OUTLINE….of RM
* KNOWN KNOWNWhat we know & we DO: **KNOWN UNKNOWNWhat we know but do not do: ***UNKNOWN KNOWNWhat we know that we do not know ****UNKNOWN UNKNOWNTOTALLY NEW .. Future
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
Recurrent pregnancy loss (RPL), also referred to as recurrent miscarriage or habitual abortion, is historically defined as 3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period.
This Presentation is made by Dr.Laxmi Shrikhande
interest in stem cells is raising in different field of medicine. The question is : is it successful in Gynecology or it is still too early to say that. The present talk may help to explore this .
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
Recurrent pregnancy loss (RPL), also referred to as recurrent miscarriage or habitual abortion, is historically defined as 3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period.
This Presentation is made by Dr.Laxmi Shrikhande
interest in stem cells is raising in different field of medicine. The question is : is it successful in Gynecology or it is still too early to say that. The present talk may help to explore this .
Recurrent Pregnancy Loss Sharing Personal Experience (10 years) Lifecare Centre
Complete over view of the causes diagnosis management of Recurrent Pregnancy Loss
it is a personal experience of treating recurrent miscarriages with excellent result
OVERVIEW
Aim
Definition
Prerequisites
Individualisation of patient.
Ohss free IUI. Clinic
{Strict cancellation of cycle if OHSS is suspected}
Newer trends
Sucess Rates in IUI with COH
PROGNOTIC FACTORS to increase Pregnancy Rates..& discussion
Role of Stem Cells in Obstetrics and Gynecology PracticeAsha Jain
Role of Stem Cells in Obstetrics and Gynecology Practice
Talk delivered at 4th Biennial International ISCSGCON 2021
on Febuary 13,2021 by Dr. Asha Jain
The loss of pregnancy at any stage - devastating experience, both patient and physician.
Recurrent miscarriage is defined as the occurrence of three or more consecutive spontaneous abortion before 20wks of gestation.
Ectopic, molar and biochemical pregnancies not included.
Recurrent Pregnancy Loss Sharing Personal Experience (10 years) Lifecare Centre
Complete over view of the causes diagnosis management of Recurrent Pregnancy Loss
it is a personal experience of treating recurrent miscarriages with excellent result
OVERVIEW
Aim
Definition
Prerequisites
Individualisation of patient.
Ohss free IUI. Clinic
{Strict cancellation of cycle if OHSS is suspected}
Newer trends
Sucess Rates in IUI with COH
PROGNOTIC FACTORS to increase Pregnancy Rates..& discussion
Role of Stem Cells in Obstetrics and Gynecology PracticeAsha Jain
Role of Stem Cells in Obstetrics and Gynecology Practice
Talk delivered at 4th Biennial International ISCSGCON 2021
on Febuary 13,2021 by Dr. Asha Jain
The loss of pregnancy at any stage - devastating experience, both patient and physician.
Recurrent miscarriage is defined as the occurrence of three or more consecutive spontaneous abortion before 20wks of gestation.
Ectopic, molar and biochemical pregnancies not included.
it is really frustrating to women and challenging to doctors when they face repeated loss of pregnancy what is called recurrent abortion: how to manage such problem?? this talk may help in answering this question
PCOD,How are they different ??Difficulties & Solutions made Easy , Dr. Sharda...Lifecare Centre
Tremendous advances and extensive human studies have uncovered the complexity and management of PCOD
Global prevalence -2.2% to 26% Roughly 1 in 15 women worldwide, (Lancet, 2007)
Sonosalpingography. Dr. Sharda Jain, Dr. Jyoti Agarwal Lifecare Centre
Evaluation of fallopian tubes forms an essential part of evaluation
Tubal pathology is a cause of infertility in 30- 35% of infertile patients
Tubal Assessment
Fallopian tubes can be assessed by:
Hysterosalpingography
Hysterosalpingo-contrast-sonography (HycoSy)
Sonosalpingography
Laparoscopy & CHROMOTUBATION
There is a recent and strong trend in western countries to advocate single embryo transfer (eSET). The rational behind this trend is to avoid complications of multiple pregnancy after IVF. However, we would urgue that twin pregnancy is totally different from high order multiple pregnancy and the long term economic analysis of twin pregnancy has never been explored before. We tried to calculate the risks and benefits of twin pregnancy from a society perspectives. Based on our model, it seems that double embryo transfer (DET) is still a valid option.
