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Recurrent Pregnancy Loss
- 1. Recurrent Pregnancy Loss -Indian scenario Presented by Raktim Roy MSGEN-04
- 2. INTRODUCTION Three or more consecutive spontaneous pregnancy losses prior to 20 weeks gestation.(1) - however many clinicians would start investigations after two unexplained losses. -actual incidence of recurrent pregnancy loss is between 0.4% and 5% in couples -approximatel 40% recurrent pregnancy losses will be unexplained (1) according to American Society For Reproductive Medicine The ASRM has defined RPL as “ a distinct disorder defined by 2 or more failed clinical pregnancies”. Ectopic and molar pregnancies are not included..
- 3. Types of RPL (Recurrent Pregnancy Loss) Primary :Has never had a previous viable infant Secondary :Woman with previous H/O delivery beyond 20 weeks and then suffered subsequent losses Tertiary : Refers to those women who have multiple misscarriages interspersed with normal pregnancies.
- 4. 1st and 2nd trimester losses -PCOS : polycystic overy syndrome -APS:Antiphospholipid syndrome -Chromosomal abnormalities -Endocrine disorders (untreated DM,thyroid desease) -Uterine abnormalities -submucuous fibriod - subseptet uterus -Cervical incompetence -Asherman Syndrome(intrauterine synechiae -Bacterial vaginosis -Uterine abnormalities - congenital:bicornuate,septate,subseptate, hypoplasia -myomas -Thromboplilias 1 to 3 months 3 to 6 months
- 5. Incidence -> 50% of all conception fail (unrecognized) 13% to 15% recognized pregnancies are lost ,90% of these before 12-14 weeks -> 10%-20% women have 1 sporadic spontaneous abortion -> 2% have 2 consecutive spontaneous abortion 0.4 % - 1% have 3 consecutive sponteneous abortion
- 6. Risk Factors Working with or using video display terminals doesnot increase the rish of misscarriage The evidence on the effect of anaesthetic gases for theater workers is conflicting. Obesity Increases the rish of both sporadic and recurrent misscarriage
- 7. Causes
- 8. Genetic causes http://www.invictagenetics.com/services/recurrent-pregnancy-loss/fertigenes-testrecurrent-pregnancy-loss-test/ Embryonic chromosomal abnormalities - account for 30%-57% of further misscarriage gametogenic error recurrent aneuploidy euploid abortion Parental chromosomal abnormality 3%-5% The risk or the misscarriage is influenced by the size and the genetic content of the rearranegd chromosomal segments Most commonly a balanced reciprocal or nonRobertsonion Translocation Inversion Mosaicsm
- 9. Diagnosis
- 11. Allo immunity Alloimmune Immune response to non-self components of pregnancy Cytotoxic anitibodies Absence of maternal blocking antibodies Inappropriate sharing of HLA Disturbence of natural killer cell function and distribution Natural killer cells There is no clear evidence that altered peripheral blood NK cells are related to reccurrent misscarriage T helper immuno dstrophism A meta-analysis concluded thet the available data ar nto consistent with association between cytokine polymorphisms and recurrent misscarriage. Immunotherapy Parental cell Immunisation Third party donor leucocyte Tropoblast membranes and intravenous immunoglobulin(IVIG) Previous unexplained recurrent misscarriag does not improve the live birth rate
- 12. Thrombophilia Thrombosis on maternal side of placenta -impair placental profusion -late fetal loss,IUGR,abruption or PIH Reltionship with early loss is less clear Large and contradictory literature May be resricted to specific defects not completely defines or presence of multiple defects Inherited thrombophilic defects, including acivated protein C resistence most commonly due to factor V Leidin gene mutation , deficiency of protein C/S antithrombin III ,hyperhomocysteinaima and prothrombin gene mutation. Established causes of thrombosis
- 13. Diagnosis Evaluate if loss > nine weeks + evidence of pacental infraction or maternal thrombosis The combined use of low dose aspirin (75-80 mg/dl) and subcutenous infractionated heparin(5000 unit twice daily) For elevated hypercystenemia with out thrombosis history (suplimentation with vitamin B6,B12 and Folic acid.
- 14. Articles Reviewed 18th March 2017 15th August, 2015 25th July,2015
- 15. Syndrome Related to RPL
- 16. APLA syndrome
- 19. How to approach
- 20. Comparison of three protocols for the investigation and treatment of recurrent pregnancy loss Source : Recurrent Pregnancy Loss Causes ,Controversies and Treatment 2011
- 21. RPL management..
- 22. Statistical view
- 23. WHO Result (2013) INDIA Pregnancylosscasesper100couple.. Against the developing countries where INDIA lies in global scenario..
- 24. Recurrent pregnancy loss in last decade in India according to WHO result 2016Percentage% Years 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Source: WHO 2016 Inernational Journal of reproduction ,contraception , obstetrics and gynocology
- 25. In India Recurrent Pregnancy Loss also holds the highest genetic counseling records relative to other diseases that require counseling . Recueernt Pregnancy loss 14% Chromosomal Disorder 10.8% Neural tube defect 4.1% Congenital anomalies 3.9% Metabolic disorder 2% Skeletal dysplesia 1.6% ICMR Report 2015
- 26. Conclusion - When recurrent pregnancy loss (RPL) is defined as 3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period, 1% to 2% of women will be affected. The risk of subsequent miscarriages is similar among women that have had 2 versus 3 miscarriages, and the probability of finding a treatable etiology is similar among the 2 groups, most experts agree that there is a role for evaluation after 2 losses. - A definitive approach to etiological factors and immune modulators may help.. Investigation should include karyotype , TSH,Prolactin,APA's,coagulation studies,cervical cultures and anatomic uterine studies. - With the introduction of OMIC studies RPL studies have become more complex than earliar. Functional analysis of genes and or their products will help to recognize th pregnancy with RPL..
- 27. - Diagnostic evaluation should include maternal and paternal karyotypes, assessment of the uterine anatomy, and evaluation for thyroid dysfunction, APS, and selected thrombophilias. - In some women, evaluation for insulin resistance, ovarian reserve, antithyroid antibodies, and prolactin disorders may be indicated. - In cases of unexplained RPL, progesterone has been shown to be beneficial in decreasing the miscarriage rate in women who had experienced at least 3 losses. Low-dose aspirin benefits those with a history of losses at more than 13 weeks of gestation. - Antenatal counseling and psychological support should be offered to all couples experiencing RPL, as these measures have been shown to increase pregnancy success rates. - Prognosis will depend on the underlying cause for pregnancy loss and the number of prior losses. Patients and physicians can be encouraged by the overall good prognosis, as even after 4 consecutive losses a patient has a greater than 60% to 65% chance of carrying her next pregnancy to term.
- 29. Acknowledgement I would like to thank our respected principle sir Amit Chakraborty for giving me the chance to do the project, and i will thank Mr. Puspal De for helping me to complete this project .
- 30. THANK YOU The gift of life is a marvel of devinity,and no word can express the awesome moment of its creation...