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Reccurent Pregnancy Loss
1) Recurrent miscarriage, defined as the loss of three or more consecutive pregnancies, affects 1% of couples trying to conceive. 2) Risk factors for recurrent pregnancy loss (RPL) include antiphospholipid syndrome, genetic factors, anatomical factors, endocrine factors, immune factors, infective agents, inherited thrombophilic defects, smoking, caffeine, alcohol, lupus anticoagulant, and anti-cardiolipin antibodies. 3) Antiphospholipid antibodies are present in 15% of women with RPL, compared to less than 2% of women with a normal obstetric history, and live birth rates without treatment can be as low as 10%
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Reccurent Pregnancy Loss
- 1. Recurrent Pregnancy Loss
- 2. Miscarriage is definedas 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.
- 4. Risk factors Epidemiological factors Antiphospholipid syndrome Genetic factors Anatomical factors Endocrine factors Immune factors Infective agents Inherited thrombophilic defects
- 8. Can these cause RPL…….? Smoking Caffeine Alcohol
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- 14. Antiphospholipid antibodies Lupus anticoagulant Anti-B2 Anticardiolipin glycoprotein-I antibodies antibodies
- 15. Antiphospholipid syndrome refers to the association between antiphospholipid antibodies and adverse or vascular pregnancy thrombosis outcome
- 16. 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 fetal week of gestation losses after the owing to 10th week of placental disease. gestation
- 17. Mechanism of APS Activation of complement And, in later pathways at Inhibition of pregnancy, the maternal– Can be trophoblastic thrombosis of fetal interface reversed by function and the resulting in a LMWH differentiation uteroplacental local vasculature. inflammatory response
- 18. Antiphospholipid antibodies arepresent in 15% of women with recurrent miscarriage. By comparison, the prevalence of antiphospholipid 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%.
- 21. How to manageAPS with RPL?
- 23. Before In the early trophoblastic pregnancy invasion Till 34 weeks
- 24. Adverse effects? Thrombocytopaenia Pregnancy Osteoporosis complications
- 26. Controlled Diabetes mellitus? Controlled Thyroid disease? Euthyroid with Antithyroid antibodies?
- 28. Yes Hyperinsulinemia Hyperandrogenaemia Insulin Resistance
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- 32. In couples withrecurrent miscarriage, chromosomal abnormalities of the embryo account for 30–57% of further miscarriages. The risk of miscarriage resulting from chromosomal abnormalities of the embryo increases with advancing maternal age.
- 33. 2–5% of coupleswith recurrent miscarriage, one of the partners carries a balanced structural chromosomal anomaly most commonly a balanced reciprocal or Robertsonian translocation.
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- 38. Partner leucocytes Immunoglobulin's infusion Steroids Stays abandoned
- 40. 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 cytokines tumour necrosis factor alpha (TNF interleukins 4,6 and 10 )
- 41. Normal pregnancy mightbe the result of a predominantly Th-2 cytokine response, whereas women with recurrent miscarriage have a bias towards mounting aTh-1 cytokine response.
- 43. Progesterone is necessary for successful implantation and the maintenance of pregnancy.
- 44. This benefit ofprogesterone could be explained by its immmunomodulatory actions in inducing a pregnancy-protective shift from pro-inflammatory Th-1 cytokine responses to a more favourable anti-inflammatory Th-2 cytokine response
- 46. The reported prevalenceof uterine anomalies in recurrent miscarriage populations ranges between 1.8% and 37.6%. The prevalence of uterine malformations appears to be higher in women with second-trimester miscarriages compared with women who suffer first-trimester miscarriages, but this may be related to the cervical weakness that is frequently associated with uterine malformation
- 47. Investigations Serial TVS during Hystero – TVS + / - 3D MRI pregnancy Laparoscopy for Cervical length
- 50. Factor V Leidenmutation protein C deficiency Protein S deficiency Antithrombin III deficiency Hyperhomocysteinaemia Prothrombin gene mutation
- 52.
- 56. Investigations TSH HbA1C Anti thyroid Antibody Anatomy screen APS screen Vaginal swab PCOD screen Cytogenetic examination of abortus Karyotyping Thrombophilias screen
- 57. Evidence based Progesterone Weight reduction Aspirin + LMWH Cerclage Clindamycin Thyroxin IVF + PGD
- 58. Eminence based Spiramycin Steroids Immunoglobulin's hCG
- 59. Unexplained RPL Repeated scanning Reinforcement Reassurance
- 60. Unexplained RPL