Role of Calcium in pregnancy DR. SHARDA JAIN Dr. Jyoti Agarwal Dr. Rashmi Jai...Lifecare Centre
ROLE OF CALCIUM IN PREGNANCY
FOCUS :
Daily requirement of calcium according to age
Calcium metabolism in pregnancy
Calcium requirement in pregnancy
Maternal benefits
Fetal benefits
Reduction in blood lead levels
Nutrition to improve calcium
Guidelines about dietary calcium intake / supplements in pregnancy
Mark Perloe, MD Atlanta, 404-843-2229 Learn about the factors that can adversely affect fertility and the tests that can help pinpoint problems. Fertility treatment options including IVF and other high tech options are presented.
Screening for any disorder in individuals is a strategy used for identifying a disease before the onset of signs or symptoms, thus enabling earlier detection and management with the aim to reduce morbidity and mortality.
OBSTETRICS AND GYNAECOLOGICAL NURSING- HIGH RISK PREGNANCY ABORTION.pptxmagie12
The students will be able to
*define abortion
*Identify the difference between various types of abortion
*Perform medical induction for abortion
*Describe various surgical techniques used for abortion
*Detect the consequences that occur by abortion and provide appropriate care
Abortion or pregnancy loss is accounts to spontaneous events or through legal termination.
The first large scale study on abortions and unintended pregnancies conducted by The Lancet in 2017 said one in three of the 48.1 million pregnancies in India end in an abortion with 15.6 million taking place in 2015.
*Definition
*Types of abortion- Spontaneous, Induced, Complete abortion, Incomplete abortion, Missed abortion, Recurrent abortion, Induced abortion
*Risk factors,
*etiology, mechanism,
* clinical manifestations of each type
*Management – medical & surgical
Nursing management
Abortion is the expulsion or extraction from its mother of an embryo or fetus weighing 500 gm or less when it is not capable of independent survival
-WHO
The 500gm of fetal development is attained
approximately at 22 weeks(154 days of gestation).
The expelled embryo or fetus is called abortus
Abortion is the cause for bleeding in early pregnancy.
Abortion occurring without medical or mechanical means to empty the uterus is referred to as spontaneous.
Another widely used term is miscarriage.
10-20% of cases of all clinical pregnancies end in miscarriage.
About 75%miscarriages –before 16th week
About 80% occur –before 12th week of pregnancy.
Increases with parity
Increased maternal and paternal age
The frequency of abortion increases from 12% in women younger than 20 years to 26% in those older than 40 years
Women conceiving within 3 months following a term birth, have a higher incidence of abortion
Anembryonic Gestational sac
- Positive HCG test as placenta secretes HCG and stops later
Presents in first few weeks of pregnancy
Removal through medical or surgical induction
Uncommon causes of abortion in human
Listeria monocytogenes
Clamydia trachomatis
Mycoplasma hominis
Ureaplasma urealyticum
Toxoplasma gondii
Diabetes mellitus
Celiac sprue
Cause both male and female infertility and recurrent abortions
ENDOCRINE ABNORMALITIES
Hypothyroidism
Thyroid autoantibodies → incidence of abortion is high
Diabetes mellitus
Poor glucose control → incidence of abortion increased
Progesterone deficiency
Luteal phase defect
Insufficient progesterone secretion by the corpus luteum or placenta
DRUG USE AND ENVIRONMENTAL FACTORS
Recurrent pregnancy loss patients : 15%
Antiphospholipid antibody : most significant
LCA (lupus anticoagulant), ACA (anticardiolipin Ab)
ALLOIMMUNE FACTORS
- Inherited thrombophilia
Uterine synechiae (Asherman syndrome)
Partial or complete obliteration of the uterine cavity by adherence of uterine wall
