This document provides an overview of recurrent miscarriage, including its definition, causes, evaluation, and treatment. It discusses the possible causes of recurrent miscarriage such as anatomic, endocrine, infectious, autoimmune and genetic factors. For evaluation, it recommends taking a medical history, physical exam, pelvic ultrasound, thyroid testing, infection screening, antiphospholipid antibody testing, thrombophilia screening, and in some cases karyotyping. For treatment, it discusses addressing correctable causes as well as treatments for unexplained recurrent miscarriage such as lifestyle modifications, progestogens, aspirin, HCG, and immunotherapy, noting that evidence is limited for treatments of unexplained cases.
Ovarian Hyperstimulation Syndrome(OHSS), is a Rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy where a patient's ovaries become swollen and fluid builds up around her abdomen
Recurrent pregnancy loss is a significant redroductive medical problem, influencing 2%–5% of couples. ... Throughout the years, proof based medications, for example, surgical correction of uterine abnormalities or asprin and heparin for antiphospholipid syndrome have improved the results for couples with repetitive pregnancy loss.
Ovarian Hyperstimulation Syndrome(OHSS), is a Rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy where a patient's ovaries become swollen and fluid builds up around her abdomen
Recurrent pregnancy loss is a significant redroductive medical problem, influencing 2%–5% of couples. ... Throughout the years, proof based medications, for example, surgical correction of uterine abnormalities or asprin and heparin for antiphospholipid syndrome have improved the results for couples with repetitive pregnancy loss.
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
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)Sujoy Dasgupta
Dr Sujoy Dasgupta invited to deliver a lecture on "RPL- ESHRE Guideline" in the Annual Conference of RCOG (Royal College of Obstetricians and Gynaecologists) IRC (International Representative Committee) India East held on 20-21 May, 2023
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
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)Sujoy Dasgupta
Dr Sujoy Dasgupta invited to deliver a lecture on "RPL- ESHRE Guideline" in the Annual Conference of RCOG (Royal College of Obstetricians and Gynaecologists) IRC (International Representative Committee) India East held on 20-21 May, 2023
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.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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.
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Title: Sense of Taste
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 structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
3. Definition
Miscarriage
Spontaneous loss of pregnancy before the fetal
viability.
includes all pregnancy losses from the time of
conception until 24w.
ectopic and molar pregnancies are not included.
Recurrent miscarriage
3 or more consecutive pregnancies
(RCOG, 2011)
2 or more
(ASRM, 2008)
ABOUBAKR ELNASHAR
5. 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.Uncontrolled thyroid disease
ABOUBAKR ELNASHAR
6. III. Infection:
1. Brucellosis
2. Bacterial vaginosis
IV. Atiphospholipid antibody syndrome
V. Inherited Thrombophilic Defects
1. Factor V Leiden mutation
2. Prothrombin gene mutation,
3. Protein s deficiency
VI. Genetic: 25%
1. Parental chromosomal abnormalities
2–5% of couples with RM
2. Embryonic chromosomal abnormalities
30–57% of further
ABOUBAKR ELNASHAR
7. Brucellosis and pregnancy outcome:
Higher rate of
Abortion
PTL
IUFD
Causes of spontaneous abortion and IUFD
Maternal bacteremia
Toxemia
Acute febrile reaction
DIC
Diagnosis:
IgM: 1 : 160 - non endemic area
1 : 320 - endemic area
ABOUBAKR ELNASHAR
8. Bacterial vaginosis
Risk factor for PTL and 2nd TM
[Leitich et al, 2007]
Vaginal swabs as screening tests during
pregnancy in high risk women with previous
history of 2nd TM.
[Trojniel et al, 2009]
ABOUBAKR ELNASHAR
9. 2. Doubtful causes: weak correlation between the cause and
miscarriage
I. Local:
1. Oocyte:
Premature ovarian aging: reduced oocyte
quality and quantity.
2. Sperm: Paternal causes
DNA fragmentation
(Vissenberg R, Goddijn, 2011)
3. Embryo
Aneuploidy
4. Endometrium
Normal endometrium can distinguish between
good-quality and poor-quality embryos.
(Teklenburg etal, 2010)
Chronic endometritisABOUBAKR ELNASHAR
10. SDF
MA: significant increase in RM
(Robinson et al, 2012)
85% of u RM
(Maynou et al, 2012)
DFI
•≥30: male infertility
•15-30: RM.
•≤15: Excellent to Good fertility potential
ABOUBAKR ELNASHAR
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
3. Thrombophilia
1. Hyperhomocysteinemia
2. Protein c def
3. Antithrombin III defABOUBAKR ELNASHAR
12. 4. Infections:
Chronic endometritis
TORCH test
not recommended
(Evidence level II).
