This document discusses investigations and management of recurrent pregnancy loss (RPL). It notes that RPL affects 1-3% of couples trying to conceive and that only about 26% of RPL patients receive an explained diagnosis. Recommended initial investigations for all RPL patients include screening for hereditary thrombophilia, pelvic ultrasound, thyroid antibodies, and parental karyotyping. Chromosomal abnormalities are a common cause of early pregnancy loss. Management involves treating any identified causes, lifestyle modifications, and psychological support. Progesterone supplementation may help reduce further losses in unexplained cases. Most RPL patients will achieve a live birth in their next pregnancy despite not receiving an explained diagnosis.
Screening for and treatment of asymptomatic bacteriuria in high-risk pregnant women reduces the risk of preterm birth. However, routine screening of all pregnant women in the first trimester with urine culture is not currently recommended due to the low prevalence of asymptomatic bacteriuria in the general pregnant population and the costs of universal screening.
This document discusses intrauterine growth restriction (IUGR) and small for gestational age (SGA) infants. It defines IUGR as impaired fetal growth and SGA as weight below the 10th percentile. IUGR incidence in India is 3-10% of pregnancies and is associated with higher stillbirth and infant mortality rates. IUGR can be symmetric, asymmetric, or combined based on effects on weight, length, and head circumference. Etiologies include placental insufficiency, genetic factors, infections, and maternal health conditions. Complications include hypoglycemia, hypothermia, and immune dysfunction. Proper management involves antenatal diagnosis, skilled delivery and resuscitation, glucose monitoring, screening for
The document discusses the use of MRI in assessing female pelvic organs and genitourinary conditions. MRI provides detailed images of the uterus, ovaries, and surrounding tissues. It can accurately diagnose adenomyosis, uterine anomalies, and characterize fibroids and ovarian cysts. MRI is also useful for staging cervical, endometrial, and ovarian cancers by identifying the extent of tumor invasion and spread to nearby organs or lymph nodes. Due to its safety during pregnancy, MRI can also evaluate obstetric complications and differentiate between benign and malignant tumors that may complicate pregnancy.
Induction of labour involves initiating uterine contractions before spontaneous onset using methods like cervical ripening, amniotomy, or pharmacological agents. The cervix status and fetal well-being must be assessed first, and induction contraindicated for issues like placenta previa or active herpes. Common ripening agents include prostaglandins like misoprostol or dinoprostone administered vaginally, and oxytocin is often used after amniotomy to induce contractions. Complications of each method and guidelines for special circumstances are outlined.
This document discusses methods of uterine hemostasis for postpartum hemorrhage (PPH). It notes that the main causes of PPH are tonicity (70%), retained tissues (20%), trauma (9%), and coagulopathy (1%). Principles of PPH management include simultaneously resuscitating the patient and identifying the specific cause. Uterotonic drugs, uterine tamponade techniques, compression sutures, and other surgical techniques are described for controlling uterine bleeding. Correct application of these techniques is emphasized, while potential issues from improper use such as ischemic necrosis are also outlined.
Cancer complicates approximately 1 in 1,000 pregnancies. The most commonly diagnosed cancers during pregnancy are breast cancer, cervical cancer, melanoma, and thyroid cancer. Diagnostic delay is not uncommon when cancer is diagnosed during pregnancy due to concerns about protecting the fetus. Treatment options must balance saving the mother's life with protecting the fetus and maintaining the mother's reproductive system.
The document discusses guidelines for using magnesium sulfate to reduce the risk of cerebral palsy in preterm infants. It describes protocols for magnesium sulfate administration before imminent preterm birth between 23-33 weeks gestation. Magnesium sulfate is thought to exert neuroprotective effects through vasodilation, anti-inflammatory actions, and modulation of NMDA receptors. Larger clinical trials and meta-analyses support the efficacy and safety of magnesium sulfate for reducing cerebral palsy.
MRI uses magnetism, radio waves, and computers to create images of areas inside the body. It involves four basic steps: (1) placing the patient in a magnetic field, (2) transmitting radio frequency pulses, (3) receiving signals from the patient, and (4) transforming the signals into images using computer processing. MRI provides superior soft tissue resolution compared to ultrasound and allows for multiplanar imaging. It is useful for evaluating various fetal and maternal conditions like brain abnormalities, tumors, placental issues, and complications in multiple pregnancies. While a valuable tool, MRI also has some limitations including high cost, inability to be used in early pregnancy or if metallic implants are present, and longer scan times than ultrasound.