The retention power of the cervix(Internal os) may be impaired functionally and or anatomically in an incompetent cervix
Etiology
Previous trauma during pregnancy
The Newer Concepts In Endometriosis Management : Dr Sharda JainLifecare Centre
The Newer Concepts In
Endometriosis Management
ENDOMETRIOSIS IS ENIGMA
DIAGNOSTIC DELEMMA
DEBILITATING DISEASE QOL
PROGRESSIVE DISEASE
RECURRENCE IS BIG PROBLEM
NO FINAL VERDICT ON CAUSE
NO PERMANENT CURE
The exact prevalence of endometriosis is unknown, but estimates 10% in the general female population in India but up to 50% in infertile women
The Newer Concepts forReduced Surgery to preserve fertility in Endometrios...Lifecare Centre
The Newer Concepts forReduced Surgery to preserve fertility in Endometriosis
ENDOMETRIOSIS IS ENIGMA
DIAGNOSTIC DILEMMA
DEBILITATING DISEASE QOL
PROGRESSIVE DISEASE
RECURRENCE IS BIG PROBLEM
NO FINAL VERDICT ON CAUSE
NO PERMANENT CURE
The exact prevalence of endometriosis is unknown, but estimates 10% in the general female population in India but up to 50% in infertile women
Anemia Free India Gynaecologist to focuss on *12gm Haemoglobin at Delivery I...Lifecare Centre
Important Highlights
Prophylactic Iron and Folic Acid Supplementation in all six target age groups.
Intensified year-round Behaviour Change Communication (BCC) Campaign for:(a) improving compliance to IFA and deworming, (b) enhancing appropriate infant and young child feeding practices, (c) encouraging increase in intake of iron-rich food through diet and/or fortified foods (d) ensuring delayed cord clamping .
Testing and treatment of anaemia, using digital methods and point of care treatment, with special focus on pregnant women and school-going adolescents.
Addressing non-nutritional causes of anaemia
in endemic pockets with special focus on malaria, hemoglobinopathies and fluorosis
Strategies for Improving Success Rates in ART PARTLifecare Centre
Strategies for Improving Success Rates in ART
Part - 2
Strategies for Improving Success Rates in ART
Tailoring Controlled Ovarian Stimulation
Strategies for Luteal Phase in ART cycles
Endometrial Receptivity Array
How to optimize success rates in ART? : Dr Sharda JainLifecare Centre
How to optimize success rates in ART? : Dr Sharda Jain
How to improve success rates in ART?
The big debate कार्य में आनंद
Evolution of In-vitro Fertilization (IVF)
Factors Influencing IVF Success Ist Part
Strategies for Improving Success Rates in ART Second Part
Innovations & Breakthroughs in IVF Part Three
OPEN DEBATE
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda JainLifecare Centre
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda Jain
Introduction
Social egg freezing (oocyte cryopreservation for non-medical reasons) has evolved as a proactive option for women looking to extend their reproductive possibilities past their peak childbearing years
It is the process of saving or protecting eggs, or reproductive tissues so that a person can use them to have biological children in future
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
2. Our PPts on RECURRENT MISCARRIAGE
is Uploaded on slideshare.net
1. An update on recurrent pregnancy loss 2015
http://www.slideshare.net/LifecareCentre/an-update-on-recurrent-pregnancy-loss-2015
2. Recurrent pregnancy loss, thrombophilia
tests : to do or not to do.
http://www.slideshare.net/LifecareCentre/recurrent-pregnancy-loss-thrombophilia-tests
3.Recurrent Pregnancy Loss Sharing Personal
Experience (10 years)
http://www.slideshare.net/LifecareCentre/recurrent-pregnancy-loss-sharing-personal-experience-
10-years
5.Interesting Update on Recurrent Miscarriage for India Gynaecologoists
3. The stories that end badly are sad, sadder still
are the ones that never began….
