SlideShare a Scribd company logo
Recurrent Pregnancy
       Loss
Definition
• Pregnancy loss is defined as the spontaneous loss
 of pregnancy before the fetus reaches viability (24
 weeks)
• Recurrent pregnancy loss, defined as the loss of
 three or more ( ≥ 3) consecutive pregnancies.
• Primary- No previous full term pregnancy
• Secondary- At least one successful pregnancy
Incidence
– 15-20% of all pregnancies

– 11-13 % in first pregnancy

– 13-17 % after first abortion

– 38 % after two abortions

– 55% after three abortions
Suspected etiologies
      Anatomical factors

        Genetic factors

       Infective agents

       Immune factors

 Antiphospholipid syndrome

Inherited thrombophilic defects

      Endocrine factors

    Epidemiological factors
Anatomical Factors
Uterine Abnormalities

 • CONGENITAL (Mullerian Duct abnormalities)

 • UTERINE NEOPLASMS (Growth)

 • IATROGENIC (Acquired)
How they affect…….

 •Smaller Uterine Cavities
 •Fewer suitable implantation sites
 •Aberrations of vascularisation
 •May be accompanied by cervical
  incompetence
 Lead to both early & later pregnancy
  losses
Septate Uterus
• Most COMMON anomaly 55%
• May be complete/ incomplete/segmental

  25% early abortions
  6.2% late abortions &
  Premature labors
Unicornuate Uterus
 • 20% of anomalies
 • Agenesis or hypoplasia of one Mullerian duct
 • May be alone or accompanied by Rudimentary
   horn
   With presence / absence of cavity
   Communicating / Non communicating
 • Associated Renal anomalies occur in 40% patients
   Ipsilateral to hypoplastic horn
Unicornuate Uterus

• Abortion Rate 51%, Premature labours,
  malpresentations, IUGR, Uterine rupture &
  ectopic pregnancies common
• Cervical encerclage to improve pregnancy
  outcome
• Rudimentary Horn resected to prevent
  dysmenorrhoea, haematometra,ectopic
  pregnancy
Uterus Didelphys

• Least common anomaly -5-7%
• Failure of lateral fusion of uterus &vagina
•  Abortion rate 43%,Premature birth rate 38%
• Resection of Vaginal septum if there is difficulty in
  intercourse / vaginal delivery
• Strassmann Operation not indicated
Bicornuate Uterus

• 10% of anomalies
• Incomplete fusion of Uterine horns at level of
  fundus
• Two separate but communicating endometrial
  cavities
• Abortion rate 32% Preterm labour 21%
• Strassman Metroplasty / Place IUCD in one horn
Arcuate Uterus

•   Near complete resorption of u-v septum
•   Mild concave indentation at fundus
•   Data conflicting Abortion rates ?45% ?13%
•   Treatment expectant
T shaped Uterus
• Diethylstilbestrol treatment for Premature labour
  started 1940 Banned 1970
• 69% female foetuses suffered Uterine anomaly
• T-Shaped uterus, small uterus, constriction rings,
• Cervical hypoplasia, cervical incompetence,
  Anterior Cervical collar, pseudopolyps
• 2 fold increase in abortion rates & 9 fold increase in
  Ectopic pregnancy rates
T SHAPED UTERUS- INFECTION
       MALA ARORA            15
Uterine Neoplasms
• Endometrial Polyps
PERIOSTEAL ENDOMETRIAL POLYP
3/24/2013     MALA ARORA        17
Leiomyomas (Fibroids) most
  common…. 20-50% of
    reproductive women
• Preconception myomectomy to improve
  reproductive outcome can be considered on an
  individual basis
• It is likely to have a place only in women who
  have recurrent pregnancy loss,
  – large submucosal fibroids, and no other
    identifiable cause for recurrent miscarriage
             Ouyang DW, Obstet Gynecol Clin North Am. 2006
Iatrogenic…


Intrauterine adhesions ,“Asherman’s Syndrome”
• Lead to Poor implantation,
• Decreased blood supply ,
• infection
Abortion rates 40% Preterm labour 23%

Management :-Hysteroscopic excision of
 adhesions
HYSTEROSCOPIC CORRECTION

• All of the above have a
  good pregnancy rate
  post hysteroscopic
  correction
• Except ashermans
  syndrome
Incompetent Cervix
• Funneling of >25% cervical length and/or
  <2.5 cms cervical length before 24 weeks of
  pregnancy
• USG follow up weekly in cases of prior 2nd
  trimester loss
• Cervical cerclage reduces the rate of preterm
  birth
                                      Carp et al, 2007

• Emergency cerclage: beneficial if no
  infection or uterine contractions
Genetic Etiology
• Chromosomal 3.5%-5%
 – Fetal chromosomal abnormalities
 – Parental balanced chromosomal rearrangement

• Single gene disorders
 – Alpha thalassemia major
 – Thrombophilia
 – X linked dominant disorders
Risk Factors for genetic abnormalities
    • Gestational age
       Higher in early gestation
           90% in anembryonic preg/Blighted ova
           50% at 8-11wk
           30% at 16-19 wk
           6-12% >20wk
Risk Factors for genetic abnormalities

 Advanced maternal age
      Affects ovarian function, giving rise to a decline
       in the number of good quality oocytes, resulting
       in chromosomally abnormal conceptions that
       rarely develop further.
      RM risk -75% in women >45years

 Previous number of miscarriages

                                                            25
Fetal chromosomal abnormality in only 25-
   32% of product of conception.
 This may be due to abnormalities in the egg,
  sperm or both.
 The most common chromosomal defects are
  Trisomy, Monosomy, Polyploidy
  Sperm aneuploidy (13,18,21,X,Y ) directly
   influences the rate of aneuploidy in the conceptus
   (Carrell et al 2003)
• Parental chromosomal abnormality (Balanced
 chromosomal rearrangements)

 –General population       6 in 1000(0.6%)

 –RM                       4.1-11%
*3-5% of couples with RM are carriers of
 balanced chromosomal rearrangements
Parental Chromosomal Abnormalities

     –Translocation (commonest) (1in 500)
      • Reciprocal [50%]

      • Robertsonian [24%]

     –Mosaicism for a numeric aberration [12%]

     –Inversion


                                                 29
Translocation
Translocation is exchange of chromosomal segments
between two, non-homologous chromosomes.
Translocations
Two major types

Reciprocal translocation- two non-
homologous chromosomes exchange
information

Robertsonian translocation -two non-
homologous acrocentric
chromosomes break at the centromere
and the long arms fuse. The short
arms are often lost.                   Source- Emery’s book of
                                       principles of Medical Genetics
• Karyotype of the abortus (POC)
( fetal/placental tissue)


• Peripheral blood Karyotyping of the parents in
  all couples with RM




                                               32
 No definite recommendations for routinely
  obtaining abortus karyotype (ACOG 2001)
 Karyotype analysis of abortus tissue for couples with a
 subsequent second or third pregnancy loss       (Hogge, et
 al 2003)

 If abortus is aneuploid, maternal cause is excluded
 (ACOG, 2001)

 If POC karyotype not possible, do parental karyotype
Direct parental karyotype is more cost
 effective.
No need for first abortion.
POC abnormal karyotype requires parental
 karyotype
Single Gene Disorders in RM
•   Second and 3rd trimester losses
•   Alpha Thalassemia
•   Myotonic dystrophy
•   X linked Dominant disorder
    –   Incontinentia Pigmenti
    –   Chondrodysplasia punctata
    –   Focal dermal hypoplasia of Goltz
    –   Rett Syndrome
    –   Aicardi Syndrome