Screening for and treatment of asymptomatic bacteriuria in high-risk pregnant women reduces the risk of preterm birth. However, routine screening of all pregnant women in the first trimester with urine culture is not currently recommended due to the low prevalence of asymptomatic bacteriuria in the general pregnant population and the costs of universal screening.
This document discusses intrauterine growth restriction (IUGR) and small for gestational age (SGA) infants. It defines IUGR as impaired fetal growth and SGA as weight below the 10th percentile. IUGR incidence in India is 3-10% of pregnancies and is associated with higher stillbirth and infant mortality rates. IUGR can be symmetric, asymmetric, or combined based on effects on weight, length, and head circumference. Etiologies include placental insufficiency, genetic factors, infections, and maternal health conditions. Complications include hypoglycemia, hypothermia, and immune dysfunction. Proper management involves antenatal diagnosis, skilled delivery and resuscitation, glucose monitoring, screening for
The document discusses the use of MRI in assessing female pelvic organs and genitourinary conditions. MRI provides detailed images of the uterus, ovaries, and surrounding tissues. It can accurately diagnose adenomyosis, uterine anomalies, and characterize fibroids and ovarian cysts. MRI is also useful for staging cervical, endometrial, and ovarian cancers by identifying the extent of tumor invasion and spread to nearby organs or lymph nodes. Due to its safety during pregnancy, MRI can also evaluate obstetric complications and differentiate between benign and malignant tumors that may complicate pregnancy.
Induction of labour involves initiating uterine contractions before spontaneous onset using methods like cervical ripening, amniotomy, or pharmacological agents. The cervix status and fetal well-being must be assessed first, and induction contraindicated for issues like placenta previa or active herpes. Common ripening agents include prostaglandins like misoprostol or dinoprostone administered vaginally, and oxytocin is often used after amniotomy to induce contractions. Complications of each method and guidelines for special circumstances are outlined.
This document discusses methods of uterine hemostasis for postpartum hemorrhage (PPH). It notes that the main causes of PPH are tonicity (70%), retained tissues (20%), trauma (9%), and coagulopathy (1%). Principles of PPH management include simultaneously resuscitating the patient and identifying the specific cause. Uterotonic drugs, uterine tamponade techniques, compression sutures, and other surgical techniques are described for controlling uterine bleeding. Correct application of these techniques is emphasized, while potential issues from improper use such as ischemic necrosis are also outlined.
Cancer complicates approximately 1 in 1,000 pregnancies. The most commonly diagnosed cancers during pregnancy are breast cancer, cervical cancer, melanoma, and thyroid cancer. Diagnostic delay is not uncommon when cancer is diagnosed during pregnancy due to concerns about protecting the fetus. Treatment options must balance saving the mother's life with protecting the fetus and maintaining the mother's reproductive system.
The document discusses guidelines for using magnesium sulfate to reduce the risk of cerebral palsy in preterm infants. It describes protocols for magnesium sulfate administration before imminent preterm birth between 23-33 weeks gestation. Magnesium sulfate is thought to exert neuroprotective effects through vasodilation, anti-inflammatory actions, and modulation of NMDA receptors. Larger clinical trials and meta-analyses support the efficacy and safety of magnesium sulfate for reducing cerebral palsy.
MRI uses magnetism, radio waves, and computers to create images of areas inside the body. It involves four basic steps: (1) placing the patient in a magnetic field, (2) transmitting radio frequency pulses, (3) receiving signals from the patient, and (4) transforming the signals into images using computer processing. MRI provides superior soft tissue resolution compared to ultrasound and allows for multiplanar imaging. It is useful for evaluating various fetal and maternal conditions like brain abnormalities, tumors, placental issues, and complications in multiple pregnancies. While a valuable tool, MRI also has some limitations including high cost, inability to be used in early pregnancy or if metallic implants are present, and longer scan times than ultrasound.
