Recurrent miscarriage ppt gynae seminar

9,850 views

Published on

Published in: Education, Health & Medicine

Recurrent miscarriage ppt gynae seminar

  1. 1. Recurrent miscarriage Dr. Kang Marcus O&G Consultant Hospital Sibu
  2. 2. Recurrent miscarriage  @ Habitual abortion  @ Recurrent pregnancy loss  Definition : 3 or more consecutive miscarriage
  3. 3. Epidemiology  1% of all women  Spontaneous abortion: 10-15% of all clinically recognised pregnancies  2 consecutive miscarriage : 2%  Theoretical risk of 3 consecutive miscarriage:  0.15 x 0.15 x 0.15 = 0.3%  Probable underlying problem leading to recurrent miscarriage  The reason why need to investigate further if recurrent miscarriage
  4. 4. Recurrent miscarriage  What about 2 consecutive miscarriage?  American Society of reproductive medicine (ASRM 2008)  Define as 2 consecutive miscarriage  Royal college of O&G, UK (RCOG 2011)  Define as 3 consecutive miscarriage  Different practices between O&G specialist  Local practice – usually take 3 consecutive miscarriage  Earlier investigation/referral should be considered for special cases:  Advanced maternal age (? How old)  Bad obstetric history (e.g. ectopic, IUD)  History of infertility  Patient request due to social reasons
  5. 5. Causes  Idiopathic in 40-50% of cases  Easier to divide into 1st or 2nd trimester losses  1st trimester losses (PACE U)  PCOS (Polycystic ovary syndrome)  APS (Antiphospholipid syndrome)  Chromosomal abnormalities  Endocrine disorders (untreated DM, thyroid disease)  Uterine abnormalities  Submucous fibroid  Subseptate uterus
  6. 6.  2nd trimester losses (CABUT)  Cervical incompetence  Asherman syndrome (intrauterine synechiae)  Bacterial vaginosis  Uterine abnormalities  Congenital – bicornuate, septate, subseptate, hypoplasia  Myomas  Thrombophilias  Others – SLE, hyperprolactinaemia
  7. 7. Polycystic ovary syndrome (PCOS)  Criteria for diagnosis (Revised 2003 international consensus)  Presence of at least 2 of the following 3 criteria:  Polycystic ovaries  ≥ 12 follicles in each ovary (<10 mm (2-9 mm in diameter)) and/or  Ovarian volume > 10 cm3  Oligomenorrhea and/or anovulation  Clinical and/or biochemical hyperandrogenism
  8. 8. Antiphospholipid syndrome (APS)  Most important treatable cause of recurrent miscarriage  Diagnosed by Revised Sapporo classification (2006):  At least one clinical criteria and one laboratory criteriaClinical Laboratory Thrombosis ≥1 documented episodes of: Arterial Venous and/or Small vessel thrombosis ACA ACA of IgG and/or IgM isotype in medium/high titre (> 40 IU) or >99th percentile Pregnancy morbidity ≥1 unexplained fetal deaths of ≥ 10 weeks POA (morphologically normal fetus) LA Detected ≥1 premature births of ≤ 34th week POA d/t: Severe PE or Placental insufficiency (IUGR) (morphologically normal neonate) Anti- beta2- glycopr otein >99th percentile ≥3 unexplained consecutive spontaneous abortions < 10 week POA * On 2 or more occasions At least 12 weeks apart
  9. 9. Chromosomal abnormalities - Karyotyping
  10. 10. Chromosomal abnormalities  Balanced translocation  Reciprocal or Robertsonian
  11. 11. Chromosomal abnormalities
  12. 12. Endocrine factors  Usually DM or thyroid disease  Well-controlled DM and treated thyroid dysfunction are not risk factors for recurrent miscarriage
  13. 13. Uterine abnormalities
  14. 14. Uterine abnormalities
  15. 15. Cervical incompetence  Diagnosis is clinical, usually based on history  Miscarriage  2nd-trimester miscarriage  Subsequent miscarriages are usually earlier  Preceded by spontaneous rupture of membranes  Bulging membranes through the cervix prior to onset of labour  Painless and progressive cervical dilatation  Fetus alive during miscarriage  History of cervical surgery (cone biopsy, LLETZ)  No satisfactory objective test
  16. 16. Asherman syndrome Normal uterus • Usually caused by pregnancy-related D&C Intrauterine synechiae
  17. 17. Bacterial vaginosis  Presence of BV in the first trimester  Reported as a risk factor for 2nd-trimester miscarriage or preterm delivery.  A RCT reported that treatment of BV early in the 2nd- trimester with oral clindamycin significantly reduces the incidence of second-trimester miscarriage and preterm birth in the general population.  No data to assess the role of antibiotic therapy in women with a previous second-trimester miscarriage.
  18. 18. Management  Emotional aspect  Lost of pregnancy – can be a devastating traumatic experience  Can lead to anxiety, stress & depression  Instead of getting sympathy and support, often made to feel that it is somehow her fault  Under intense pressure to provide a child for the family  May even lead to family problem @ divorce  Sensitivity is required in assessing and counselling couples  Approach with sympathy and understanding  DO NOT blame, scold or make her feel at fault
  19. 19. Management  Should refer to hospital with specialist for further management.  Preliminary management that can be done in district hospital/clinics:  History  Examination