                                           35
Management?
Role of Infections
Its time to say goodbye
              to
     TORCH tests…….

 Cochrane Review has
 categorically proven in
multiple meta-analysis that
 none of the “TORCH”
 group of infections are
      responsible for
     RECURRENT
    SPONTANEOUS
      ABORTIONS
So which infections, if any are
    responsible for RM?
 Female
 • Viral infections ? ?
    – Coxasackie B
    – Parovo-virus B
 • Bacterial infections
    – Bacterial Vaginosis
    – Tuberculosis
    – Chlamydia trachomatis
 Male factors:
 • Semen infections can cause
   anueploidy and be the reason of RSA
Bacterial Vaginosis
• Commonest cause of vaginitis
• Amsel's criteria for diagnosis of
  BV
                                              Bacterial
   – Thin, homogeneous discharge              Vaginosis
   – Release of an amine                        50%
     (putrescine, cadaverine, &
     trimethylamine) or fishy odor      Trichomona Candida
     on addition of KOH is to           s vaginalis albicans
     vaginal discharge                  25%           25%
   – "Clue cells" (Vaginal epithelial
     cells coated with coccobacilli)
   – Vaginal pH > 4.5
• Nugent score: Gram Stain of
                    vaginal swab
BV and RPL
• BV one of the most frequently founded cause
  of spontaneous abortions and prematurity birth
• Diagnostics is easy and not expensive
• High vaginal pH is diagnostic
• Treatment is simple using
  Metronidazole/Clindamycin
1. Damianov L, Damianova V. Akush Ginekol (Sofiia). 2004;43 Suppl 2:26-7.
2. Mania-Pramanik J, Kerkar SC, et al. J Clin Lab Anal. 2008;22(5):375-9.
3. Li TC, Makris M, et al. Hum Reprod Update. 2002 Sep-Oct;8(5):463-81
IMMUNOLOGIC FACTORS

      Autoimmune                       Alloimmune
   (directed to self)          (directed to foreign)
  tissues/cells)

-Systemic Lupus Erythmatosus      An abnormalmaternal
-Antiphospholipid Syndrome        immune response to
                               fetal or placental
  antigen.
Antiphospholipid Antibody Syndrome
                and
     Recurrent Pregnancy Loss




                                45
Incidence
• About 1% of women have recurrent pregnancy
  loss.
• Antiphospholipid antibodies are found in about
  2% of a Caucasian population. Not studied in a
  general Asian / Indian population
• 5 – 20% of women with recurrent pregnancy
  loss have antiphospholipid antibodies

                                               46
Statistical Distribution
• Prevalence of antiphospholipid antibodies in
  various categories of women was studied
Women with 3 or more   Women with normal    Women who have not
  early fetal losses   pregnancy outcome   been pregnant (includes
                                             women not desiring
                                           pregnancy and infertile
                                                  women)


       16%                   7%                     3%


                                                                     47
Pitfalls in diagnosis of APS
• Usually an overdiagnosed syndrome
• Not meeting clinical and the strict laboratory
  criteria
• Not repeating the laboratory test at 6 weeks
• Non standardized ELISA for ACL antibodies
• Interlaboratory variations for phospholipid
  dependent coagulation tests used for screening
  for lupus anticoagulant
                                               49
False results in APS
• Improperly collected and processed samples
• Temporal and trimester wise fluctuations
• VDRL positive patients who may or may not
  have syphilis
• General infections and inflammations
• Coagulopathies and anticoagulant medication
  users (including aspirin, heparin)


                                                50
Management
Women with APS without Women with APS with
a history of thrombotic history of thrombotic
events                  events (past or present)
(most women with RPL)

Prophylactic therapies such Full anticoagulation with
as aspirin, heparin in      heparin (or warfarin) in
pregnancy and 6 to 8        pregnancy and postpartum
weeks postpartum


                                                    51
Aspirin alone v/s Aspirin + Heparin

• Recent meta analysis shows that the
  combination of Aspirin + Heparin is better
  than Aspirin alone in achieving live births in
  women with recurrent pregnancy loss and
  antiphospholipid antibodies
                       Mak A et al, Rheumatology (Oxford) 2010




                                                            52
Is Heparin + Aspirin really better?
  • The metaanalysis was based on data from five trials
    involving 334 patients across non uniform care
    platforms
  • Overall live birth rates were 74.27 and 55.83% in the
    combination and aspirin alone groups
     – RR 1.301; 95% CI 1.040, 1.629
     – Number needed to treat is 5.6
  • There is no placebo group for comparison
  • Another metaanalysis showed that LMW heparin +
    Asprin does not significantly improve birth rates. The
    benefits is present only with unfractionated heparin
                                       Zikas PD et al, Obstet Gynecol 2010
                                                                        53
Clinical Tips for using Heparin
• There is controversy as to whether LMW Heparin
  is effective in preventing recurrent pregnancy loss
• Consider costs, convenience and compliance
  before initiating therapy
• Therapy should be started when fetal cardiac
  activity is demonstrated and continued throughout
  pregnancy and postpartum
• Heparin in prophylactic doses needs to be stopped
  for about 24 hours around the time of labor and
  delivery
                                                    54
Clinical Tips for using Heparin
• Heparin in prophylactic doses can not be
  monitored and does not require monitoring by
  coagulation parameters
• Do a platelet count at 3 days, 1 week and
  bimonthly when the patient is on heparin
• Standard doses
  – Unfractionated heparin – 5000 units sc bd
  – Enoxaparin – 40 mg subQ daily or in two doses

                                                    55
Full Anticoagulation : Practical
• Preconception : Warfarin
• Switch to Heparin when fetal cardiac activity is
  demonstrated
• Warfarin should be considered in the second
  trimester
• Switch back to Heparin at 34 to 36 weeks
• After delivery : Warfarin

                                                     56
What not to do for APS
• Steroid therapy should be avoided for APS
  because it significantly increases morbidity
  (hypertension, diabetes, preterm births)
  without any demonstrable benefit
• Immunoglobulin therapy is experimental and
  not for clinical use at present

                                                 57
Alloimmune mechanism
Theory: Normally pregnancy(foreign tissue graft) is
 tolerated by the maternal immune system through
 formation of antigen blocking antibodies.

Felt that in couples that share similar types of HLA, there
  is inadequate formation of blocking antibodies in the
  maternal environment.

Therefore the maternal immune system mounts an
  immune response to the implanting pregnancy and a
  spontaneous abortion occurs.

Multiple recent studies have not confirmed this.
ALLOIMMUNITY

DIAGNOSIS
• HLA crossmatching
  Husband’s lymphocytes + wife’s serum

  TREATMENT
• Transfusion of husband’s lymphocytes
   Pure suspension of husband’s lymphocytes
   [ 300ml of blood = 10ml of suspension ]
   Inject 5ml IV, 1 ml subcu and 1ml intradermal
Immunologic Factors -Treatment
• Immunostimulating Therapies-Leukocyte
  Immunization

• Immunosuppressive Therapies
Intravenous immunoglobulin
• theory
    – an overzealous immune reactivity to their implanting fetus

• Mechanism
    – decreased autoantibody production and increased
      autoantibody clearance, T-cell and Fc receptor regulation,
      complement inactivation, enhanced T-cell suppressor function,
      decreased T-cell adhesion to the extracellular matrix, and
      downregulation of Th1 cyokine synthesis

• disadvantage
    – expensive, invasive, and time-consuming, requiring multiple
      intravenous infusions over the course of pregnancy

• side effects
    – nausea, headache, myalgias, hypotension, anaphylaxis
Progesterone
• Mechanism
  – inhibits Th1 immunity
  – shift from Th1-to Th2 type responses

• This benefit of progesterone could be explained by
   administered
    its immmunomodulatory actions in inducing a
    – intramuscularly
  pregnancy-protective shift from pro-inflammatory
    – intravaginally
  Th-1 •cytokine responses to a more favourable anti-
          may increase local, intrauterine concentration
          inflammatory Th-2 cytokine response
        • averting any adverse systemic side effects
Inherited thrombophilic defects
        (Hypercoagulable state)


Factor V Leiden mutation                               protein C deficiency


                              Protein S deficiency


Antithrombin III deficiency                          Hyperhomocysteinaemia


                              Prothrombin gene
                                  mutation
THROMBOPHILIA
• Thrombosis on maternal side of the placenta 
  impair placental perfusion
   – Late fetal loss, IUGR, abruption, or PIH
• Relationship with early loss is less clear
   – large and contradictory literature
   – May be restricted to specific defects not
     completely defined, or presence of multiple defects
Inherited Thrombophilias
Antithrombotic Therapy
• The combined use of low-dose aspirin (75-80mg/dl)
  and subcutaneous unfractionated heparin (5000unit
  twice daily)
ENDOCRINE FACTORS