Not:
Toxoplasmosis, Mycoplasma
L. monocytogenes, C. trachomatis
HSV, CMV
ABOUBAKR ELNASHAR
13. 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)
ABOUBAKR ELNASHAR
19. Physical examination
Signs of endocrinopathy
Hirsutism
Galactorrhea
Pelvic organ abnormalities
uterine malformation
cervical laceration.
ABOUBAKR ELNASHAR
20. INVESTIGATIONS
1. Anatomical factors
Pelvic ultrasound and/or HSG or
sonohysterography
initial screening test
Hysteroscopy, laparoscopy or 3DUS
definitive diagnosis.
2. Endocrine
TSH
3. Infection
IgM for Brucellosis
ABOUBAKR ELNASHAR
21. 4. Antiphospholipid antibodies
Diagnosis:
2 positive tests at least 12 w apart for either
LA or
ACL or
Anti-B2 glycoprotein-I antibodies
of IgG and/or IgM
medium or high titre over 40 g/l or ml/l, or
above the 99th percentile.
ABOUBAKR ELNASHAR
23. 6. Karyotyping
Cytogenetic analysis of products of conception
of 3rd and subsequent consecutive
miscarriage(s).
Parental peripheral blood karyotyping
of both partners where testing of products of
conception reports an unbalanced structural
chromosomal abnormality.
.
ABOUBAKR ELNASHAR
25. I. Treatment of possible causes
1. Anatomical factors
1. Congenital uterine malformations
uterine septum
hysteroscopic resection
2. Submucosal fibroid:
Hysteroscopic myomectomy
3. Severe IU adhesions:
Hysteroscopic surgery
ABOUBAKR ELNASHAR
26. 4. Cervical incompetence
Cervical cerclage:
Indication:
1. one or more 2nd TM or PTL before 24 w.
TVS: cervix is 25 mm or less
2. Three or more previous PTL and/or 2nd TM.
ABOUBAKR ELNASHAR
27. 2. Treatment of hypothyroidism
Eltroxin
Objective
TSH: 2.5 mIU/L
Dose
Non pregnant:
1.7 μg/kg/d or
25 μg/d adjusted by 25 μg/d every 2 to 4 ws
until euthyroid state is achieved.
Pregnant:
Increase 30%
ABOUBAKR ELNASHAR
28. 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
ABOUBAKR ELNASHAR
29. Asymptomatic abnormal vaginal flora and
bacterial vaginosis
Oral clindamycin
•early in 2nd T:
•300mg PO BID x 7 days
significantly reduces the rate of late miscarriage
and spontaneous preterm birth in a general
obstetric population
(Evidence II).
ABOUBAKR ELNASHAR
30. 4. Antiphospholipid syndrome
low-dose aspirin plus heparin
reduces the miscarriage rate by 54%
No difference in efficacy and safety between
unfractionated heparin and LMWH when combined
with aspirin
Low dose Asprin
no adverse fetal outcomes
ABOUBAKR ELNASHAR
32. 6. Genetic factors
Abnormal parental karyotype:
I. Referral to a clinical geneticist.
1. Prognosis for the risk of future pregnancies
with an unbalanced chromosome complement
2. Familial chromosome studies.
3. Proceeding to a further natural pregnancy with
or without a prenatal diagnosis test
ABOUBAKR ELNASHAR
33. II. Treatment of doubtful causes
1. PCOS
Metformin : debatable.
MA: preconception Met did not reduce RM
Small retrospective: reductions in RM.
(Glueck etal, 2001; Jakubowicz et al, 2001)
ABOUBAKR ELNASHAR
34. 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%).
ABOUBAKR ELNASHAR
35. 3. Hyperprolactinemia
RCT
[Hirahara et al, 1998].
Bromocriptine
significantly higher rate of successful
pregnancy (86 Vs 52%)
Treatment of hyperprolactinemia and RM, even in
the absence of overt hypogonadism : recommend
(Up to date, 2013)
ABOUBAKR ELNASHAR
36. 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.
37. III. Treatment of unexplained RM
No evidence-based tt.
Low risk, simple, and cheap
1. Psychological supportive care/TLC.
Early and frequently repeated ultrasounds
βHCG monitoring
practical advice concerning life style and diet,
emotional support in the form of counselling,
Clear policy for the upcoming 12 w and medication.
Chance of a live birth is good: over 50%
ABOUBAKR ELNASHAR
39. 3. Decrease SDF
1. Oral antioxidant
2. Life style modifications:
stop smoking and wt loss
3. Identify and tt underlying condition:
GTI and varicocele
4. Consider TESA-ICSI
ABOUBAKR ELNASHAR
40. 4. Progestogen
Cochrane Database S R. 2013
4 trials, 225 women
El-Zibdeh
2005
Goldzieher 1964Le Vine
1964
Swyer
1953
1805456113
10 mg bid oral
Dydrogesterone,
5000 IU IM
hCG/4d
Duration: 12th w
10 mg/d oral
Dydrogesterone,
Duration: not
stated.