Here are a few key things we can do:
1. Provide thorough preconception counseling to assess risk and optimize medical condition before pregnancy if possible.
2. Ensure careful multidisciplinary antenatal care involving cardiologists, obstetricians, anesthesiologists to monitor for complications.
3. Plan delivery carefully considering hemodynamic changes, with options for early delivery or C-section if needed.
4. Be vigilant for dangerous periods like labor/delivery when changes in volume and pressure occur abruptly. Have low threshold for ICU admission.
5. Educate patients and families on warning signs and ensure close postpartum follow up as this is a high risk period.
6.
This document discusses hypertensive disorders of pregnancy, including gestational hypertension, preeclampsia, HELLP syndrome, eclampsia, and chronic hypertension. It covers the definitions, classifications, risk factors, clinical presentations, and management approaches for these conditions. Hypertensive disorders affect 5-10% of pregnancies and represent a spectrum of conditions characterized by new-onset hypertension and often proteinuria after 20 weeks of gestation. Preeclampsia is the most common disorder, occurring in 2-7% of pregnancies, and can range from mild to severe disease.
This document discusses placenta accreta syndrome, including risk factors, diagnostic methods, and management strategies. It begins with an overview of placenta accreta classifications. Ultrasound and MRI are important diagnostic tools, with ultrasound being the primary method. Risk factors include prior c-sections, placenta previa, and uterine surgeries. Early diagnosis allows for elective c-section and interventions like arterial embolization to reduce bleeding. Hysterectomy is often needed to control hemorrhage but conservative approaches aim to preserve the uterus. Proper multidisciplinary care and prevention of delays in management can improve outcomes for this serious condition.
PPROM refers to rupture of membranes before 37 weeks of pregnancy, while PROM occurs at or after 37 weeks but before the onset of labor. PPROM and PROM are associated with risks like cord prolapse, maternal and neonatal infection, and 40% of preterm deliveries. Diagnosis involves history of fluid leakage and examination finding a smaller uterus and pooling of fluid in the vagina. Management of PPROM includes antibiotics and steroids to reduce infection rates while PROM may allow labor or require induction depending on presence of meconium. Chorioamnionitis is a maternal infection following rupture that requires delivery and IV antibiotics.
This document summarizes information about post-term pregnancy and induction of labor. It defines post-term pregnancy as beyond 42 weeks gestation, which increases risks of complications. Induction of labor is commonly recommended between 41-42 weeks to reduce risks. Common methods of induction include amniotomy, prostaglandins like misoprostol, and oxytocin infusion. Risks of induction include greater pain, uterine hyperstimulation, and potential need for C-section if induction fails. Accurate dating and fetal surveillance are important aspects of managing post-term pregnancies.
induction of labor - A Clinical Case DiscussionAfiqi Fikri
A 24-year-old woman, Puan Nina, was admitted to the hospital at 40 weeks and 1 day gestation to induce labor for post-maturity. She had two previous normal deliveries with no medical issues in the current pregnancy. Upon examination, her cervix was 2 cm dilated. Artificial rupture of membranes and Syntocinon were used to induce labor. The woman progressed well and delivered a healthy baby girl weighing 3.5kg with good Apgar scores.
1. Shoulder dystocia is a potentially dangerous complication of childbirth where the baby's shoulders get stuck after delivery of the head.
2. It cannot be reliably predicted but certain risk factors like macrosomia, diabetes, and large babies in previous pregnancies increase likelihood.
3. When shoulder dystocia occurs, a series of maneuvers called HELPERR should be performed which include applying suprapubic pressure, rotating the baby's shoulders, and in severe cases rolling the mother onto her side to disimpact the shoulders.
This document discusses hypertension in pregnancy and preeclampsia. It begins by defining hypertension and preeclampsia and discussing their incidence and complications. It then covers prediction and prevention of preeclampsia, including optimal aspirin dosage and timing. The document recommends tight blood pressure control and lists antihypertensive agents. It provides guidance on managing severe hypertension, including intravenous drugs and magnesium sulfate administration. Throughout, it compares guidelines from ISSHP 2018, NICE 2010, and other sources.