• Mild endocrine diseases are likely not causes
  for recurrent abortion.
1)Thyroid disease
   – Poorly controlled hypo- or hyper-thyroidism
      • Infertility & pregnancy loss
   – ↑ thyroid antibody, even if euthyroid.
      • No strong evidence
2)Diabetes mellitus
  – Poorly controlled (↑Blood glucose &
    HbA1c levels in 1st trimester  risk for loss.
  – Miscarriage risk rises with the level of
    HbA1c
  – Well-controlled : No ↑ risk.
• 3) Polycystic Ovarian Syndrome
• Polycystic ovary morphology itself does not predict an
  increased risk of future pregnancy loss among ovulatory
  women with a history of recurrent miscarriage who conceive
  spontaneously(RCOG)
• Hyperinsulinemia & ↑ level of Plasminogen Activator Inhibitor
  activity – implicated as the proximate cause of incidence of
  loss(30-50%)among PCOS women
                                 (Br J Obst Gynecol,1993)
• METFORMIN treatment can reduce or eliminate risk of
  miscarriage in PCOS women
              (Fertility Sterility,2001;J Clin Endocrino 2002)
4)Luteal phase defect
  – Progesterone is essential for implantation
    and maintenance of pregnancy
     • A defect in Corpus luteum impaired
       progesterone production.
     • However, LPD cannot be diagnosed
       during pregnancy; a consistently short
       luteal phase duration is the most reliable
       diagnostic criterion.
TREATMENT

– luteal-phase support with progesterone
– There is insufficient evidence to evaluate the effect
  of progesterone supplementation in pregnancy to
  prevent a miscarriage (RCOG)

– However newer evidences is coming up as large
  multicentre study PROMISE is currently on the
  way.
5)Hyperprolactinemia
• There is insufficient evidence to assess the effect of
  hyperprolactinaemia as a risk factor for recurrent
  miscarriage.
              RCOG Green-top Guideline No. 17
                                     April 2011
Epidemiologic factors
• Cigarette smoking has been suggested to have an
  adverse
• effect on trophoblastic function and is linked to an
  increased risk of sporadic pregnancy loss.
• Obesity has also been shown to be associated
  with an increased risk of RM in women who
  conceive naturally.
• Other lifestyle habits such as cocaine use, alcohol
  consumption, and increased caffeine consumption
• (>3 cups of coffee) have been associated with risk
  of miscarriage.
Unexplained…
• No apparent causative factor is identified in
  50% to 75% of couples with RM.
• It is important to emphasize to patients with
  unexplained RM that the chance for a future
  successful pregnancy can exceed 50%–60%
  depending on maternal age and parity.
Take home message…
Investigations

                     TSH

                   HbA1C

            Anti thyroid Antibody

               Anatomy screen

                 APS screen

                Vaginal swab

                PCOD screen

      Cytogenetic examination of abortus

                 Karyotyping

            Thrombophilias screen
Evidence based


           Progesterone

         Weight reduction

         Aspirin + LMWH

             Cerclage

           Clindamycin

             Thyroxin

            IVF + PGD
Eminence based


         Spiramycin

          Steroids

      Immunoglobulin's

            hCG
Unexplained
            RM


            Repeated
            scanning




Reinforcement          Reassurance
Unexplained
   RM
Recurrent pregnancy loss
Recurrent pregnancy loss

More Related Content

What's hot

MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANI
MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANIMANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANI
MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANI
DR SHASHWAT JANI
 
Role of tubal surgery in era of ivf
Role of tubal surgery in era of ivfRole of tubal surgery in era of ivf
Role of tubal surgery in era of ivf
Sanjay Makwana
 
Advanced reproductive age and fertility by Dr. Gayathiri
Advanced reproductive age and fertility by Dr. GayathiriAdvanced reproductive age and fertility by Dr. Gayathiri
Advanced reproductive age and fertility by Dr. Gayathiri
Morris Jawahar
 
Recurrent pregnancy loss: interactive session
Recurrent pregnancy loss: interactive sessionRecurrent pregnancy loss: interactive session
Recurrent pregnancy loss: interactive session
Aboubakr Elnashar
 
Uterus Transplantation Utx (obstetric and gynecology)
Uterus Transplantation Utx (obstetric and gynecology) Uterus Transplantation Utx (obstetric and gynecology)
Uterus Transplantation Utx (obstetric and gynecology)
D.A.B.M
 
Recurrent pregnancy loss
Recurrent pregnancy lossRecurrent pregnancy loss
Recurrent pregnancy loss
vandana bansal
 
Step wise pelvic devascularisation
Step wise pelvic devascularisationStep wise pelvic devascularisation
Step wise pelvic devascularisation
Niranjan Chavan
 
Epidemiology of Recurrent Pregnancy Loss
Epidemiology of Recurrent Pregnancy LossEpidemiology of Recurrent Pregnancy Loss
Epidemiology of Recurrent Pregnancy Loss
Kirtan Vyas
 
Induction of ovulation
Induction of ovulationInduction of ovulation
Induction of ovulation
muhammad al hennawy
 
PCOS - Ovulation Induction 1 - Dr Bharati Dhorepatil
PCOS - Ovulation Induction 1 - Dr Bharati DhorepatilPCOS - Ovulation Induction 1 - Dr Bharati Dhorepatil
PCOS - Ovulation Induction 1 - Dr Bharati Dhorepatil
Bharati Dhorepatil
 
Luteal Phase Insufficiency.pptx
Luteal Phase Insufficiency.pptxLuteal Phase Insufficiency.pptx
Luteal Phase Insufficiency.pptx
Raju Nair
 
Ivf stimulation protocols by Dr. Mahalakshmi Saravanan
Ivf stimulation protocols by Dr. Mahalakshmi SaravananIvf stimulation protocols by Dr. Mahalakshmi Saravanan
Ivf stimulation protocols by Dr. Mahalakshmi Saravanan
Morris Jawahar
 
Overview of IUGR FGR
Overview of IUGR FGROverview of IUGR FGR
Overview of IUGR FGR
Dr.Laxmi Agrawal Shrikhande
 
Role of progestogens in obstetrics and gynecology
Role of progestogens in obstetrics and gynecologyRole of progestogens in obstetrics and gynecology
Role of progestogens in obstetrics and gynecology
Ahmad Saber
 
Recurrent pregnancy loss
Recurrent pregnancy lossRecurrent pregnancy loss
Recurrent pregnancy loss
Ahmed Elbohoty
 
Micronised progesterone in preterm labour
Micronised progesterone in preterm labourMicronised progesterone in preterm labour
Micronised progesterone in preterm labour
Dr Meenakshi Sharma
 
Management of Female Infertility
Management of Female InfertilityManagement of Female Infertility
Management of Female Infertility
Sathish Kumar
 
Selective progesteron reuptake modualtors
Selective progesteron reuptake modualtorsSelective progesteron reuptake modualtors
Selective progesteron reuptake modualtors
Dr. Rupendra Bharti
 
PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015
PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015
PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015
Aboubakr Elnashar
 
Recurrent Pregnancy Loss Sharing Personal Experience (10 years)
Recurrent Pregnancy Loss Sharing Personal Experience (10 years)    Recurrent Pregnancy Loss Sharing Personal Experience (10 years)
Recurrent Pregnancy Loss Sharing Personal Experience (10 years)
Lifecare Centre
 

What's hot (20)

MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANI
MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANIMANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANI
MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANI
 
Role of tubal surgery in era of ivf
Role of tubal surgery in era of ivfRole of tubal surgery in era of ivf
Role of tubal surgery in era of ivf
 
Advanced reproductive age and fertility by Dr. Gayathiri
Advanced reproductive age and fertility by Dr. GayathiriAdvanced reproductive age and fertility by Dr. Gayathiri
Advanced reproductive age and fertility by Dr. Gayathiri
 
Recurrent pregnancy loss: interactive session
Recurrent pregnancy loss: interactive sessionRecurrent pregnancy loss: interactive session
Recurrent pregnancy loss: interactive session
 
Uterus Transplantation Utx (obstetric and gynecology)
Uterus Transplantation Utx (obstetric and gynecology) Uterus Transplantation Utx (obstetric and gynecology)
Uterus Transplantation Utx (obstetric and gynecology)
 
Recurrent pregnancy loss
Recurrent pregnancy lossRecurrent pregnancy loss
Recurrent pregnancy loss
 
Step wise pelvic devascularisation
Step wise pelvic devascularisationStep wise pelvic devascularisation
Step wise pelvic devascularisation
 
Epidemiology of Recurrent Pregnancy Loss
Epidemiology of Recurrent Pregnancy LossEpidemiology of Recurrent Pregnancy Loss
Epidemiology of Recurrent Pregnancy Loss
 
Induction of ovulation
Induction of ovulationInduction of ovulation
Induction of ovulation
 