  20. 20. History  Full history including:  Complete obstetric history  Year of miscarriage  Gestation  How was the pregnancy confirmed?  UPT? Ultrasound?  Assumed pregnant as missed menses?  Spontaneous, D&C or termination?  Life embryo at miscarriage?  Any complications  If 2nd timester loss, ask for features of cervical incompetence
  21. 21. History  Any surgical history esp uterine instrumentation, cervical surgery  Any medical illnesses  Consanguinity?
  22. 22. Examination  Features of PCOS  Features of SLE  Speculum  Any features of genital tract infection
  23. 23. Investigations  PCOS screen  Se testosterone  SHBG  Antiphospholipid antibodies  Anticardiolipin antibodies (ACA) & Lupus anticoagulant  Anti-beta2 glycoprotein – if available  Karyotyping (both couples)  To detect chromosomal abnormalities i.e. balanced translocations  Should be performed on POC of the 3rd and subsequent consecutive miscarriages  Parenteral karyotyping of both partners should be performed when testing of POC reports an unbalanced structural chormosomal abnormality.
  24. 24.  If karyotype of the miscarried pregnancy is abnormal, there is a better prognosis for the next pregnancy  Risk of miscarriage as a result of fetal aneuploidy decreases with an increasing number of pregnancy loss
  25. 25.  Pelvic ultrasound – assess uterine anatomy  HSG can also be used as an initial screening test  Suspected uterine anomalies may require further investigations to confirm diagnosis:  Hysteroscopy  Laparoscopy  3D ultrasound  Thrombophilia screen – for 2nd trimester miscarriage
  26. 26.  Screening for diabetes, thyroid disorders is only indicated if there is clinical suspicion. Not recommended as a routine test.  However, as subclinical hypothyroidism increases risk of miscarriage, some authors recommend doing TFT  TORCHES – Not useful
  27. 27. Investigations  Routine cervical cultures for Chlamydia sp. Or mycoplasma sp. and vaginal evaluation for bacterial vaginosis are not useful among healthy women.
  28. 28. Management – Unexplained RM  Good prognosis for future pregnancy outcome  75% chance of a eventual live birth in subsequent pregnancy  However, prognosis worsens with:  Increasing maternal age  Number of previous miscarriages  Maternal age and number of previous miscarriage are two independent risk factors for a further miscarriage.  Advancing maternal age is associated with a decline in the number and quality of the remaining oocytes.
  29. 29. Management – Unexplained RM  Unexplained recurrent miscarriage (idiopathic)  Role of progesterone  Role of aspirin
  30. 30. Efficacy of progestogens in recurrent miscarriage 33 Haas & Ramsey 2008; Swyer & Daley 1953; Goldzieher 1964; LeVine 1964; El-Zibdeh 2005 Study or Progestogen Placebo Peto Odds Ratio Weight Peto Odds Ratio subgroup n/N n/N Peto Fixed 95% CI Peto Fixed 95% CI El-Zibdeh 2005 11/82 14/48 46.9% 0.37 [0.15, 0.90] Goldzieher 1964 1/6 4/10 8.5% 0.36 [0.04, 2.99] Le Vine 1964 4/15 8/15 18.4% 0.34 [0.08, 1.44] Swyer 1953 7/27 9/20 26.1% 0.44 [0.13, 1.46] Total (95% CI) 130 93 100.0% 0.38 [0.20, 0.70] Total events 23 (Progestogen), 35 (Placebo) Heterogenety: Chi2 = 0.08, df = 3 (P = 0.99) i2 = 0.0% Test for overall effect: Z = 3.10 (P = 0.0020) 0.1 10 Favours progestogen Favours placebo
  31. 31. Management – Unexplained RM  Role of aspirin  Usually prescribed for women with unexplained recurrent miscarriage  Alone or in combination with heparin  2 recent RCTs – neither treatment improves live birth rate among these women.  Use of this empirical treatment is unnecessary and should be resisted (RCOG, UK April 2011)
  32. 32. Management  Idiopathic or not investigated  Start when pregnancy confirmed:  T. Duphaston 10mg od/bd till 20/52 POA  Insufficient evidence to evaluate the effect of progesterone supplementation in pregnancy (RCOG, UK April 2011)  Lifestyle modification – can increase fertility potential  Stop smoking  Reduce alcohol intake  Reduce BMI (for obese women)
  33. 33. Cervical incompetence  2 options in the next pregnancy  Cervical surveillance  Start at 14-16 weeks  Every 2 weeks as long as cervical length >30mm  Increase frequency to weekly if 25-29mm  If <25mm before 24 weeks, consider cerclage  Cervical cerclage at 12-14 weeks POA
  34. 34. Management - APS  Low-dose aspirin and heparin until 36 weeks of pregnancy
  35. 35. PCOS  Role of Metformin  Previously prescribed to reduce risk of recurrent miscarriage  Insufficient evidence to evaluate the effect of metformin supplementation  Recent meta-analysis of 17 RCTs - metformin has no effect on sporadic miscarriage risk  Uncontrolled small studies (no RCTs) – associated with reduction in miscarriage rate in women with recurrent miscarriage
  36. 36. Endocrine  Optimize disease  Should be stable for around 6 months  Refer Prepregnancy Clinic when plan to embark on pregnancy  Counselling  Drug adjustment – minimize, safe

×