This document discusses preterm prelabour rupture of membranes (PPROM), which complicates 2% of pregnancies but is associated with 40% of preterm deliveries and can result in neonatal morbidity and mortality. It is diagnosed through maternal history and sterile speculum exam. Ultrasound may help confirm but a normal fluid index does not rule it out. Women should be observed for signs of chorioamnionitis every 4-6 hours. The document outlines antibiotic, corticosteroid and tocolytic treatment and discusses the timing of delivery for managing PPROM.
This document discusses intrauterine growth restriction (IUGR), including definitions, health burden, classification, etiology, pathophysiology, screening, prevention, diagnosis, interventions, management, and long-term outcomes. IUGR is defined as a fetus that does not achieve expected in utero growth potential due to genetic or environmental factors. It affects about 10% of live births and is a leading cause of perinatal morbidity and mortality. Causes include fetal, maternal, placental, and environmental factors. Screening involves ultrasound and Doppler assessments. Management involves timing of delivery based on gestational age and severity. IUGR is associated with short and long-term complications.
This document outlines protocols for managing multiple pregnancies, including twins and triplets. It discusses ultrasound monitoring schedules to assess chorionicity, growth, anatomy and complications. It recommends referral to specialist centers for complex or high-risk cases like monochorionic twins. Guidelines are provided for timing of delivery based on gestational age and chorionicity/amnionicity. Vaginal delivery is considered for uncomplicated dichorionic twins presenting vertex, while C-section is preferred for monochorionic twins. Postnatal support includes advice on breastfeeding and contraception.
This document discusses breech presentation, which occurs when a baby is positioned bottom or feet first in the uterus instead of head first. It defines the different types of breech positions and discusses risk factors, diagnosis, management options, and complications associated with vaginal breech delivery and cesarean section for breech babies. Management options include external cephalic version, vaginal delivery, or cesarean section depending on the specific situation. Risks and procedures for both vaginal delivery and cesarean section are outlined.
Fetal growth restriction (FGR), formerly called intrauterine growth restriction (IUGR), refers to a condition in which an unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb.
Mild FGR usually doesn't cause long-term problems. In fact, most babies who have it catch up in height and weight by age 2. But severe FGR can seriously harm a baby before and after birth. The extent of the problems depends on the cause and how severe the growth restriction is. It also depends on what point in the pregnancy it starts.
This document discusses pregnancy induced hypertension (PIH), also known as preeclampsia. PIH is a multisystem disorder characterized by high blood pressure and protein in the urine that develops during pregnancy. It can lead to serious complications for both the mother and baby if untreated. The document covers the definition, classification, signs and symptoms, risk factors, pathogenesis, diagnosis, and management of mild and severe cases of PIH.
1. Selective progesterone receptor modulators (SPRMs) are a class of drugs that act as agonists or antagonists of the progesterone receptor in a tissue-selective manner.
2. Several SPRMs are discussed in the document, including mifepristone, ulipristal acetate, telapristone, and asoprisnil, which are being studied for uses like emergency contraception and treatment of uterine fibroids.
3. Clinical trials have compared the effectiveness of different SPRMs to other medications for emergency contraception and found them to be similarly effective while also having fewer side effects in some cases. SPRMs are also being researched for their potential mechanisms of action and effects on tissues like
Thyroid diseases with pregnancy RCOG vs ACOGBasem Hamed
Universal screening for thyroid disease in pregnancy is not recommended. Levels of TSH and free T4 should be measured to diagnose thyroid disease in pregnancy. The first-line screening test used to assess thyroid status in patients is TSH level. Pregnant women with overt hypothyroidism should be treated with adequate thyroid hormone replacement to minimize the risk of adverse outcomes. The level of TSH should be monitored in pregnant women being treated for hypothyroidism. The level of free T4 should be monitored in pregnant women being treated for hyperthyroidism.
This document provides an overview of the management of hypertensive disorders in pregnancy. It discusses the differences between gestational hypertension and chronic hypertension, how to assess proteinuria, prevention strategies, recommendations for various stages of mild to severe hypertension during pregnancy and postpartum, which antihypertensive medications to use and avoid, risk factors for preeclampsia, and conclusions about early diagnosis and treatment improving outcomes for both mother and baby. The conclusions recommend labetolol and methyldopa as first-line drugs, watching high risk women closely for preeclampsia, using urine protein to creatinine ratio for proteinuria screening, and aspirin as the only proven primary prevention method.