PCOS - Ovulation Induction 1 - Dr Bharati Dhorepatil
PCOS - Ovulation Induction 1 - Dr Bharati DhorepatilPCOS - Ovulation Induction 1 - Dr Bharati Dhorepatil
PCOS - Ovulation Induction 1 - Dr Bharati Dhorepatil
 
Luteal Phase Insufficiency.pptx
Luteal Phase Insufficiency.pptxLuteal Phase Insufficiency.pptx
Luteal Phase Insufficiency.pptx
 
Ivf stimulation protocols by Dr. Mahalakshmi Saravanan
Ivf stimulation protocols by Dr. Mahalakshmi SaravananIvf stimulation protocols by Dr. Mahalakshmi Saravanan
Ivf stimulation protocols by Dr. Mahalakshmi Saravanan
 
Overview of IUGR FGR
Overview of IUGR FGROverview of IUGR FGR
Overview of IUGR FGR
 
Role of progestogens in obstetrics and gynecology
Role of progestogens in obstetrics and gynecologyRole of progestogens in obstetrics and gynecology
Role of progestogens in obstetrics and gynecology
 
Recurrent pregnancy loss
Recurrent pregnancy lossRecurrent pregnancy loss
Recurrent pregnancy loss
 
Micronised progesterone in preterm labour
Micronised progesterone in preterm labourMicronised progesterone in preterm labour
Micronised progesterone in preterm labour
 
Management of Female Infertility
Management of Female InfertilityManagement of Female Infertility
Management of Female Infertility
 
Selective progesteron reuptake modualtors
Selective progesteron reuptake modualtorsSelective progesteron reuptake modualtors
Selective progesteron reuptake modualtors
 
PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015
PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015
PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015
 
Recurrent Pregnancy Loss Sharing Personal Experience (10 years)
Recurrent Pregnancy Loss Sharing Personal Experience (10 years)    Recurrent Pregnancy Loss Sharing Personal Experience (10 years)
Recurrent Pregnancy Loss Sharing Personal Experience (10 years)
 

Viewers also liked

recurrent pregnancy loss
recurrent pregnancy lossrecurrent pregnancy loss
recurrent pregnancy loss
Kamel Ibrahim
 
An update on recurrent pregnancy loss 2015
An update on  recurrent pregnancy loss 2015An update on  recurrent pregnancy loss 2015
An update on recurrent pregnancy loss 2015
Lifecare Centre
 
Recurrent pregnancy loss
Recurrent pregnancy lossRecurrent pregnancy loss
Recurrent pregnancy loss
Priya Bhave.
 
Multiple pregnancy
Multiple pregnancyMultiple pregnancy
Multiple pregnancy
Fahad Zakwan
 
GnRH costeffectiveness
GnRH costeffectivenessGnRH costeffectiveness
GnRH costeffectiveness
Hesham Al-Inany
 
Balloon technique for hysteroscopic correction of a complete septate uterus.
Balloon technique for hysteroscopic correction of a complete septate uterus.Balloon technique for hysteroscopic correction of a complete septate uterus.
Balloon technique for hysteroscopic correction of a complete septate uterus.
Asha Reddy
 
P 424
P 424P 424
Ethics in ART
Ethics in ARTEthics in ART
Ethics in ART
Hesham Al-Inany
 
Implantation Failure in IVF
Implantation Failure in IVFImplantation Failure in IVF
N acetyl cysteine
N acetyl cysteineN acetyl cysteine
N acetyl cysteine
Hesham Al-Inany
 
Recurrent pregnancy loss
Recurrent pregnancy loss Recurrent pregnancy loss
Recurrent pregnancy loss
drmcbansal
 
Septum uterusa - je li resekcija opravdana; Septate uterus - is resection jus...
Septum uterusa - je li resekcija opravdana; Septate uterus - is resection jus...Septum uterusa - je li resekcija opravdana; Septate uterus - is resection jus...
Septum uterusa - je li resekcija opravdana; Septate uterus - is resection jus...
Beta Plus
 
Early pregnancy
Early pregnancyEarly pregnancy
Early pregnancy
airwave12
 
Stem cells in gynecology
Stem cells in gynecologyStem cells in gynecology
Stem cells in gynecology
Hesham Al-Inany
 
Fertility Europe policy statements 2016
Fertility Europe policy statements 2016Fertility Europe policy statements 2016
Fertility Europe policy statements 2016
Asociatia SOS Infertilitatea - www.vremcopii.ro
 
Rpl
RplRpl
Repeated Pregnancy Loss in First Trimester
Repeated Pregnancy Loss in First TrimesterRepeated Pregnancy Loss in First Trimester
Repeated Pregnancy Loss in First Trimester
Sujoy Dasgupta
 
Twins after IVF : revisited
Twins after IVF : revisitedTwins after IVF : revisited
Twins after IVF : revisited
Hesham Al-Inany
 
Repeated Implantation failure
Repeated Implantation failureRepeated Implantation failure
Repeated Implantation failure
Ahmad Saber
 
Implantation factors
Implantation factorsImplantation factors
Implantation factors
Michael M
 

Viewers also liked (20)

recurrent pregnancy loss
recurrent pregnancy lossrecurrent pregnancy loss
recurrent pregnancy loss
 
An update on recurrent pregnancy loss 2015
An update on  recurrent pregnancy loss 2015An update on  recurrent pregnancy loss 2015
An update on recurrent pregnancy loss 2015
 
Recurrent pregnancy loss
Recurrent pregnancy lossRecurrent pregnancy loss
Recurrent pregnancy loss
 
Multiple pregnancy
Multiple pregnancyMultiple pregnancy
Multiple pregnancy
 
GnRH costeffectiveness
GnRH costeffectivenessGnRH costeffectiveness
GnRH costeffectiveness
 
Balloon technique for hysteroscopic correction of a complete septate uterus.
Balloon technique for hysteroscopic correction of a complete septate uterus.Balloon technique for hysteroscopic correction of a complete septate uterus.
Balloon technique for hysteroscopic correction of a complete septate uterus.
 
P 424
P 424P 424
P 424
 
Ethics in ART
Ethics in ARTEthics in ART
Ethics in ART
 
Implantation Failure in IVF
Implantation Failure in IVFImplantation Failure in IVF
Implantation Failure in IVF
 
N acetyl cysteine
N acetyl cysteineN acetyl cysteine
N acetyl cysteine
 
Recurrent pregnancy loss
Recurrent pregnancy loss Recurrent pregnancy loss
Recurrent pregnancy loss
 
Septum uterusa - je li resekcija opravdana; Septate uterus - is resection jus...
Septum uterusa - je li resekcija opravdana; Septate uterus - is resection jus...Septum uterusa - je li resekcija opravdana; Septate uterus - is resection jus...
Septum uterusa - je li resekcija opravdana; Septate uterus - is resection jus...
 
Early pregnancy
Early pregnancyEarly pregnancy
Early pregnancy
 
Stem cells in gynecology
Stem cells in gynecologyStem cells in gynecology
Stem cells in gynecology
 
Fertility Europe policy statements 2016
Fertility Europe policy statements 2016Fertility Europe policy statements 2016
Fertility Europe policy statements 2016
 
Rpl
RplRpl
Rpl
 
Repeated Pregnancy Loss in First Trimester
Repeated Pregnancy Loss in First TrimesterRepeated Pregnancy Loss in First Trimester
Repeated Pregnancy Loss in First Trimester
 
Twins after IVF : revisited
Twins after IVF : revisitedTwins after IVF : revisited
Twins after IVF : revisited
 
Repeated Implantation failure
Repeated Implantation failureRepeated Implantation failure
Repeated Implantation failure
 
Implantation factors
Implantation factorsImplantation factors
Implantation factors
 

Similar to Recurrent pregnancy loss

Cervical precancerous lesions and cervical cancer
Cervical precancerous lesions and cervical cancerCervical precancerous lesions and cervical cancer
Cervical precancerous lesions and cervical cancer
Marmara University School of Medicine
 
MSc Embryo implantation lecture
MSc Embryo implantation lectureMSc Embryo implantation lecture
MSc Embryo implantation lecture
Bolarinde Ola MB BS, FWACS, FRCOG, MD.
 