7. * KNOWN KNOWN
What we know & we DO:
**KNOWN UNKNOWN
What we know but do not do:
***UNKNOWN KNOWN
What we know that we do not know
****UNKNOWN UNKNOWN
TOTALLY NEW .. Future
OUTLINE….of RM
…Caring hearts, healing hands
11. DEFINITION
Recurrent Miscarriage is defined as
the occurrence of three or more
consecutive spontaneous abortions
Before 20 weeks
(24 weeks in UK)
12. INCIDENCE
15-20% of clinically
detectable pregnancies abort
5% women have RPL > 2
1 % women have RPL > 3
The risk increases by about 10% with each abortion; estimated risk
being 24% after two clinically recognized losses, 30% after three losses
and 40% - 50% after four losses.
13. The ASRM has defined RPL as “a
distinct disorder defined by 2
or more failed clinical
pregnancies”
* Ectopic and Molar pregnancies
are NOT included.
DEFINITION
14. TYPES OF RPL
• PRIMARY RPL have never had a previous viable
infant.
• SECONDARY RPL woman with previous H/o
delivery beyond 20 weeks and then suffered
subsequent losses.
• TERTIARY RPL refers to those women who have
multiple miscarriages interspersed with normal
pregnancies.
15. Should we start investigating the
couple after 2nd ABORTION ??
Yes
It is Reasonable to Determine
the cause of their pregnancy loss, especially when
the woman is older than 35 years of age, or when
the couple have had difficulty in conceiving
BMJ2000;320:1708-12
16. Women with 2 LOSSES have
identifiable problems just as frequently as
women with 3 or more losses; thus,
evaluation for causes may be initiated
after 2 losses.
BMJ2000;320:1708-12
17. THREE INDEPENDENT RISK
FACTORS
• Gestational Age at abortion
• Age of the patient (Both Husband / Wife)
• History of previous abortions
18. Is Gestational Age of any importance?
Gest. Age at abortion guides us of the cause:
• 4 - 7 wks - Genetic causes
• 8 - 10 wks – APLA SYND/TB
• 10 weeks or Mid trimester - Anatomical Causes , APLA
SYND.
Yes
1
20. AGE of parents
*MATERNAL AGE..
Advanced age declines both the
Number & Quality of Oocytes
**PATERNAL AGE:
Advanced paternal age is also a risk
21. ADVANCED PARENTAL AGE
• MATERNAL AGE: increased risk of chromosomal abnormality
(Trisomy 13, 18, 21, 47XXY, 47XXX)
• PATERNAL AGE: increased risk of Autosomal dominant, X-
linked recessive Disorder
22. AGE OF THE PATIENT
Oocyte
quality and
ovarian
reserve
Decline
starts after
35 yrs
60% oocytes after 35 yrs are aneuploid
23. *Risk of miscarriage in is
20% after one loss
**30% after 2 losses
** 40% after 3 consecutive losses
among patients without a history of a
live birth.
15 to 18% sporadic miscarriage
************
What?
**Previous O.H…
is independent RISK factor**
3
24. Summary of Causes of RPL
as we view in India
AETIOLOGY
Genetic
Causes
APLA
syndrome
Uterine Causes
Cervical weakness
Inherited
Thrombophilia
?
Allo-munity
?
•Environmental
Causes
• Oxidative stress
•Psychological
•Unknown aetiology
Tuberculosis
PCOD ?
Obesity ?
LPD ?
Male factor ?
Endocrine &
Metabolic
26. CAUSES DIAGNOSIS
EVALUATION
THERAPY
Genetic Karyotype partners
Karype products of conception
Normal
Abnormal – karyotyping of
partners
Genetic counseling
*****
Donor gamets
****
preimplantation
genetic diagnosis
GENETIC CAUSES
WHAT WE NEED TO DO ?