This document discusses antepartum haemorrhage (APH), defined as bleeding from or into the genital tract occurring from 24 weeks of pregnancy until birth. APH complicates 3-5% of pregnancies and is a leading cause of perinatal and maternal mortality worldwide. The most important causes of APH are placenta praevia and placental abruption. This guideline aims to provide recommendations for identifying risk factors, assessing and managing APH, and improving outcomes for both mother and baby. It finds that while some risk factors are known, APH cannot be reliably predicted or prevented due to its heterogeneous nature. Clinicians should be aware of complications associated with APH such as preterm birth and still
Choosing Wisely: 15 Things Physicians and Patients Should QuestionVõ Tá Sơn
This document provides 15 recommendations for clinical practices that should be questioned in obstetrics based on a lack of evidence of benefit or potential for harm. Specifically, it recommends against: performing inherited thrombophilia evaluations; placing cerclages in twin pregnancies; offering noninvasive prenatal testing to low-risk patients; screening for intrauterine growth restriction with Doppler; using progestogens for multifetal gestations; and several other prenatal tests and interventions when scientific evidence is lacking. The recommendations are intended to discourage common practices that have not been shown to meaningfully improve outcomes.
Here are a few key things we can do:
1. Provide thorough preconception counseling to assess risk and optimize medical condition before pregnancy if possible.
2. Ensure careful multidisciplinary antenatal care involving cardiologists, obstetricians, anesthesiologists to monitor for complications.
3. Plan delivery carefully considering hemodynamic changes, with options for early delivery or C-section if needed.
4. Be vigilant for dangerous periods like labor/delivery when changes in volume and pressure occur abruptly. Have low threshold for ICU admission.
5. Educate patients and families on warning signs and ensure close postpartum follow up as this is a high risk period.
6.
This document discusses hypertensive disorders of pregnancy, including gestational hypertension, preeclampsia, HELLP syndrome, eclampsia, and chronic hypertension. It covers the definitions, classifications, risk factors, clinical presentations, and management approaches for these conditions. Hypertensive disorders affect 5-10% of pregnancies and represent a spectrum of conditions characterized by new-onset hypertension and often proteinuria after 20 weeks of gestation. Preeclampsia is the most common disorder, occurring in 2-7% of pregnancies, and can range from mild to severe disease.
This document discusses placenta accreta syndrome, including risk factors, diagnostic methods, and management strategies. It begins with an overview of placenta accreta classifications. Ultrasound and MRI are important diagnostic tools, with ultrasound being the primary method. Risk factors include prior c-sections, placenta previa, and uterine surgeries. Early diagnosis allows for elective c-section and interventions like arterial embolization to reduce bleeding. Hysterectomy is often needed to control hemorrhage but conservative approaches aim to preserve the uterus. Proper multidisciplinary care and prevention of delays in management can improve outcomes for this serious condition.
PPROM refers to rupture of membranes before 37 weeks of pregnancy, while PROM occurs at or after 37 weeks but before the onset of labor. PPROM and PROM are associated with risks like cord prolapse, maternal and neonatal infection, and 40% of preterm deliveries. Diagnosis involves history of fluid leakage and examination finding a smaller uterus and pooling of fluid in the vagina. Management of PPROM includes antibiotics and steroids to reduce infection rates while PROM may allow labor or require induction depending on presence of meconium. Chorioamnionitis is a maternal infection following rupture that requires delivery and IV antibiotics.
This document summarizes information about post-term pregnancy and induction of labor. It defines post-term pregnancy as beyond 42 weeks gestation, which increases risks of complications. Induction of labor is commonly recommended between 41-42 weeks to reduce risks. Common methods of induction include amniotomy, prostaglandins like misoprostol, and oxytocin infusion. Risks of induction include greater pain, uterine hyperstimulation, and potential need for C-section if induction fails. Accurate dating and fetal surveillance are important aspects of managing post-term pregnancies.
induction of labor - A Clinical Case DiscussionAfiqi Fikri
A 24-year-old woman, Puan Nina, was admitted to the hospital at 40 weeks and 1 day gestation to induce labor for post-maturity. She had two previous normal deliveries with no medical issues in the current pregnancy. Upon examination, her cervix was 2 cm dilated. Artificial rupture of membranes and Syntocinon were used to induce labor. The woman progressed well and delivered a healthy baby girl weighing 3.5kg with good Apgar scores.
