Reccurent Pregnancy Loss


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CME given at Aluva on 17th February, 2012

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Reccurent Pregnancy Loss

  1. 1. Recurrent Pregnancy Loss
  2. 2. Miscarriage is defined as the spontaneous loss of pregnancy before the fetus reaches viability (24 weeks) Recurrent miscarriage, defined as the loss of three or more ( ≥ 3) consecutive pregnancies. Affects 1% of couples trying to conceive.
  3. 3. Risk factors Epidemiological factors Antiphospholipid syndrome Genetic factors Anatomical factors Endocrine factors Immune factors Infective agentsInherited thrombophilic defects
  4. 4. Can these cause RPL…….? SmokingCaffeine Alcohol
  5. 5. Can it….?
  6. 6. Antiphospholipid antibodies Lupus anticoagulant Anti-B2 Anticardiolipinglycoprotein-I antibodies antibodies
  7. 7. Antiphospholipid syndrome refers to the association between antiphospholipid antibodies and adverseor vascular pregnancythrombosis outcome
  8. 8. Adverse pregnancy outcome Three or more consecutive miscarriages before 10 weeks of gestation One or more One or more preterm births morphologically before the 34th normal fetalweek of gestation losses after the owing to 10th week ofplacental disease. gestation
  9. 9. Mechanism of APS Activation of complement And, in later pathways at Inhibition of pregnancy, the maternal– Can betrophoblastic thrombosis of fetal interface reversed by function and the resulting in a LMWHdifferentiation uteroplacental local vasculature. inflammatory response
  10. 10. Antiphospholipid antibodies are present in15% of women with recurrent miscarriage. By comparison, the prevalence ofantiphospholipid antibodies in women with a low-risk obstetric history is less than 2%.In women with recurrent miscarriage associated with antiphospholipid antibodies, the live birth rate in pregnancies with no pharmacological intervention has been reported to be as low as 10%.
  11. 11. How to manage APS with RPL?
  12. 12. BeforeIn the early trophoblastic pregnancy invasion Till 34 weeks
  13. 13. Adverse effects? Thrombocytopaenia Pregnancy Osteoporosiscomplications
  14. 14. Controlled Diabetes mellitus? Controlled Thyroid disease? Euthyroid with Antithyroid antibodies?
  15. 15. Yes HyperinsulinemiaHyperandrogenaemia Insulin Resistance
  16. 16. Metformin?
  17. 17. In couples with recurrent miscarriage, chromosomal abnormalities of the embryoaccount for 30–57% of further miscarriages. The risk of miscarriage resulting fromchromosomal abnormalities of the embryo increases with advancing maternal age.
  18. 18. 2–5% of couples with recurrent miscarriage, one of the partners carries a balanced structuralchromosomal anomaly most commonly a balanced reciprocal or Robertsonian translocation.
  19. 19. How todiagnose?
  20. 20. Management?
  21. 21. Partnerleucocytes Immunoglobulins infusion Steroids Stays abandoned
  22. 22. Cytokines T-helper-1 (Th-1) type, with production of the pro- T-helper-2 (Th-2) type, with inflammatory cytokines production of the anti- interleukin 2, interferon and inflammatory cytokinestumour necrosis factor alpha (TNF interleukins 4,6 and 10 )
  23. 23. Normal pregnancy might be the result of apredominantly Th-2 cytokine response, whereas women with recurrent miscarriage have a bias towards mounting aTh-1 cytokine response.
  24. 24. Progesterone is necessary for successfulimplantation and the maintenance of pregnancy.
  25. 25. This benefit of progesterone could be explainedby its immmunomodulatory actions in inducing apregnancy-protective shift from pro-inflammatory Th-1 cytokine responses to a more favourable anti-inflammatory Th-2 cytokine response
  26. 26. The reported prevalence of uterine anomalies in recurrentmiscarriage populations ranges between 1.8% and 37.6%.The prevalence of uterine malformations appears to behigher in women with second-trimester miscarriagescompared with women who suffer first-trimestermiscarriages, but this may be related to the cervicalweakness that is frequently associated with uterinemalformation
  27. 27. Investigations Serial TVS during Hystero –TVS + / - 3D MRI pregnancy Laparoscopy for Cervical length
  28. 28. Factor V Leiden mutation protein C deficiency Protein S deficiencyAntithrombin III deficiencyHyperhomocysteinaemia Prothrombin gene mutation
  29. 29. Can Infectiveagents cause RPL?
  30. 30. Investigations TSH HbA1C Anti thyroid Antibody Anatomy screen APS screen Vaginal swab PCOD screen Cytogenetic examination of abortus Karyotyping Thrombophilias screen
  31. 31. Evidence based Progesterone Weight reduction Aspirin + LMWH Cerclage Clindamycin Thyroxin IVF + PGD
  32. 32. Eminence based Spiramycin Steroids Immunoglobulins hCG
  33. 33. Unexplained RPL Repeated scanningReinforcement Reassurance
  34. 34. Unexplained RPL