6. Unexplained:
Possible (definite or probable) causes
(Good correlation between the cause & RM) are
excluded by basic investigations
No more than 2 doubtful causes
(Christiansen et al, 2008)
8. Possible: strong correlation between the cause and
miscarriage
I. Anatomic:10%
1. Congenital uterine malformation.
2. Submucous fibroid
3. Cervical incompetence
4. Severe IU synechiae
II. Endocrine: 5%
1.Uncontrolled DM
2.Hypothyroidism
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9. WHAT ARE INFECTIONS CAUSING RPL?
III. Infection:
1. Brucellosis
2. Bacterial vaginosis
IV. Atiphospholipid antibody syndrome
V. Paternal causes
DNA fragmentation
(Vissenberg R, Goddijn, 2011)
VI. Genetic: 25%
1. Parental chromosomal abnormalities
2–5% of couples with RM
2. Embryonic chromosomal abnormalities
30–57% of further
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10. 2. Doubtful causes: weak correlation between the cause and
miscarriage
I. Local:
1. Oocyte:
Premature ovarian aging: reduced oocyte
quality and quantity.
2. Embryo
Aneuploidy
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11. II. Systemic Factors
1. Anatomic:
Arcuate uterus
Not: RVF, Mild IU adhesions, Subserous fibroid
2. Endocrine:
1. PCOS
2. Endometriosis.
3. Inadequate luteal phase
4. Hyperprolactinemia
5. Obesity or significantly underweight :negative
impact on chances of a live birth (ESHRE, 2017)
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12. 3. Inherited Thrombophilic Defects
1. Factor V Leiden mutation
2. Prothrombin gene mutation,
3. Protein s deficiency
(RCOG, 2011)
Hyperhomocysteinemia
Protein c def
Antithrombin III def
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13. 4. Infections:
Chronic endometritis
IS TORCH TEST INDICATED IN RPL?
TORCH test
not recommended
(Evidence level II).
Not:
Toxoplasmosis, Mycoplasma
L. monocytogenes, C. trachomatis
HSV, CMV
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14. Chronic endometritis (CE)
Diagnosis:
Histopatholgy: plasma cell
Office hysteroscopy :
Oedema
Micropolyposis
Hyperaemia
Culture
High prevalence in RM.
(McQueen et al, 2015; Bouet et al, 2016)
Further research is needed before screening for
endometritis can be recommended.
(ESHRE, 2017)
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16. 6. Environmental and occupational
(few small studies) exposure to
1. heavy metals
2. solvents& industrial chemicals
3. Pesticide: increased risk of PL
(ESHRE, 2017)
4. Herbicide spraying.
5. Electromagnetic field
6. Radiation
7. anesthetic gases
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17. Stress:
no evidence that stress causes PL.
(ESHRE, 2017)
Age:
risk of PL
lowest between 20 to 35 years
rapidly increases after the age of 40
(ESHRE, 2017)
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18. 1. Smoking
negative impact on chances of a live birth
2. Caffeine intake
late PL.
(Some studies)
3. Alcohol consumption
risk factor for
PL
fetal problems (Fetal alcohol syndrome).
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21. WHAT IS EVIDENCE OF USE OF METFORMIN
DURING PREGNANCY IN PCOS?
1. PCOS
Metformin : debatable.
MA: preconception Met did not reduce RM
Small retrospective: reductions in RM.
(Glueck etal, 2001; Jakubowicz et al, 2001)
Insufficient evidence to recommend metformin
Pituitary suppression before induction of ovulation
could be an option to reduce the risk of PL
(ESHRE, 2017)
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22. HOW TO TREAT INCREASED SPERM DNA
FRAGMENTATION?
2. Increased SDF
1. Oral antioxidant
have not been shown to improve the chance of a
live birth
(ESHRE, 2017)
2. Life style modifications:
stop smoking and wt loss
3. Identify and tt underlying condition:
GTI and varicocele
4. Consider TESA-ICSI
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23. 2. Euthyroid women with high serum thyroid peroxidase
antibody
RCT: [Negr et al, 2006].
levothyroxine (50 mcg daily): decreased
miscarriage rate (13.8 to 3.5%)
PTL (22,4 to 7%).
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24. 3. Hyperprolactinemia
RCT
[Hirahara et al, 1998].
Bromocriptine
significantly higher rate of successful pregnancy
(86 Vs 52%)
Bromocriptine treatment is recommended to increase
LBR
(ESHRE, 2017)
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25. HOW TO TREAT CHRONIC ENDOMETRITIS?
4. Chronic endometritis
Regimen:
Ofloxacin: 400 mg daily for 2w
Doxycycline: 100 mg twice daily for 2 w
Persistent CE:
Ciprofloxacin: 500mg and
Metronidazole: 500 mg twice daily for 2 weeks.
26. Treatment of Unexplained miscarriage
No evidence-based tt.
Low risk, simple, and cheap
1. TLC
2. Life style modification: No RCT.
3. Progestagen
4. Combination: Prednisone: 20 mg/d; Dydrogesterone: 20 mg/d
Aspirin: 100 mg/d.; Folate: 5 mg/second day: No RCT
[Tempfer et al, 2006].
5. Aspirin, Heparin: No improvement
6. HCG, HMG: equivocal
7. Intralipid, Endometrial scraching: No improvement
8. PGS: Not recommended
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27. 3 or more consecutive miscarriages
Progestogen tt:
significant decrease in miscarriage rate
compared to placebo or no tt
(Peto OR 0.39; 95% CI 0.21 to 0.72).
2 prior miscarriages.
a trend but not a significant reduction in
miscarriage rates
(Peto OR 0.68; 95% CI 0.43 to 1.07).
Limitations of MA:
these 4 trials were of poorer methodological
quality.
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28. Coomarasamy et al, 2015: NEMJ
PROMISE STUDY: 836 patients
Multicenter, double-blind, placebo, RCT
Vaginal suppositories:
400 mg micronized progesterone in 1st T
did not result in a significantly higher LBR
among women with a history of un RM.
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30. ABOUBAKR ELNASHAR
≥3 consecutive miscarriages of unknown cause.
(Roepkke et al, SR &MA, 2018)
21 RCT regarding
No significant difference in LBR
acetylsalicylic acid
LMWH
IV Img
leukocyte immune therapy
Treatment with progesterone
starting in the luteal phase effective in increasing
LBR
RR 1.18 (95% CI1.09-1.27) but not when started
after conception.
31. 3. Treatment of Infection
Brucellosis
• Rifampin: 900 mg once daily for 6 w
• Rifampin: 900 mg once daily plus
trimethoprim-Sulphmethoxazole
(TMP-SMX; 5 mg/kg of the trimethoprim component twice
daily) for 4 w
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32. Asymptomatic abnormal vaginal flora and
bacterial vaginosis
Oral clindamycin
•early in 2nd T:
•300mg PO BID x 7 days
significantly reduces
late miscarriage and
spontaneous preterm birth
(Evidence II).
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