1. Shoulder dystocia is a potentially dangerous complication of childbirth where the baby's shoulders get stuck after delivery of the head.
2. It cannot be reliably predicted but certain risk factors like macrosomia, diabetes, and large babies in previous pregnancies increase likelihood.
3. When shoulder dystocia occurs, a series of maneuvers called HELPERR should be performed which include applying suprapubic pressure, rotating the baby's shoulders, and in severe cases rolling the mother onto her side to disimpact the shoulders.
This document discusses hypertension in pregnancy and preeclampsia. It begins by defining hypertension and preeclampsia and discussing their incidence and complications. It then covers prediction and prevention of preeclampsia, including optimal aspirin dosage and timing. The document recommends tight blood pressure control and lists antihypertensive agents. It provides guidance on managing severe hypertension, including intravenous drugs and magnesium sulfate administration. Throughout, it compares guidelines from ISSHP 2018, NICE 2010, and other sources.
This document discusses preterm prelabour rupture of membranes (PPROM), which complicates 2% of pregnancies but is associated with 40% of preterm deliveries and can result in neonatal morbidity and mortality. It is diagnosed through maternal history and sterile speculum exam. Ultrasound may help confirm but a normal fluid index does not rule it out. Women should be observed for signs of chorioamnionitis every 4-6 hours. The document outlines antibiotic, corticosteroid and tocolytic treatment and discusses the timing of delivery for managing PPROM.
This document discusses intrauterine growth restriction (IUGR), including definitions, health burden, classification, etiology, pathophysiology, screening, prevention, diagnosis, interventions, management, and long-term outcomes. IUGR is defined as a fetus that does not achieve expected in utero growth potential due to genetic or environmental factors. It affects about 10% of live births and is a leading cause of perinatal morbidity and mortality. Causes include fetal, maternal, placental, and environmental factors. Screening involves ultrasound and Doppler assessments. Management involves timing of delivery based on gestational age and severity. IUGR is associated with short and long-term complications.
This document outlines protocols for managing multiple pregnancies, including twins and triplets. It discusses ultrasound monitoring schedules to assess chorionicity, growth, anatomy and complications. It recommends referral to specialist centers for complex or high-risk cases like monochorionic twins. Guidelines are provided for timing of delivery based on gestational age and chorionicity/amnionicity. Vaginal delivery is considered for uncomplicated dichorionic twins presenting vertex, while C-section is preferred for monochorionic twins. Postnatal support includes advice on breastfeeding and contraception.
This document discusses breech presentation, which occurs when a baby is positioned bottom or feet first in the uterus instead of head first. It defines the different types of breech positions and discusses risk factors, diagnosis, management options, and complications associated with vaginal breech delivery and cesarean section for breech babies. Management options include external cephalic version, vaginal delivery, or cesarean section depending on the specific situation. Risks and procedures for both vaginal delivery and cesarean section are outlined.
Fetal growth restriction (FGR), formerly called intrauterine growth restriction (IUGR), refers to a condition in which an unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb.
Mild FGR usually doesn't cause long-term problems. In fact, most babies who have it catch up in height and weight by age 2. But severe FGR can seriously harm a baby before and after birth. The extent of the problems depends on the cause and how severe the growth restriction is. It also depends on what point in the pregnancy it starts.
This document discusses pregnancy induced hypertension (PIH), also known as preeclampsia. PIH is a multisystem disorder characterized by high blood pressure and protein in the urine that develops during pregnancy. It can lead to serious complications for both the mother and baby if untreated. The document covers the definition, classification, signs and symptoms, risk factors, pathogenesis, diagnosis, and management of mild and severe cases of PIH.
1. Selective progesterone receptor modulators (SPRMs) are a class of drugs that act as agonists or antagonists of the progesterone receptor in a tissue-selective manner.
2. Several SPRMs are discussed in the document, including mifepristone, ulipristal acetate, telapristone, and asoprisnil, which are being studied for uses like emergency contraception and treatment of uterine fibroids.
