Recurrent miscarriage is defined as two or more spontaneous abortions before 20 weeks of gestation. The causes are often multifactorial and idiopathic. Common causes include endocrinopathies, genetic factors, infections, inherited thrombophilia, autoimmunity, antiphospholipid antibody syndrome, uterine anomalies, and cervical incompetence. Treatment depends on the underlying cause but may include progesterone supplementation, cerclage procedures, anticoagulation therapy, surgical correction of anomalies, and lifestyle modifications. The prognosis is best when a cause can be identified and treated appropriately.

1. Recurrent miscarriage
By-Monu yadav
Final year mbbs

2. Recurrent miscarriage
• Recurrent miscarriage is defined as the sequence of two or more
spontaneous abortions as documented by either sonography or on
histopathology,before 20 week of gestation.

3. Etiology
• Multifactorial
• Most common cause-idiopathic
• Most common group of cause-endocrinopathies
• Single most common established cause –APLA syndrome

4. Genetic factors
• Most common abnormality –balanced translocation

6. Endocrine
• Poorly controlled diabetes
• Presence of thyroid autoantibodies
• Luteal phase defect
• Pcos

7. Infection
• They can cause sporodic abortion
• Relation to recurrent fetal wastage is inconclusive

8. Inherited thrombophilia
• Cause-protein c resistance,protein c,s and antithrombin 3 deficiency
• Most common- protein c resistance
• It leads to intravascular and placental intervillous thrombosis
• Early and late miscarriage

9. Autoimmunity
• Rejection of early pregnancy in 2nd trimester
• Responsible antibodies –antinuclear antibodies,anti-DNA
antibodies,antiphospolipid antibodies

10. APLA syndrome
• In this antibody present against any of following
• Lupus anticoagulant antibody-most common
• Anti cardiolipin antibody
• Beta 2 microglobulin antibody
• All these leads to thrombosis of artery , venous or placental

11. Effect on pregnancy
• Recurrent miscarriage –inhibition of trophoblast proliferation and
function, release of local inflammatory mediators,spiral artery and
intervillous thrombosis and decidual vasculopathy with fibrinoid
uterus

12. Cont.
• Complete cutoff of blood supply less than 20 week- abortion
• Complete cut off after 20 week- stillbirth
• Incomplete cut off- IUGR, PIH in mother

13. Diagnosis

14. Management
• Non pregnant –warfarin
• Low dose heparin- given in all APLA syndrome cases,as soon as
pregnancy is diagnosed, ideally started before conception
• Low molecular weight heparin- after confirmation of pregnancy in
patient with history of abortion or history of thrombosis .

16. Uterine anomalies
• Congenital or acquired
• Congenital- defect in mullerian duct fusion or resorption (eg.
Unicornuate ,bicornuate ,septate uterus)
• Acquired –intrauterine adhesions, uterine fibroid , endometriosis and
cervical incompetence

17. Defective mullerian fusion
• Abortion occur mostly after 12 week
• Septate uterus >bicornuate
• Investigations- usg and HSG

18. Fibroid
• Leads to recurrent miscarriage,pre term labour and iugr
• Defective implantation of the placenta
• Poorly developed endometrium
• Reduced space for fetus and placenta

19. Cervical incompetence
• Functionally or anatomically loss of retention power of cervix
• Congenital uterine anomalies
• Acquired- following D and C operation, induced abortion by D and E
,vaginal operative delivery through an undilated cervix and
amputation of the cervix or cone biopsy
• Others- multiple gestations,prior preterm birth

20. Findings
• History – repeated midtrimester painless cervical dilation (without
apparent cause) and escape of liquor annii and followed by painless
expulsion of the product of conception
• Internal examination – in interconceptional period bimanual
examination reveals presence of unilateral or bilateral tear

21. Investigation
• Interconceptional period – passage of 6-8 Hegar dialator beyond the
internal os .
• Premenstrual hysterocervicography- funnel shaped shadow
• During pregnancy –(A) clinical – painless cervical shortening and
dilation (B) sonography – short cervix<25 mm (C) Y shaped ,V shaped
,U shaped (D) speculam examination – detection of dilation of
internal os with herniation of the membrane

24. Diagnosis
• History wise- more than or equal to 2 Second trimester painless
abortion
• Usg based- history of one 2nd trimester painless abortion and cervical
length less than or equal to 2.5 cm
• In non pregnant female – hegar no.8 dialator