27. Nondisjunction during meiosis
Autosomal trisomy, monopsony X,
triploid, tetraploidy, translocations
********
Incidence increases with maternal
age
60 -80 % of concepts
GENETIC: EMBRYONIC
28. Carriers of balanced chromosomal abnormalities
3-5% of RPL couples
*****
Risk of severely handicapped child is
due to ANEUPLOIDY &
on the size of genetic material in the relocated
segment
******
Chances of miscarriage is greater than
those of RPL couples who are not
carriers ( 50 % vs. 30%). (Franssen,BMJ;2006)
GENETIC: PATERNAL
31. Miscarriage#1
(No action unless clinically indicated)
2nd Consecutive miscarriages*
Or
3rd Nonconsecutive Miscarriages*
Obtain Fetal POC
Karyotype
Aneuploid Karyotype
Unbalanced Chromosomal
Translocation or Inversion
Euploid Karyotype
RPL Workup
No further Evaluation
And consider
Preimplantation
Genetic diagnosis(PGD) for
Future pregnancy attempt
Perform parental
Karyotypes and offer
Preimplantation genetic
Diagnosisis (PGD) for
future
pregnancy attempts
Miscarriage is defined by the loss of a clinical pregnancy documented by
ultrasonography or histopathological examination
32. PREIMPLANTATION GENETIC DIAGNOSIS (PGD)
PGD is subdivided into 2 broad categories
* Pre - implantation genetic diagnosis (PGD)
* The purpose of PGD is to prevent the birth of
affected children from parents with a known genetic
abnormality
* PGD is widely acknowledged as acceptable for
routine clinical application
• Preimplantation genetic screening (PGS)
* attempts to identify aneuploidy in embryos to improve
pregnancy success in certain patient populations
* Parents with no identified genetic defect or disease
* PGS remains controversial for routine application
The results obtained by PGD may not always reflect the fetus genetic
composition.
33. • Modern Treatment of balanced translocation is PGD
with IVF. But most Indian patients say that they readily
conceive & find IVF & PGD very expensive.
• Antenatal genetic testing includes time – tested
diagnostic evaluations such as chorionic villus sampling
or amniocentesis. In addition, newer minimally invasive
testing modalities( NIPT) are currently being developed
and applied..
• Benefit seen over 50% which is more than IVF & PGD
PARENTAL CHROMOSOMAL
ABNORMALITIES (3-5%)
What we do in India
35. INCIDENCE of Antiphospholipid antibody
syndrome: 15% in women with RPL vs
2% with low risk Obst .
********
Causes of RM / Preterm Birth /IUD / IUGR
ANTIPHASPHOLIPID SYNDROME [APS]
36. ANTIPHOSPHOLIPID ANTIBODY
SYNDROME
• Anticardiolipin antibodies
• Lupus anticoagulant
• B2 Glycoprotein antibodies
ANTIPHOSPHOLIPID ANTIBODIES –
inhibit the trophoblastic differentiation,
cause inflammatory response,
in later pregnancy, cause thrombosis in the placenta
vasculature.
37. Clinical and laboratory criteria established for the
research of definite antiphospholipid
syndrome: the Sydney criteria 2010
Note : at least 1 clinical and 1 laboratory criterion
must be present for definite APS.
CLINICAL CRITERIA
1. VASCULAR THROMBOSIS
One or more clinical episodes of an arterial,
venous , or small vessel thrombosis confirmed by
imaging or doppler studies or histopathology,
without significant evidence of inflamation in the
vessel well.