Impact Of Genetic Testing For RPL Couples
Impact Of Genetic Testing For RPL CouplesImpact Of Genetic Testing For RPL Couples
Impact Of Genetic Testing For RPL Couples
CONSULTANT IN OBGYN, ODISHA ,INDIA
 
From down syndrome screening to nipt
From down syndrome screening to niptFrom down syndrome screening to nipt
From down syndrome screening to nipt
PathKind Labs
 
Miscarriages,,!!!
Miscarriages,,!!!Miscarriages,,!!!
Miscarriages,,!!!
Sarah Safdar
 
Infertility.pptx
Infertility.pptxInfertility.pptx
Infertility.pptx
Prajesh Jadhav
 
prenatal diagnosis.ppt..pptx
prenatal diagnosis.ppt..pptxprenatal diagnosis.ppt..pptx
prenatal diagnosis.ppt..pptx
MMridhunaManoharan
 
reccurent miscarriages.ppt
reccurent miscarriages.pptreccurent miscarriages.ppt
reccurent miscarriages.ppt
ZunairaKhalid20
 
Overview of Recurrent Pregnancy Loss
Overview of Recurrent Pregnancy LossOverview of Recurrent Pregnancy Loss
Overview of Recurrent Pregnancy Loss
Dr.Laxmi Agrawal Shrikhande
 
Stillbirth
StillbirthStillbirth
ABORTION.ppt
ABORTION.pptABORTION.ppt
ABORTION.ppt
HansarKemal1
 
'GENETICS OF MALE & FEMALE INFERTILITY.pptx
'GENETICS OF MALE & FEMALE INFERTILITY.pptx'GENETICS OF MALE & FEMALE INFERTILITY.pptx
'GENETICS OF MALE & FEMALE INFERTILITY.pptx
Rahul Sen
 
37233502 amniocentesis-and-cvs
37233502 amniocentesis-and-cvs37233502 amniocentesis-and-cvs
37233502 amniocentesis-and-cvs
scopulovic
 
Subfertility
SubfertilitySubfertility
Subfertility
Jwan Abdullah
 
Familial gynacological malignancy
Familial gynacological malignancyFamilial gynacological malignancy
Familial gynacological malignancy
Prashanth Varatharasan
 
Infertility ppt
Infertility pptInfertility ppt
Infertility ppt
KaveriS14
 
Mullerian anomalies
Mullerian anomaliesMullerian anomalies
Mullerian anomalies
Dr ABU SURAIH SAKHRI
 
Dagan wells (1)
Dagan wells (1)Dagan wells (1)
Dagan wells (1)
t7260678
 
Dagan wells
Dagan wellsDagan wells
Dagan wells
t7260678
 
Undescended testis
Undescended testisUndescended testis
Undescended testis
GAURAV NAHAR
 

Similar to Recurrent pregnancy loss (20)

Cervical precancerous lesions and cervical cancer
Cervical precancerous lesions and cervical cancerCervical precancerous lesions and cervical cancer
Cervical precancerous lesions and cervical cancer
 
MSc Embryo implantation lecture
MSc Embryo implantation lectureMSc Embryo implantation lecture
MSc Embryo implantation lecture
 
Impact Of Genetic Testing For RPL Couples
Impact Of Genetic Testing For RPL CouplesImpact Of Genetic Testing For RPL Couples
Impact Of Genetic Testing For RPL Couples
 
From down syndrome screening to nipt
From down syndrome screening to niptFrom down syndrome screening to nipt
From down syndrome screening to nipt
 
Miscarriages,,!!!
Miscarriages,,!!!Miscarriages,,!!!
Miscarriages,,!!!
 
Infertility.pptx
Infertility.pptxInfertility.pptx
Infertility.pptx
 
prenatal diagnosis.ppt..pptx
prenatal diagnosis.ppt..pptxprenatal diagnosis.ppt..pptx
prenatal diagnosis.ppt..pptx
 
reccurent miscarriages.ppt
reccurent miscarriages.pptreccurent miscarriages.ppt
reccurent miscarriages.ppt
 
Overview of Recurrent Pregnancy Loss
Overview of Recurrent Pregnancy LossOverview of Recurrent Pregnancy Loss
Overview of Recurrent Pregnancy Loss
 
Stillbirth
StillbirthStillbirth
Stillbirth
 
ABORTION.ppt
ABORTION.pptABORTION.ppt
ABORTION.ppt
 
'GENETICS OF MALE & FEMALE INFERTILITY.pptx
'GENETICS OF MALE & FEMALE INFERTILITY.pptx'GENETICS OF MALE & FEMALE INFERTILITY.pptx
'GENETICS OF MALE & FEMALE INFERTILITY.pptx
 
37233502 amniocentesis-and-cvs
37233502 amniocentesis-and-cvs37233502 amniocentesis-and-cvs
37233502 amniocentesis-and-cvs
 
Subfertility
SubfertilitySubfertility
Subfertility
 
Familial gynacological malignancy
Familial gynacological malignancyFamilial gynacological malignancy
Familial gynacological malignancy
 
Infertility ppt
Infertility pptInfertility ppt
Infertility ppt
 
Mullerian anomalies
Mullerian anomaliesMullerian anomalies
Mullerian anomalies
 
Dagan wells (1)
Dagan wells (1)Dagan wells (1)
Dagan wells (1)
 
Dagan wells
Dagan wellsDagan wells
Dagan wells
 
Undescended testis
Undescended testisUndescended testis
Undescended testis
 

More from faheta

Time between decision to admit and ICU arrival
Time between decision to admit and ICU arrivalTime between decision to admit and ICU arrival
Time between decision to admit and ICU arrival
faheta
 
Progesterone in preterm birth
Progesterone in preterm birthProgesterone in preterm birth
Progesterone in preterm birth
faheta
 
How to read a paper
How to read a paperHow to read a paper
How to read a paper
faheta
 
Prevention of GIT bleeding in the icu
Prevention of GIT bleeding in the icuPrevention of GIT bleeding in the icu
Prevention of GIT bleeding in the icu
faheta
 
Obstetric emergencies in ICU
Obstetric emergencies in ICUObstetric emergencies in ICU
Obstetric emergencies in ICU
faheta
 
VAP bundle compliance in ICU - Clinical Audit
VAP bundle compliance in ICU - Clinical AuditVAP bundle compliance in ICU - Clinical Audit
VAP bundle compliance in ICU - Clinical Audit
faheta
 
The impact of abbreviations on patient safety jc
The impact of abbreviations on patient safety jcThe impact of abbreviations on patient safety jc
The impact of abbreviations on patient safety jc
faheta
 
Quality Promotion
Quality PromotionQuality Promotion
Quality Promotion
faheta
 
Clinical audit project
Clinical audit projectClinical audit project
Clinical audit project
faheta
 
Clinical audit presentation
Clinical audit presentationClinical audit presentation
Clinical audit presentation
faheta
 
Towards better documentations
Towards better documentationsTowards better documentations
Towards better documentations
faheta
 
Clinical audit
Clinical audit Clinical audit
Clinical audit
faheta
 
Novel Coronavirus spotlight
Novel Coronavirus spotlightNovel Coronavirus spotlight
Novel Coronavirus spotlight
faheta
 

More from faheta (13)

Time between decision to admit and ICU arrival
Time between decision to admit and ICU arrivalTime between decision to admit and ICU arrival
Time between decision to admit and ICU arrival
 
Progesterone in preterm birth
Progesterone in preterm birthProgesterone in preterm birth
Progesterone in preterm birth
 
How to read a paper
How to read a paperHow to read a paper
How to read a paper
 
Prevention of GIT bleeding in the icu
Prevention of GIT bleeding in the icuPrevention of GIT bleeding in the icu
Prevention of GIT bleeding in the icu
 
Obstetric emergencies in ICU
Obstetric emergencies in ICUObstetric emergencies in ICU
Obstetric emergencies in ICU
 
VAP bundle compliance in ICU - Clinical Audit
VAP bundle compliance in ICU - Clinical AuditVAP bundle compliance in ICU - Clinical Audit
VAP bundle compliance in ICU - Clinical Audit
 
The impact of abbreviations on patient safety jc
The impact of abbreviations on patient safety jcThe impact of abbreviations on patient safety jc
The impact of abbreviations on patient safety jc
 
Quality Promotion
Quality PromotionQuality Promotion
Quality Promotion
 
Clinical audit project
Clinical audit projectClinical audit project
Clinical audit project
 
Clinical audit presentation
Clinical audit presentationClinical audit presentation
Clinical audit presentation
 
Towards better documentations
Towards better documentationsTowards better documentations
Towards better documentations
 
Clinical audit
Clinical audit Clinical audit
Clinical audit
 
Novel Coronavirus spotlight
Novel Coronavirus spotlightNovel Coronavirus spotlight
Novel Coronavirus spotlight
 

