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Recurrent miscarriage ppt gynae seminar

This document discusses recurrent miscarriage, providing definitions and epidemiology. It defines recurrent miscarriage as 3 or more consecutive miscarriages. Causes discussed include polycystic ovary syndrome, antiphospholipid syndrome, chromosomal abnormalities, endocrine disorders, and uterine abnormalities. Investigation and management strategies are presented for different potential causes. For unexplained recurrent miscarriage, progesterone and aspirin are discussed but evidence for their effectiveness is limited. Counseling and lifestyle modifications are recommended.

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Recurrent miscarriage Dr. Kang Marcus O&G Consultant Hospital Sibu
Recurrent miscarriage  @ Habitual abortion  @ Recurrent pregnancy loss  Definition : 3 or more consecutive miscarriage
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
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
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
 2nd trimester losses (CABUT)  Cervical incompetence  Asherman syndrome (intrauterine synechiae)  Bacterial vaginosis  Uterine abnormalities  Congenital – bicornuate, septate, subseptate, hypoplasia  Myomas  Thrombophilias  Others – SLE, hyperprolactinaemia
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
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
Chromosomal abnormalities - Karyotyping
Chromosomal abnormalities  Balanced translocation  Reciprocal or Robertsonian
Chromosomal abnormalities
Endocrine factors  Usually DM or thyroid disease  Well-controlled DM and treated thyroid dysfunction are not risk factors for recurrent miscarriage
Uterine abnormalities
Uterine abnormalities
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
Asherman syndrome Normal uterus • Usually caused by pregnancy-related D&C Intrauterine synechiae
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.
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
Management  Should refer to hospital with specialist for further management.  Preliminary management that can be done in district hospital/clinics:  History  Examination
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
History  Any surgical history esp uterine instrumentation, cervical surgery  Any medical illnesses  Consanguinity?
Examination  Features of PCOS  Features of SLE  Speculum  Any features of genital tract infection
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.
 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
 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
 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
Investigations  Routine cervical cultures for Chlamydia sp. Or mycoplasma sp. and vaginal evaluation for bacterial vaginosis are not useful among healthy women.
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.
Management – Unexplained RM  Unexplained recurrent miscarriage (idiopathic)  Role of progesterone  Role of aspirin
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
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)
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)
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
Management - APS  Low-dose aspirin and heparin until 36 weeks of pregnancy
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
Endocrine  Optimize disease  Should be stable for around 6 months  Refer Prepregnancy Clinic when plan to embark on pregnancy  Counselling  Drug adjustment – minimize, safe