RPL >/=3 pregnancy loss• WHO-expusion.extraction of fetus weighing <500g from mother• RPL-1-2%• Spontaneous successfulpregnancy after 2miscarriage is 80%• Cause found in <10%, +cost• No apparent cause in 50%
History• Age-<16y, >35• OBH—GA<^6 w, 6-8w, FHR+/-• MH-oligomenorrhoea, PCO• Medical history- renal, look for s/s of autoimmune disease,SLE(RPL-22%)• Family history-pedigree, thrombophilia, birth defects• O/E –ENDODRINE ,Pelvic-uterine anomaly
Genetic• Maternal age correlates +vely with errors is meiosis 1• Oocytes ovulated earlier in life less prone to nondysjunction• Recurrent aneuploidy can occur in ART cycles , hence prone for RPL but cannot be the cause in higher order loss• Paraffin blocks of POC are suitable for FISH
Structural chromosomal rearrangement• Balanced translocation-4-5% – Rarely tranlocation precludes normal live born except in homologus acrocentric chromosome – If father has such rearrangement AID is an option.• Inversion –pericentric(lower risk)/paracentric – The extent of ,origin of crossing crossing inflences likelihood of fetal out come – Inversion involving small segment more lethalthan larger inversion
Role of fetal karyotyping in RPL• It is not necessry I• Cytogenetic analysis should be performed on products of conception of the third and• subsequent consecutive miscarriage(s).• Parental peripheral blood karyotyping of
Infection and its association with RPL is unclear• Chlamydia –eradicating it prior to pregnancy improved pregnancy out come – May cause endometrialdamage /immunlogical effect(epitoe shared by chlamydia and fetal ag. BV –it spontaneously remits in 30-50% in early preganacy ^ rplby 3fold, and also PTL Clindamycin –pv /po, as well as metrogyl are effective (more effective than oral ampicillin) Reduces PTL by 60%
APS now recognized as leading cause in RPL• now recognized as leading cause in RPL• With treatment (ASA+HEPARIN) live birth rate is improved
Congenital thrombophilia• Women with second-trimester miscarriage should be screened for inherited• thrombophilias including factor V Leiden, factor II (prothrombin) genemutation and• protein S• Pregnant women with antiphospholipid syndrome should be considered for• treatment with low-dose aspirin plus heparin to prevent further miscarriage.
When to test for hereditory thrombophila• away from the acute event• • when anticoagulation is discontinued• • when the woman is not pregnant or on the combined contraceptive pill.
immunological• Paternal cell immunisation, third-party donor leucocytes, trophoblast membranes• and intravenous immunoglobulin in women with previous unexplained recurrent• miscarriage does not improve the live birth rate