Recently uploaded

Chapter 11 Nutrition and Chronic Diseases.pptx
Chapter 11 Nutrition and Chronic Diseases.pptxChapter 11 Nutrition and Chronic Diseases.pptx
Chapter 11 Nutrition and Chronic Diseases.pptx
Earlene McNair
 
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptxEar and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Dr. Rabia Inam Gandapore
 
The Electrocardiogram - Physiologic Principles
The Electrocardiogram - Physiologic PrinciplesThe Electrocardiogram - Physiologic Principles
The Electrocardiogram - Physiologic Principles
MedicoseAcademics
 
Best Ayurvedic medicine for Gas and Indigestion
Best Ayurvedic medicine for Gas and IndigestionBest Ayurvedic medicine for Gas and Indigestion
Best Ayurvedic medicine for Gas and Indigestion
Swastik Ayurveda
 
Top Effective Soaps for Fungal Skin Infections in India
Top Effective Soaps for Fungal Skin Infections in IndiaTop Effective Soaps for Fungal Skin Infections in India
Top Effective Soaps for Fungal Skin Infections in India
SwisschemDerma
 
Basavarajeeyam - Ayurvedic heritage book of Andhra pradesh
Basavarajeeyam - Ayurvedic heritage book of Andhra pradeshBasavarajeeyam - Ayurvedic heritage book of Andhra pradesh
Basavarajeeyam - Ayurvedic heritage book of Andhra pradesh
Dr. Madduru Muni Haritha
 
Role of Mukta Pishti in the Management of Hyperthyroidism
Role of Mukta Pishti in the Management of HyperthyroidismRole of Mukta Pishti in the Management of Hyperthyroidism
Role of Mukta Pishti in the Management of Hyperthyroidism
Dr. Jyothirmai Paindla
 
Cell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune DiseaseCell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune Disease
Health Advances
 
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPromoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
PsychoTech Services
 
share - Lions, tigers, AI and health misinformation, oh my!.pptx
share - Lions, tigers, AI and health misinformation, oh my!.pptxshare - Lions, tigers, AI and health misinformation, oh my!.pptx
share - Lions, tigers, AI and health misinformation, oh my!.pptx
Tina Purnat
 
Adhd Medication Shortage Uk - trinexpharmacy.com
Adhd Medication Shortage Uk - trinexpharmacy.comAdhd Medication Shortage Uk - trinexpharmacy.com
Adhd Medication Shortage Uk - trinexpharmacy.com
reignlana06
 
Dehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in Dehradun
Dehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in DehradunDehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in Dehradun
Dehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in Dehradun
chandankumarsmartiso
 
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Oleg Kshivets
 
Histololgy of Female Reproductive System.pptx
Histololgy of Female Reproductive System.pptxHistololgy of Female Reproductive System.pptx
Histololgy of Female Reproductive System.pptx
AyeshaZaid1
 
Journal Article Review on Rasamanikya
Journal Article Review on RasamanikyaJournal Article Review on Rasamanikya
Journal Article Review on Rasamanikya
Dr. Jyothirmai Paindla
 
Aortic Association CBL Pilot April 19 – 20 Bern
Aortic Association CBL Pilot April 19 – 20 BernAortic Association CBL Pilot April 19 – 20 Bern
Aortic Association CBL Pilot April 19 – 20 Bern
suvadeepdas911
 
How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
How STIs Influence the Development of Pelvic Inflammatory Disease.pptxHow STIs Influence the Development of Pelvic Inflammatory Disease.pptx
How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
FFragrant
 
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdfCHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
rishi2789
 
Osteoporosis - Definition , Evaluation and Management .pdf
Osteoporosis - Definition , Evaluation and Management .pdfOsteoporosis - Definition , Evaluation and Management .pdf
Osteoporosis - Definition , Evaluation and Management .pdf
Jim Jacob Roy
 
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
Holistified Wellness
 

Recently uploaded (20)

Chapter 11 Nutrition and Chronic Diseases.pptx
Chapter 11 Nutrition and Chronic Diseases.pptxChapter 11 Nutrition and Chronic Diseases.pptx
Chapter 11 Nutrition and Chronic Diseases.pptx
 
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptxEar and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
 
The Electrocardiogram - Physiologic Principles
The Electrocardiogram - Physiologic PrinciplesThe Electrocardiogram - Physiologic Principles
The Electrocardiogram - Physiologic Principles
 
Best Ayurvedic medicine for Gas and Indigestion
Best Ayurvedic medicine for Gas and IndigestionBest Ayurvedic medicine for Gas and Indigestion
Best Ayurvedic medicine for Gas and Indigestion
 
Top Effective Soaps for Fungal Skin Infections in India
Top Effective Soaps for Fungal Skin Infections in IndiaTop Effective Soaps for Fungal Skin Infections in India
Top Effective Soaps for Fungal Skin Infections in India
 
Basavarajeeyam - Ayurvedic heritage book of Andhra pradesh
Basavarajeeyam - Ayurvedic heritage book of Andhra pradeshBasavarajeeyam - Ayurvedic heritage book of Andhra pradesh
Basavarajeeyam - Ayurvedic heritage book of Andhra pradesh
 
Role of Mukta Pishti in the Management of Hyperthyroidism
Role of Mukta Pishti in the Management of HyperthyroidismRole of Mukta Pishti in the Management of Hyperthyroidism
Role of Mukta Pishti in the Management of Hyperthyroidism
 
Cell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune DiseaseCell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune Disease
 
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPromoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
 
share - Lions, tigers, AI and health misinformation, oh my!.pptx
share - Lions, tigers, AI and health misinformation, oh my!.pptxshare - Lions, tigers, AI and health misinformation, oh my!.pptx
share - Lions, tigers, AI and health misinformation, oh my!.pptx
 
Adhd Medication Shortage Uk - trinexpharmacy.com
Adhd Medication Shortage Uk - trinexpharmacy.comAdhd Medication Shortage Uk - trinexpharmacy.com
Adhd Medication Shortage Uk - trinexpharmacy.com
 
Dehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in Dehradun
Dehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in DehradunDehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in Dehradun
Dehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in Dehradun
 
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
 
Histololgy of Female Reproductive System.pptx
Histololgy of Female Reproductive System.pptxHistololgy of Female Reproductive System.pptx
Histololgy of Female Reproductive System.pptx
 
Journal Article Review on Rasamanikya
Journal Article Review on RasamanikyaJournal Article Review on Rasamanikya
Journal Article Review on Rasamanikya
 
Aortic Association CBL Pilot April 19 – 20 Bern
Aortic Association CBL Pilot April 19 – 20 BernAortic Association CBL Pilot April 19 – 20 Bern
Aortic Association CBL Pilot April 19 – 20 Bern
 
How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
How STIs Influence the Development of Pelvic Inflammatory Disease.pptxHow STIs Influence the Development of Pelvic Inflammatory Disease.pptx
How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
 
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdfCHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
CHEMOTHERAPY_RDP_CHAPTER 6_Anti Malarial Drugs.pdf
 
Osteoporosis - Definition , Evaluation and Management .pdf
Osteoporosis - Definition , Evaluation and Management .pdfOsteoporosis - Definition , Evaluation and Management .pdf
Osteoporosis - Definition , Evaluation and Management .pdf
 