Clin onstet gynecol 2010;53:617-27
38. Clinical and laboratory criteria established for the
research of definite antiphospholipid
syndrome: the Sydney criteria
2. OBSTETRIC MORBIDITY
• One or more unexplained demise of a morphologically normal
fetus at or beyond 10 week of gestation, or
• One or more premature birth of a morphologically normal fetus
at or before 34 weeks of gestation, caused by severe
preeclampsia or severe placental insufficient, or
• At least 3 unexplained , consecutive miscarriages of less than 10
weeks of gestation with no known factors associated with
recurrent miscarriages including parental genetic, anatomic and
endocrinologic factor. Clin onstet gynecol 2010;53:617-27
39. LABORATORY CRITERIA
1. aCL --- IgG and / or IgM in blood , present in
medium or high titers (greater than 40 PL or MPL or
greater than the 99th percentile) on 2 or more occasions
at least 12 weeks apart measuresd by a standardized
ELISA
2. Anti –B2 Gp1 Antibody -- of IgG and /or IgM isotype in
blood (greater than the 99th percentile) or 2 or more
occasions at least 12 weeks apart measured by a
standardized ELISA
3. Lupus anti coagulant
Clin onstet gynecol 2010;53:617-27
40. TREATMENT
Pregnant women with Apla syndrome should
be treated with LOW – DOSE ASPIRIN plus
HEPARIN to prevent further miscarriage This
treatment is initiated, early .
This treatment combination significantly
reduces the miscarriage rate by >50%
41. TREATMENT
Without treatment only 10% of
pregnancies in women with
recurrent miscarriage and
APLA Synd. will be live born.
Antiphospholipid antibodies inhibit the
trophoblastic differentiation, cause inflammatory
response, and , in later pregnancy, cause
thrombosis in the placenta vasculature.
These effects reversed by heparin
43. ANATOMIC CAUSES OF RM
1. Congenital malformations of the reproductive
tract
*Septum: partial, complete
**Bicornuate,
***unicornuate uteri
2. Intrauterine adhesions
3. Intrauterine masses, including fibroids or polyps
4. Cervical weakness
44. UTERINE MALFORMATIONS
Usually coincidental , rather than the cause.
Present in 2% of women with normal
reproductive history .
Prevalence higher -5 to 25% in women with
second trimester miscarriage
45. CERVICAL WEAKNESS
Exact incidence unknown but is a recognized
cause of second – trimester miscarriage
diagnosis is based on clinical history of
second – trimester miscarriage,
preceded by SROM or
painless cervical dilatation
Serial cervical Sonography surveillance or cervical
cerclage may be offered to women with a history
of second – trimester miscarriage where cervical
weakness is suspected
46.
47.
48. *Poor vascularity of the
septum, *disordered
myometrium
*uterine contractions
Anatomic - - Septum
PARTIAL & COMPLETE
49. Septate Uterus
• Most COMMON anomaly 55%
• May be complete/ incomplete
•25 % early abortions
•5 - 7% late abortions & Premature labors
50. ANATOMIC CAUSES (22.4%)
Congenital Anomalies
Septum = 2.05 %
Bicornuate Uterus = 2.7 %
Acquired Abnormalities
Synaechie = 3.5% + more
Submucous Myoma = 4 %
Endometrial Polyp = 4.5%??
Experience
Some cases had more than 1 cause
51. UTERINE ABNORMALITIES
Treatment SUMMARY as practiced in
• Uterine septum: GnRH analogue and hysteroscopic
septal resection and given the practice of
temporary intrauterine device.
• Intrauterine adhesions : hysteroscopic division and
temporary intrauterine device: postoperative
course of cyclic estrogen and progesterone therapy.
• Fibroids: GnRH analogue and myomectomy
53. HYPOTHYROIDISM / ANTIBODIES
• Thyroid gland function is critical in the maintainence
of early pregnancy.
• Overt or Sub clinical hypothyroidism is co – related
with poor pregnancy outcome
• Antithyroid antibodies (thyroglobulin and thyroid
peroxidase) are raised in euthyroid recurrent
aborters.
• Thyroid hormone replacement therapy along with
careful monitoring prior to
pregnancy & early pregnancy periods is associated
with improved outcomes
54. DIABETES MELLITUS
• Diabetic women with good metabolic control are
probably no more likely to miscarry than non-
diabetic women.
• Diabetic women with raised glycosylated Hb
concentrations in first trimester are at increased risk.