500 mg/w
IM
17 oh PC
Duration:
until 36 w
6 x 25 mg
progesterone
pellets
Duration: unclear.
ABOUBAKR ELNASHAR
41. 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.
ABOUBAKR ELNASHAR
42. 5. Aspirin with or without heparin
No improvement
Insufficient evidence to support the routine use
of LMWH to improve pregnancy outcomes in
women with a history of pregnancy loss.
(Mantha et al, 2009, MA)
No support of the use of anticoagulants in
women with unRM.
(Cochrane Database Syst 2014)
Daily LMWH injections do not increase ongoing pregnancy or livebirth
rates in women with unexplained RPL. Given the burden of the
injections, they are not recommended for preventing miscarriage
Schleussner et al, 2015.
ABOUBAKR ELNASHAR
43. 6. Combination therapy
An observational study
before and during pregnancy with
Prednisone: 20 mg/d
Dydrogesterone: 20 mg/d
Aspirin: 100 mg/d
Folate: 5 mg/second day
[Tempfer et al, 2006].
In treated group:
1st T M : 19% Vs 63% (not statistically significant).
LBR: 77 Vs 35%, respectively (P = 0.04).
The nonrandomized design and small number of cases also
limits the usefulness of this study.
ABOUBAKR ELNASHAR
44. 7. HCG
During early gestation may be useful in
preventing miscarriage
{endogenous hCG plays a critical role in the
establishment of pregnancy }
The evidence: equivocal
(Chochrane S R, 2013)
ABOUBAKR ELNASHAR
45. 8. HMG
observational study:
effective for tt of endometrial defects in
women with RPL
[Li et al, 2001].
Mechanism:
correction of a luteal phase defect
stimulation of a thicker endometrium: better implantation
site.
Clinical experience supports the efficacy of this
treatment
(Tulandi et al, 2013).
ABOUBAKR ELNASHAR
46. 9. Immunotherapy
Paternal cell immunisation
third-party donor leucocytes
trophoblast membranes
IVIG in women with previous uRM
does not improve LBR
(Cochrane systematic review, 2006 ; RCOG, 2011)
Immunotherapy should not be advised.
[Porter etalm 2006] (Evidence level II)
IVIG:
confirmed this conclusion
Expensive
Serious adverse effects: transfusion
reaction, anaphylactic shock and hepatitis.
(Stephenson et al, 2010MA)
ABOUBAKR ELNASHAR
47. Intralipid Therapy
Form:
20% IV administered fat emulsion routinely used as
a source of fat and energy for patients in need of
extra intake
Composed of :
purified soybean oil, purified egg
phospholipids, glycerol, and water.
Some evidence effective in
1. RM due to immunologic causes, particularly
elevated natural killer cells or other unidentified
immunologic causes.
2. uRM
3. uRIF ABOUBAKR ELNASHAR
48. In vitro studies:
Intralipid suppress Natural Killer cell cytotoxicity:
decreases the number of natural killer cells.
Administration:
IV infusion in an office setting.
100 mls of Intralipid are mixed with 500 mls NS.
60-90 minutes.
TT start at the start of the IVF cycle
continued monthly should a positive pregnancy test
result until the 24th w of pregnancy.
Side effects
No
ABOUBAKR ELNASHAR
49. Endometrial scratching
When:
cycle preceding the actual treatment cycle.
(Friedler et al., 1993; Barash et al., 2003; Raziel et al., 2007; Zhou et
al., 2008).
7 days prior to the onset of menstruation,
immediately before the start of ovarian
stimulation for IVF tt.
In the follicular phase of the index cycle : no
benefit
(Karimzade et al., 2010; Zhou et al., 2008).
Not on the day of OR:
significantly reduce CPR
(Nastri et al, 2012)
ABOUBAKR ELNASHAR
50. 10. ICSI and PGD
Evidence is lacking: Similar results.
(Pellicer et al, 1999)
Not recommend
(Visenberg, 2012)
SR (Musters et al, 2011):
Miscarriage rates following PGS may be slightly lower
, but
lack of RCTs
invasiveness of ART
relatively good prognosis of women with uRM and
natural conception
: this tt is inappropriate.ABOUBAKR ELNASHAR
52. Investigations
After two or three consecutive miscarriages:
1. Pelvic US (or HSG or Sonohysterography)
2. TSH
3. Brucellosis IGM
4. Antiphospholipid antibodies
5. Factor V Leiden, factor II (prothrombin) gene
mutation and protein S.
6. If the above examinations are normal: karyotype of
the abortus: unbalanced structural chromosomal
abnormality: Parental karyotype
ABOUBAKR ELNASHAR
56. You can get this lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://www.facebook.com/groups/2277
44884091351/
2.Slide share web site
3.elnashar53@hotmail.com
4.My clinic: Elthwara St. Mansura