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptx
 

Recurrent pregnancy loss

  • 2. Definition • Pregnancy loss is defined as the spontaneous loss of pregnancy before the fetus reaches viability (24 weeks) • Recurrent pregnancy loss, defined as the loss of three or more ( ≥ 3) consecutive pregnancies. • Primary- No previous full term pregnancy • Secondary- At least one successful pregnancy
  • 3. Incidence – 15-20% of all pregnancies – 11-13 % in first pregnancy – 13-17 % after first abortion – 38 % after two abortions – 55% after three abortions
  • 4. Suspected etiologies Anatomical factors Genetic factors Infective agents Immune factors Antiphospholipid syndrome Inherited thrombophilic defects Endocrine factors Epidemiological factors
  • 6. Uterine Abnormalities • CONGENITAL (Mullerian Duct abnormalities) • UTERINE NEOPLASMS (Growth) • IATROGENIC (Acquired)
  • 7. How they affect……. •Smaller Uterine Cavities •Fewer suitable implantation sites •Aberrations of vascularisation •May be accompanied by cervical incompetence Lead to both early & later pregnancy losses
  • 8. Septate Uterus • Most COMMON anomaly 55% • May be complete/ incomplete/segmental 25% early abortions 6.2% late abortions & Premature labors
  • 9. Unicornuate Uterus • 20% of anomalies • Agenesis or hypoplasia of one Mullerian duct • May be alone or accompanied by Rudimentary horn With presence / absence of cavity Communicating / Non communicating • Associated Renal anomalies occur in 40% patients Ipsilateral to hypoplastic horn
  • 10. Unicornuate Uterus • Abortion Rate 51%, Premature labours, malpresentations, IUGR, Uterine rupture & ectopic pregnancies common • Cervical encerclage to improve pregnancy outcome • Rudimentary Horn resected to prevent dysmenorrhoea, haematometra,ectopic pregnancy
  • 11. Uterus Didelphys • Least common anomaly -5-7% • Failure of lateral fusion of uterus &vagina • Abortion rate 43%,Premature birth rate 38% • Resection of Vaginal septum if there is difficulty in intercourse / vaginal delivery • Strassmann Operation not indicated
  • 12. Bicornuate Uterus • 10% of anomalies • Incomplete fusion of Uterine horns at level of fundus • Two separate but communicating endometrial cavities • Abortion rate 32% Preterm labour 21% • Strassman Metroplasty / Place IUCD in one horn
  • 13. Arcuate Uterus • Near complete resorption of u-v septum • Mild concave indentation at fundus • Data conflicting Abortion rates ?45% ?13% • Treatment expectant
  • 14. T shaped Uterus • Diethylstilbestrol treatment for Premature labour started 1940 Banned 1970 • 69% female foetuses suffered Uterine anomaly • T-Shaped uterus, small uterus, constriction rings, • Cervical hypoplasia, cervical incompetence, Anterior Cervical collar, pseudopolyps • 2 fold increase in abortion rates & 9 fold increase in Ectopic pregnancy rates
  • 15. T SHAPED UTERUS- INFECTION MALA ARORA 15
  • 18. Leiomyomas (Fibroids) most common…. 20-50% of reproductive women
  • 19. • Preconception myomectomy to improve reproductive outcome can be considered on an individual basis • It is likely to have a place only in women who have recurrent pregnancy loss, – large submucosal fibroids, and no other identifiable cause for recurrent miscarriage Ouyang DW, Obstet Gynecol Clin North Am. 2006
  • 20. Iatrogenic… Intrauterine adhesions ,“Asherman’s Syndrome” • Lead to Poor implantation, • Decreased blood supply , • infection Abortion rates 40% Preterm labour 23% Management :-Hysteroscopic excision of adhesions
  • 21. HYSTEROSCOPIC CORRECTION • All of the above have a good pregnancy rate post hysteroscopic correction • Except ashermans syndrome
  • 22. Incompetent Cervix • Funneling of >25% cervical length and/or <2.5 cms cervical length before 24 weeks of pregnancy • USG follow up weekly in cases of prior 2nd trimester loss • Cervical cerclage reduces the rate of preterm birth Carp et al, 2007 • Emergency cerclage: beneficial if no infection or uterine contractions
  • 23. Genetic Etiology • Chromosomal 3.5%-5% – Fetal chromosomal abnormalities – Parental balanced chromosomal rearrangement • Single gene disorders – Alpha thalassemia major – Thrombophilia – X linked dominant disorders
  • 24. Risk Factors for genetic abnormalities • Gestational age Higher in early gestation 90% in anembryonic preg/Blighted ova 50% at 8-11wk 30% at 16-19 wk 6-12% >20wk
  • 25. Risk Factors for genetic abnormalities Advanced maternal age  Affects ovarian function, giving rise to a decline in the number of good quality oocytes, resulting in chromosomally abnormal conceptions that rarely develop further.  RM risk -75% in women >45years Previous number of miscarriages 25
  • 26.
  • 27. Fetal chromosomal abnormality in only 25- 32% of product of conception.  This may be due to abnormalities in the egg, sperm or both.  The most common chromosomal defects are Trisomy, Monosomy, Polyploidy Sperm aneuploidy (13,18,21,X,Y ) directly influences the rate of aneuploidy in the conceptus (Carrell et al 2003)
  • 28. • Parental chromosomal abnormality (Balanced chromosomal rearrangements) –General population 6 in 1000(0.6%) –RM 4.1-11% *3-5% of couples with RM are carriers of balanced chromosomal rearrangements
  • 29. Parental Chromosomal Abnormalities –Translocation (commonest) (1in 500) • Reciprocal [50%] • Robertsonian [24%] –Mosaicism for a numeric aberration [12%] –Inversion 29
  • 30. Translocation Translocation is exchange of chromosomal segments between two, non-homologous chromosomes.
  • 31. Translocations Two major types Reciprocal translocation- two non- homologous chromosomes exchange information Robertsonian translocation -two non- homologous acrocentric chromosomes break at the centromere and the long arms fuse. The short arms are often lost. Source- Emery’s book of principles of Medical Genetics
  • 32. • Karyotype of the abortus (POC) ( fetal/placental tissue) • Peripheral blood Karyotyping of the parents in all couples with RM 32
  • 33.  No definite recommendations for routinely obtaining abortus karyotype (ACOG 2001)  Karyotype analysis of abortus tissue for couples with a subsequent second or third pregnancy loss (Hogge, et al 2003)  If abortus is aneuploid, maternal cause is excluded (ACOG, 2001)  If POC karyotype not possible, do parental karyotype
  • 34. Direct parental karyotype is more cost effective. No need for first abortion. POC abnormal karyotype requires parental karyotype
  • 35. Single Gene Disorders in RM • Second and 3rd trimester losses • Alpha Thalassemia • Myotonic dystrophy • X linked Dominant disorder – Incontinentia Pigmenti – Chondrodysplasia punctata – Focal dermal hypoplasia of Goltz – Rett Syndrome – Aicardi Syndrome 35
  • 37.
  • 39. Its time to say goodbye to TORCH tests……. Cochrane Review has categorically proven in multiple meta-analysis that none of the “TORCH” group of infections are responsible for RECURRENT SPONTANEOUS ABORTIONS
  • 40. So which infections, if any are responsible for RM? Female • Viral infections ? ? – Coxasackie B – Parovo-virus B • Bacterial infections – Bacterial Vaginosis – Tuberculosis – Chlamydia trachomatis Male factors: • Semen infections can cause anueploidy and be the reason of RSA
  • 41. Bacterial Vaginosis • Commonest cause of vaginitis • Amsel's criteria for diagnosis of BV Bacterial – Thin, homogeneous discharge Vaginosis – Release of an amine 50% (putrescine, cadaverine, & trimethylamine) or fishy odor Trichomona Candida on addition of KOH is to s vaginalis albicans vaginal discharge 25% 25% – "Clue cells" (Vaginal epithelial cells coated with coccobacilli) – Vaginal pH > 4.5 • Nugent score: Gram Stain of vaginal swab
  • 42. BV and RPL • BV one of the most frequently founded cause of spontaneous abortions and prematurity birth • Diagnostics is easy and not expensive • High vaginal pH is diagnostic • Treatment is simple using Metronidazole/Clindamycin 1. Damianov L, Damianova V. Akush Ginekol (Sofiia). 2004;43 Suppl 2:26-7. 2. Mania-Pramanik J, Kerkar SC, et al. J Clin Lab Anal. 2008;22(5):375-9. 3. Li TC, Makris M, et al. Hum Reprod Update. 2002 Sep-Oct;8(5):463-81
  • 43.
  • 44. IMMUNOLOGIC FACTORS Autoimmune Alloimmune (directed to self) (directed to foreign) tissues/cells) -Systemic Lupus Erythmatosus An abnormalmaternal -Antiphospholipid Syndrome immune response to fetal or placental antigen.
  • 45. Antiphospholipid Antibody Syndrome and Recurrent Pregnancy Loss 45
  • 46. Incidence • About 1% of women have recurrent pregnancy loss. • Antiphospholipid antibodies are found in about 2% of a Caucasian population. Not studied in a general Asian / Indian population • 5 – 20% of women with recurrent pregnancy loss have antiphospholipid antibodies 46
