" refers to thosewho have had repetitive losses followinga successful pregnancy 6. INCIDENCE 50% of all conceptions fail (most unrecognized)13-15% of recognized pregnancies are lost, 90 %of these before 12-14 weeks10-20% of pregnant women have 1sporadicspontaneous abortion2% have 2 consecutive Spontaneous Abortion 0.4-1% have 3 consecutive Spontaneous Abortion 7. Prior losses % RiskWomen who012 %have at least 1live birth 124 % 226 % 332 % 426 %Women who2 or more 40-45 %have no livebirth 8. Recurrence suggests a persistent cause(not just a bad luck)which must be identified and treated 9. RISK FACTORS AND ETIOLOGY Only in 50 %, the cause can be determined Etiological categories: Uterine Immunologic Endocrine Genetic Thrombophilic Environmental 10. RPL -When To Start Investigating ? Ideally after 3 losses but earlier if high risk pt,elderly, with medical disorders and knownfamily history. How to Investigate ? Investigate commoner and treatable causesfirst Do not order a blind screen 11. RPL __1 st STEP Detailed history Clarify and Document RPL Recurrent Spont. Abortions Chemical Pregnancy Loss Early Pregnancy Loss ..... Before8wk.s & After 8 wk.s 2nd Trimester Abortions Still Births 12. Past Obstetric History Full term birth, premature birth Malformed fetus Term of pregnancy at the time of abortion Location of fetal heart / anembryonicpregnancies 13. Environmental factors can diagnosed byhistory only Smoking Anesthetic gases Toxins, chemicalsHigh risk factors Life Style Obesity Daily caffeine intake > 300 mg Alcohol consumption Use of NSAIDs 14. UTERINE FACTORS Acquired or congenital anomalies Congenital anomalies: 10 -15 % in womenwith RPL vs. 7 % in all women. Abnormal implantation: vascularity (septum) inflammation (fibroid) sensitivity to steroid hormones 15. SEPTATE UTERUS Most common Poorest outcome Miscarriage > 60 % Fetal survival with untreated cases 6 to 28 % The mechanism Not clearly understood Poor blood supply poor implantation 16. LEIOMYOMA Submucous The mechanism - Their position Poor endometrial receptivity Degeneration with increasing cytokine production 17. OTHER UTERINE CAUSES Endometrial polyps Intrauterine adhesions Curettage for pregnancy complications(4/52) Traumatize basalis layer granulationtissue Insufficient endometrium to supportfetoplacental growth Menstrual irregularities (hypomenorrhea,amenorrhea), cyclic pelvic pain, infertility. 18. OTHER UTERINE CAUSES Cervical insufficiency Recurrent mid-trimester loss Other AnomaliesDES exposure (T shaped uterus+/- cervical changes) 19. UTERINE ASSESSMENT Sonohysterography (SIS) More accurate than HSG Differentiate septate & bicornuate uterus Hysterosalpingogram (HSG) Does not evaluate outer contour Not ideal for the cavity Hysteroscopy Gold standard for Dx + Rx intrauterine lesions Reserved for when no Dx is made 20. UTERINE ASSESSMENT Ultrasound Presence and location of uterine myomas Associated renal abnormalities MRI Differentiate septate from bicornuate Hysteroscopy, laparoscopy, or MRI second-line tests when additional information isrequired 21. TREATMENTSurgery HysteroscopyProcedure of choiceSeptum excision, polypectomy Laparoscopic myomectomyFor fibroids Laparotomy 22. CERVICAL INCOMPETENCE Cervical cerclage is associated withpotential hazards related to the surgeryand the risk of stimulating uterinecontractions and hence should only beconsidered in women who are likely tobenefit. Transabdominal cerclage has been advocatedas a treatment for second-trimestermiscarriage and the prevention of earlypreterm labour in selected women withprevious failed transvaginal cerclage and/or avery short and scarred cervix 23. CERVICAL INCOMPETENCE Women with a history of second-trimestermiscarriage and suspected cervical weaknesswho have not undergone a history-indicatedcerclage may be offered serial cervicalsonographic surveillance. In women with a singleton pregnancy and ahistory of one second-trimester miscarriageattributable to cervical factors, an ultrasound-indicated cerclage should be offered. 24. IMMUNOLOGIC FACTORS Autoimmune Alloimmune (directed to self)(directed to foreign tissues/cells)-Systemic Lupus ErythmatosusAn abnormalmaternal-Antiphospholipid Syndromeimmune response tofetal or placental antigen. 25. Autoimmune Systemic Lupus Erythmatosus (SLE)-Risk for loss is 20%,mostly in 2nd and 3rd trimester of pregnancy and associated with antiphospholipid antibodies. Antiphospholipid syndrome (APA) 5 - 15 % of womenwith RPL may have APA APA likely induce microthrombi at placentation site.Altered vascularity affects developing embryo, induces abortion 26. Antiphospholipid syndrome An Autoimmune disorder having specific clinical & lab criteria. --Sapporo criteria Diagnosis requires at least one of each.CLINICAL 1) Thrombolic events-arterial,venous,small vessel2)Pregnancy loss- 3 losses at


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