• Diabetic patients should be euglycaemic before
attempting a pregnancy
Kalter et al Am.J.O.G.,
60. Microbiologic Agents
<1%
Organisms implicated in causing Recurrent Abortion include:
Chlymadia
Mycoplasma
Ureaplasma
Herpes
Cytomegalovirus
Toxoplasma
TORCH is a useless
Investigation
DILEMMA
61. TUBERCULOSIS Is a BIG Cause
of RPL (Good 1/3 cases)
&
Is extensively studied both by
Dr. Sharda Jain (Lifecare Centre Team)
& Dr. Sonia Malik
In Indian RPL Patients
Majority of Indian Obstetrician
Do Endorse the same
Our PPT Ref. http://www.slideshare.net/LifecareCentre/genital-tb-in-infertility-
our-experience-dr-sharda-jain-dr-jyoti-agarwal-dr-jyoti-bhaskar?qid=a22f617e-cb42-4e86-87bd-07deac56e48f&v=qf1&b=&from_search=5
Slideshare.net
62. LUTEAL PHASE DEFECT
• Not a valid cause of infertility or
RPL
• Difficult to Diagnose
(Bukulmez, OGClinNA,2004)
64. PCOS – the risk of recurrent miscarriage is
attributed to
* insulin resistance, ** Hyperinsuliaemia
and *** Hyperandrogenism
There is insufficient evidence to advocate the use of progesterone or matformin in
women with recurrent miscarriage
Free testosterone
Reverse FSH / LH ratio
USG picture
66. OBESITY – Risk of sporadic and RM is
increased
Patients of BMI > 27.5 kg/m2
are likely to take longer to conceive
So it is good to lose weight by
structured weight loss programme
Over weight BMI > 22.5
Obese BMI > 27.5
Severe Obese BMI > 32.5
Morbid Obesity BMI >37.5
67. The current 2014 march guidelines on RPL do not
recommend screening for
Thrombophilia
unless a personal history of
Venous thromboembolism is present.
Key point & Recommendation
ACOG 2014
Obstet. & Gynae clinics of north america
March 2014-volume 41 – number 1
68. INHERITED THROMBOPHILIA
Few important points in treatment
• Factor V Leiden. Factor ii (Prothrombin) gene
mutation, and protein S deficiency
• There is insufficient evidence to advocate
heparin in pregnancy in women with recurrent
first – trimester miscarriage associated with
inherited thrombophilia.
• Heparin therapy during pregnancy may improve
the live birth rate of women with
SECOND – TRIMESTER miscarriage associated
with inherited thrombophilia
69. Anticoagulation for
unexplained RPL
• Combined aspirin/heparin
treatment versus placebo in women
with unexplained RM
( Kaandorp2010, NEJM)
• NO difference in LBR
• Significant side effects in treatment
group
70. Anticoagulation for RM with
ANA/ Thrombophilia
HepASA trial: no difference in LBR
between ASA alone versus ASA
and heparin
(Laskin, Journal of Rheumatology,2009)
Trial stopped prematurely due to
equivalent LBR in both groups.
72. Unexplained Infertility
& Recurrent Pregnancy Loss
• there is enough evidence that test of sperm DNA
damage may be predictor of failed natural
pregnancy out come in Unexplain infertility
• Couple with Recurrent pregnancy loss.
there is enough evidence that high level DNA
damage are associated with R.M.
*****
At Lifecare Centre we are routinely screening
73. Diagnostic Cutoff Point
of sperm DNA fragmentation
DFI Fertility potential
<15% Excellent
15% - 30% Good
>30% Poor
75. HCG for RPL
COCHRANE
A statistically significant
benefit in using hCG
(risk ratio (RR) 0.51, 95% confidence
interval
(CI) 0.32 to 0.81; five studies, 302
women ( Jan 2013)
76. HCG for RPL
• High heterogeneity in RM population ( 39%)
• After excluding data from poorly designed
studies, revised RR 0.74 (CI 0.44 to 1.23).
• Still Small number of cases.
• Chromosomal analysis not carried out.
77.