  • 47. Statistical Distribution • Prevalence of antiphospholipid antibodies in various categories of women was studied Women with 3 or more Women with normal Women who have not early fetal losses pregnancy outcome been pregnant (includes women not desiring pregnancy and infertile women) 16% 7% 3% 47
  • 48.
  • 49. Pitfalls in diagnosis of APS • Usually an overdiagnosed syndrome • Not meeting clinical and the strict laboratory criteria • Not repeating the laboratory test at 6 weeks • Non standardized ELISA for ACL antibodies • Interlaboratory variations for phospholipid dependent coagulation tests used for screening for lupus anticoagulant 49
  • 50. False results in APS • Improperly collected and processed samples • Temporal and trimester wise fluctuations • VDRL positive patients who may or may not have syphilis • General infections and inflammations • Coagulopathies and anticoagulant medication users (including aspirin, heparin) 50
  • 51. Management Women with APS without Women with APS with a history of thrombotic history of thrombotic events events (past or present) (most women with RPL) Prophylactic therapies such Full anticoagulation with as aspirin, heparin in heparin (or warfarin) in pregnancy and 6 to 8 pregnancy and postpartum weeks postpartum 51
  • 52. Aspirin alone v/s Aspirin + Heparin • Recent meta analysis shows that the combination of Aspirin + Heparin is better than Aspirin alone in achieving live births in women with recurrent pregnancy loss and antiphospholipid antibodies Mak A et al, Rheumatology (Oxford) 2010 52
  • 53. Is Heparin + Aspirin really better? • The metaanalysis was based on data from five trials involving 334 patients across non uniform care platforms • Overall live birth rates were 74.27 and 55.83% in the combination and aspirin alone groups – RR 1.301; 95% CI 1.040, 1.629 – Number needed to treat is 5.6 • There is no placebo group for comparison • Another metaanalysis showed that LMW heparin + Asprin does not significantly improve birth rates. The benefits is present only with unfractionated heparin Zikas PD et al, Obstet Gynecol 2010 53
  • 54. Clinical Tips for using Heparin • There is controversy as to whether LMW Heparin is effective in preventing recurrent pregnancy loss • Consider costs, convenience and compliance before initiating therapy • Therapy should be started when fetal cardiac activity is demonstrated and continued throughout pregnancy and postpartum • Heparin in prophylactic doses needs to be stopped for about 24 hours around the time of labor and delivery 54
  • 55. Clinical Tips for using Heparin • Heparin in prophylactic doses can not be monitored and does not require monitoring by coagulation parameters • Do a platelet count at 3 days, 1 week and bimonthly when the patient is on heparin • Standard doses – Unfractionated heparin – 5000 units sc bd – Enoxaparin – 40 mg subQ daily or in two doses 55
  • 56. Full Anticoagulation : Practical • Preconception : Warfarin • Switch to Heparin when fetal cardiac activity is demonstrated • Warfarin should be considered in the second trimester • Switch back to Heparin at 34 to 36 weeks • After delivery : Warfarin 56
  • 57. What not to do for APS • Steroid therapy should be avoided for APS because it significantly increases morbidity (hypertension, diabetes, preterm births) without any demonstrable benefit • Immunoglobulin therapy is experimental and not for clinical use at present 57
  • 58. Alloimmune mechanism Theory: Normally pregnancy(foreign tissue graft) is tolerated by the maternal immune system through formation of antigen blocking antibodies. Felt that in couples that share similar types of HLA, there is inadequate formation of blocking antibodies in the maternal environment. Therefore the maternal immune system mounts an immune response to the implanting pregnancy and a spontaneous abortion occurs. Multiple recent studies have not confirmed this.
  • 59. ALLOIMMUNITY DIAGNOSIS • HLA crossmatching Husband’s lymphocytes + wife’s serum TREATMENT • Transfusion of husband’s lymphocytes Pure suspension of husband’s lymphocytes [ 300ml of blood = 10ml of suspension ] Inject 5ml IV, 1 ml subcu and 1ml intradermal
  • 60. Immunologic Factors -Treatment • Immunostimulating Therapies-Leukocyte Immunization • Immunosuppressive Therapies
  • 61. Intravenous immunoglobulin • theory – an overzealous immune reactivity to their implanting fetus • Mechanism – decreased autoantibody production and increased autoantibody clearance, T-cell and Fc receptor regulation, complement inactivation, enhanced T-cell suppressor function, decreased T-cell adhesion to the extracellular matrix, and downregulation of Th1 cyokine synthesis • disadvantage – expensive, invasive, and time-consuming, requiring multiple intravenous infusions over the course of pregnancy • side effects – nausea, headache, myalgias, hypotension, anaphylaxis
  • 62. Progesterone • Mechanism – inhibits Th1 immunity – shift from Th1-to Th2 type responses • This benefit of progesterone could be explained by administered its immmunomodulatory actions in inducing a – intramuscularly pregnancy-protective shift from pro-inflammatory – intravaginally Th-1 •cytokine responses to a more favourable anti- may increase local, intrauterine concentration inflammatory Th-2 cytokine response • averting any adverse systemic side effects
  • 63. Inherited thrombophilic defects (Hypercoagulable state) Factor V Leiden mutation protein C deficiency Protein S deficiency Antithrombin III deficiency Hyperhomocysteinaemia Prothrombin gene mutation
  • 64. THROMBOPHILIA • Thrombosis on maternal side of the placenta  impair placental perfusion – Late fetal loss, IUGR, abruption, or PIH • Relationship with early loss is less clear – large and contradictory literature – May be restricted to specific defects not completely defined, or presence of multiple defects
  • 66. Antithrombotic Therapy • The combined use of low-dose aspirin (75-80mg/dl) and subcutaneous unfractionated heparin (5000unit twice daily)
  • 67. ENDOCRINE FACTORS • Mild endocrine diseases are likely not causes for recurrent abortion. 1)Thyroid disease – Poorly controlled hypo- or hyper-thyroidism • Infertility & pregnancy loss – ↑ thyroid antibody, even if euthyroid. • No strong evidence
  • 68. 2)Diabetes mellitus – Poorly controlled (↑Blood glucose & HbA1c levels in 1st trimester  risk for loss. – Miscarriage risk rises with the level of HbA1c – Well-controlled : No ↑ risk.
  • 69. • 3) Polycystic Ovarian Syndrome • Polycystic ovary morphology itself does not predict an increased risk of future pregnancy loss among ovulatory women with a history of recurrent miscarriage who conceive spontaneously(RCOG) • Hyperinsulinemia & ↑ level of Plasminogen Activator Inhibitor activity – implicated as the proximate cause of incidence of loss(30-50%)among PCOS women (Br J Obst Gynecol,1993) • METFORMIN treatment can reduce or eliminate risk of miscarriage in PCOS women (Fertility Sterility,2001;J Clin Endocrino 2002)
  • 70. 4)Luteal phase defect – Progesterone is essential for implantation and maintenance of pregnancy • A defect in Corpus luteum impaired progesterone production. • However, LPD cannot be diagnosed during pregnancy; a consistently short luteal phase duration is the most reliable diagnostic criterion.
  • 71. TREATMENT – luteal-phase support with progesterone – There is insufficient evidence to evaluate the effect of progesterone supplementation in pregnancy to prevent a miscarriage (RCOG) – However newer evidences is coming up as large multicentre study PROMISE is currently on the way.
  • 72. 5)Hyperprolactinemia • There is insufficient evidence to assess the effect of hyperprolactinaemia as a risk factor for recurrent miscarriage. RCOG Green-top Guideline No. 17 April 2011
  • 73. Epidemiologic factors • Cigarette smoking has been suggested to have an adverse • effect on trophoblastic function and is linked to an increased risk of sporadic pregnancy loss. • Obesity has also been shown to be associated with an increased risk of RM in women who conceive naturally. • Other lifestyle habits such as cocaine use, alcohol consumption, and increased caffeine consumption • (>3 cups of coffee) have been associated with risk of miscarriage.
  • 74. Unexplained… • No apparent causative factor is identified in 50% to 75% of couples with RM. • It is important to emphasize to patients with unexplained RM that the chance for a future successful pregnancy can exceed 50%–60% depending on maternal age and parity.
  • 75.
  • 77. Investigations TSH HbA1C Anti thyroid Antibody Anatomy screen APS screen Vaginal swab PCOD screen Cytogenetic examination of abortus Karyotyping Thrombophilias screen
  • 78. Evidence based Progesterone Weight reduction Aspirin + LMWH Cerclage Clindamycin Thyroxin IVF + PGD
  • 79. Eminence based Spiramycin Steroids Immunoglobulin's hCG
  • 80. Unexplained RM Repeated scanning Reinforcement Reassurance