3. Clinical trials have compared the effectiveness of different SPRMs to other medications for emergency contraception and found them to be similarly effective while also having fewer side effects in some cases. SPRMs are also being researched for their potential mechanisms of action and effects on tissues like
Thyroid diseases with pregnancy RCOG vs ACOGBasem Hamed
Universal screening for thyroid disease in pregnancy is not recommended. Levels of TSH and free T4 should be measured to diagnose thyroid disease in pregnancy. The first-line screening test used to assess thyroid status in patients is TSH level. Pregnant women with overt hypothyroidism should be treated with adequate thyroid hormone replacement to minimize the risk of adverse outcomes. The level of TSH should be monitored in pregnant women being treated for hypothyroidism. The level of free T4 should be monitored in pregnant women being treated for hyperthyroidism.
This document provides an overview of the management of hypertensive disorders in pregnancy. It discusses the differences between gestational hypertension and chronic hypertension, how to assess proteinuria, prevention strategies, recommendations for various stages of mild to severe hypertension during pregnancy and postpartum, which antihypertensive medications to use and avoid, risk factors for preeclampsia, and conclusions about early diagnosis and treatment improving outcomes for both mother and baby. The conclusions recommend labetolol and methyldopa as first-line drugs, watching high risk women closely for preeclampsia, using urine protein to creatinine ratio for proteinuria screening, and aspirin as the only proven primary prevention method.
This document discusses antepartum haemorrhage (APH), defined as bleeding from or into the genital tract occurring from 24 weeks of pregnancy until birth. APH complicates 3-5% of pregnancies and is a leading cause of perinatal and maternal mortality worldwide. The most important causes of APH are placenta praevia and placental abruption. This guideline aims to provide recommendations for identifying risk factors, assessing and managing APH, and improving outcomes for both mother and baby. It finds that while some risk factors are known, APH cannot be reliably predicted or prevented due to its heterogeneous nature. Clinicians should be aware of complications associated with APH such as preterm birth and still
Choosing Wisely: 15 Things Physicians and Patients Should QuestionVõ Tá Sơn
This document provides 15 recommendations for clinical practices that should be questioned in obstetrics based on a lack of evidence of benefit or potential for harm. Specifically, it recommends against: performing inherited thrombophilia evaluations; placing cerclages in twin pregnancies; offering noninvasive prenatal testing to low-risk patients; screening for intrauterine growth restriction with Doppler; using progestogens for multifetal gestations; and several other prenatal tests and interventions when scientific evidence is lacking. The recommendations are intended to discourage common practices that have not been shown to meaningfully improve outcomes.
This document summarizes recent advances in the diagnosis and treatment of ectopic pregnancy. It begins by describing ectopic pregnancy as occurring when the gestational sac is outside the uterus, which can be life-threatening. It then discusses the following key points:
- Diagnosis is challenging but important given the condition's prevalence among pregnant patients presenting with bleeding or pain.
- Ultrasound is now the initial investigation, while serum human chorionic gonadotropin and progesterone levels can help when ultrasound results are unclear.
- Advances have allowed less invasive surgical and medical treatments like laparoscopy and methotrexate to become more common options.
- The review aims to summarize the current literature on impacts of
This document discusses recurrent pregnancy loss (RPL), defined as 3 or more losses prior to 20 weeks. It provides background on incidence and risk factors for RPL. Etiologies of RPL include genetic, anatomic, immunologic, endocrine, inherited thrombophilias, infectious, and unexplained factors. Investigations of couples with RPL may include screening for antiphospholipid antibodies, cytogenetic analysis, karyotyping, pelvic ultrasound, and screening for inherited thrombophilias. Treatment options depend on etiology and may include aspirin and heparin for antiphospholipid syndrome, referral for genetic factors, surgery for anatomical factors, progesterone supplementation, and supportive care for unexplained RPL.
Recurrent pregnancy loss is defined as three or more consecutive miscarriages before 20 weeks. The main investigations recommended are testing for antiphospholipid antibodies, hysterosalpingography or sonohysterography to check for uterine anomalies, karyotyping of both parents and any fetal tissue to check for genetic abnormalities, and checking the thyroid, glucose, and thrombophilia profiles. The results of these tests can help identify causes like antiphospholipid syndrome, structural uterine issues, chromosomal translocations, thyroid abnormalities, or inherited bleeding disorders and guide further treatment.