78. PROGESTERONE for RPL
encouraging results
• PROMISE trial underway
• 760 women randomised
• Immunomodulatory action:
upregulate TGF-β secretion in
response to trophoblast,
• Blocks Th-l immunity to trophoblast.
• Myometrial relaxation
79. Tender loving care…
• Three small non randomized trials
(Stray-Pederson, Liddel 1991,
Clifford 1997)
• Control groups not matched and
small
• No testing for APS
• Livebirth rates claimed to increase
by 50% for groups receiving TLC
80. GREAT FACT
A significant proportion of cases of recurrent
miscarriage remains unexplained despite detailed
investigation.
• These women can be reassured that the prognosis for
a successful future pregnancy with supportive care
alone is in the region of 65%.
However prognosis does worsen with increasing age and
number of previous miscarriages
81. We Run Dedicated
Recurrent Pregnancy Loss Clinic
since 2003
Our Experience of 753 Recurrent
Consecutive Miscarriages – Updated
(31st July 2016)
FOCUS IS ON CAUSES
82. Etiology
The causes are complex and
obscure with more than one
factor operating in many cases.
Factor may be recurrent or non –
recurrent.
83. LIFECARE GUIDELINES
1. THE COMPLETE EVALUATION
* Genital Tuberculosis (MTBC / PCR)
* Genetic
* Anatomical
*APLA syndrome
* Endocrinology
* * Iatrogenic
should be initiated when the decision to evaluate
a couple is made.
2. A complete evaluation for RPL shows possible
causes in good 80%of cases in contrast to 60% quoted in world
literature
84. Lifecare RPL clinic’s Break – up of Causes
In
50%
More
Than
1
cause
GENETIC 2.8 % 3.8%
ENDOCRINE CAUSES
- ↑ Glycosylated HB 16%
15%
- S/C Hypothyrodism 26 % 21%
- Thyroids Anti Bodies + 9 % 11%
- LPD 22% 17%
- PCOD – ↑ LH 14% 20%
TUBERCULOSIS
39 % 36%
TB + TNF a ↑ 31% 35%
Apla Syndrome 6% 10%
Thrombophilia 3 % 7% Now we have
stopped investigating
Alloimmunity
TNF a, and / or NK Cells
8 % 5% Stopped investigating
ANATOMICAL /UTERINE 22.4 % 24%
Jan 2013 July 2016 No. 753
85. Recommended
diagnostic evaluation
BASIC BLOOD TESTS
. Haemogram
. Glycosylated HbA1c
. TSH ,Anti TPO
TRANS VAGINAL ULTRASOUND
2D, If needed 3D Hysteroscopy
Tubercular DIagnostic Tests..
Endometrial Biopsy for TB PCR or MTBC
Blood tests for APLA syndrome
Genetic screening - Parents / POC Karyotyping
* Anticardiolipin antibodies
* Lupus anticoagulant
* B2 Glycoprotein antibodies
86. MANAGEMENT TIPS
• TLC .. Tender Loving Care
. COUNSELLING
. Specific Cause Related Treatment
.. Aspirin and LMWH for APLA Syndrome
.. PGS/PGD for genetic abnormalities after
counseling otherwise Antenatal Fetal Screening
.. Surgical Treatment only for Uterine Septum with
history of Recurrent Miscarriage
• Anti – oxidant , HCG & liberal vaginal Progesterone
90. UNEXPLAINED RM
• Type 1 unexplained RM: occurring by
chance
• Type 2 unexplained RM: due to an
underlying pathology that is not
currently identified by routine clinical
investigations or due to significant
environmental and lifestyle risk
factors. eg. Younger women, higher order
miscarriages
(Saravelos, HR2012)
92. THANKS !!!
*When you know something & it is
experience too--to hold on
that you know it.
** When you do not know - a thing,
….Please do admit & allow that you do
not know it,
this is gateway to knowledge
Confucius
93. Useful PRAYER – for both
Patients and Doctors !
“God grant me the serenity to accept the
things I cannot change;
The courage to change the things I can;
And the WISDOM to know the
difference”.