25. Management
• Cerclage operation
• Shirodkar and Mcdonald operation
• Supplemental progesterone

26. Cerclage operation
• Principle- the procedure reinforce the weak cervix by a
nonabsorbable tape,placed around the cervix at the level of internal
os
• Time- ideal time 12-14 wk or 2 week earlier than the lowest period of
previous wastage as early as 10 week
Can be done upto 24 week
Emergency –when their is bulging of membrane

27. Shirodkar procedure
• Patient is put under gen anaesthesia and placed in lithotomy position
with good exposure of cervix by a posterior vaginal speculum .the lips
of cervix are pulled down by a sponge holding forceps
• A transverse incision is made anteriorly below the base of the bladder
on the vaginal wall and the bladder is pushed up. To expose the level
of the internal os.a vertical incision is made posteriorly on the
cervicovaginal junction

28. Cont
• The non adsorbable suture material is passed submucously with the
help of cervical needle to bring the suture end through the post
incision
• The end of tapes are tied up

30. McDonald’s operation
• Nonabsorbable suture material is placed as a purse string suture as
high as possible at the junction of vaginal epithelium and the smooth
vaginal part of cervix below the level of the bladder
• The suture starts at the ant wall ,take deep bites and it is carried
around the lateral and posterior walls back to the ant wall again
where the two ends of the suture are tied

31. Removal of stitch
• Should be removed at 37th week
• Earlier if labor pain starts or features of abortion appears
• Not cut at time-uterine rupture or cervical tear
• If stitch is cut prior to the onset of labor,it is preferable to cut in ot as
there is increased chance of cord prolapse especially is case of
floating head

32. Contraindications
• Intrauterine infection
• Ruptured membrane
• Presence of vaginal bleeding
• Fetal death or gross congenital anomaly which is not compatible with
life
• Cervical dilation greater than 4 cm.

33. Complication
• Slipping or cutting through the suture
• Chorioamnionitis
• Rupture of membrane
• Abortion/preterm labor
• Cervical laceration during delivery
• Cervical scarring and dystocia requiring cesarean delivery

34. Cases
• A G2P1 female come at 14 week of gestation for routine ANC ,She has
history of previous t2 abortion at 18 wk of gestation,what is your next
step?
• G3P0 female came for routine checkup,has history of 2 t2
abortion,what is next step?
• A G3P2 female of 18 week of gestation with no history of
abortions,on tvs , cervical length is less than 2.5 cm .
• A female with 16 wk pregnancy comes with dilated cervic and bulging
of membrane without membrane rupture.

35. Investigation for recurrent miscarriage
• History
• Blood glucose,TSH,
• Autoimmune antibody – lupus anticoagulant and anticardilipin antibodies
• Serum LH ON D2 /D3 of the cycle
• USG – malformations, fibroid and pcos
• HSG- CERVICAL incompetence, uterine synechiae and uterine
malformations.
• Karyotyping
• Endocervical swab for chalmydia , mycoplasma and bacterial vaginosis

36. Treatment
• Counseling the couple to alleviate and improve psychology.
• Hysteroscopic resection and uterine unification operation
• Chromosomal anomalies –if chromosomal abnormality is
detected,then genetic counseling is undertaken.
Karyotyping
preimplantation genetic counseling
antenatal diagnosis

37. Cont.
• Women with pcos- treated for insulin resistance,hyperinsulinemia
and hyperandrogenemia
Metformin therapy is helpful
• Endocrine dysfunction –correct thyroid disorder and diabetes
• Genital tract infection –treated appropriately following culture
emerical treatment with doxycycline or erythromycin is cost effective

38. During pregnancy
• Reassurance and tender loving care
• Ultrasound – to detect viable pregnancy
• Rest- avoid strenuous activities, intercourse and traveling
• Progesterone therapy – helpful in luteal phase defect and recurrent
miscarriage
Natural micronized progesterone 100 mg daily as vaginal suppository
Started 2 day after ovulation untill 10-12 week of gestation
Immunomodulatory role

39. Cont.
• Antiphospolipid syndrome
• Cerclage operation
• Chromosomal anomalies –antenal diagnosis
• Inherited throbophillia –antithromobitic therapy
heparin(5,000 IU SC twice daily) or LMWH SC once daily upto 34 wk.
• Medical complication –delay the pregnancy
specific management is continued

40. Unexplained
• 40-60% are idiopathic
• Tender loving care and some supportive therapy improves the
pregnancy outcome by 70%