Recurrent pregnancy loss is defined as three or more consecutive pregnancy losses before 20 weeks of gestation. The document discusses the types, causes, risk factors, diagnosis, and management of recurrent pregnancy loss. It notes that chromosomal abnormalities account for 30-57% of recurrent losses. Thrombophilias and autoimmune factors like antiphospholipid syndrome may also play a role. Evaluation includes testing for genetic and anatomical abnormalities, as well as endocrine, immune, and coagulation disorders. Progesterone supplementation and low-dose aspirin are beneficial for some cases of unexplained recurrent pregnancy loss.
Recurrent pregnancy loss, thrombophilia tests : to do or not to do Dr. Sharda...Lifecare Centre
This document discusses recurrent pregnancy loss (RPL) and the role of thrombophilia testing. It notes that RPL affects 15-20% of clinically detectable pregnancies and that its cause remains unknown in 50% of cases. While thrombophilia testing was commonly done for RPL, guidelines now recommend against routine testing. Studies found only a weak association between thrombophilia and pregnancy outcomes. No causative relationship has been established. As a result, current recommendations are against thrombophilia screening for RPL cases. The document examines this issue in the context of the authors' experience treating over 700 RPL cases at their recurrent pregnancy loss clinic in Delhi, India.
unexplained recurrent pregnancy loss case scenarioAhmed Mosad
This patient has a history of 6 miscarriages between 8-9 weeks of pregnancy. Testing showed normal hormone levels, thyroid function, parental karyotypes, and other factors. The patient was treated with various medications for subsequent pregnancies with one live birth. For the seventh pregnancy, the patient underwent paternal leukocyte immunization and developed antibodies, resulting in an uneventful pregnancy and live birth. The eighth pregnancy is currently ongoing.
1. Recurrent miscarriage, defined as three or more consecutive pregnancy losses, affects 1% of couples trying to conceive. Risk factors include advancing maternal and paternal age, previous miscarriages, antiphospholipid syndrome, genetic factors, anatomical abnormalities, endocrine disorders, immune factors, and certain infections.
2. Antiphospholipid syndrome, caused by antiphospholipid antibodies that inhibit trophoblast function and cause inflammation and thrombosis, is the most important treatable cause, present in 15% of recurrent miscarriage cases.
3. Other factors discussed include parental chromosomal rearrangements in 2-5% of cases, embryonic chromosomal abnormalities accounting for 30-57% of further miscarri
- Recurrent pregnancy loss is defined as 3 or more consecutive miscarriages before 20 weeks.
- Genetic causes like chromosomal abnormalities are a major cause and account for around 70% of early miscarriages. Karyotyping of pregnancy tissue can identify chromosomal abnormalities.
- Advanced parental age increases the risk of genetic defects leading to miscarriage due to declining egg/sperm quality. Parental karyotyping may identify balanced translocations in 3-5% of couples.
- A thorough evaluation including genetic, endocrine, anatomical, immunological, and infectious factors can identify a cause in 60% of recurrent pregnancy loss cases.
1) Recurrent miscarriage is defined as 3 or more consecutive pregnancy losses at or before 20 weeks gestation. It affects approximately 1% of fertile couples.
2) The main causes of recurrent pregnancy loss are parental chromosomal abnormalities, uterine abnormalities, and antiphospholipid antibody syndrome. Other potential causes include endocrine, immunological, thrombophilic, and infectious factors.
3) Evaluation of patients with recurrent miscarriage includes obtaining a thorough history, physical exam, testing for antiphospholipid antibodies and parental chromosome analysis, and evaluating the uterine cavity through procedures like hysterosalpingogram or hysteroscopy. No cause is identified in around 50% of couples.
This document discusses recurrent pregnancy loss, providing definitions and discussing possible causes and management approaches. It defines recurrent pregnancy loss as the loss of two or more pregnancies and notes that a cause can be found in only 60% of cases. Possible causes discussed include advanced maternal age, chromosomal abnormalities, immunological factors like antiphospholipid syndrome, anatomical issues, infections, hormonal imbalances, environmental exposures, personal habits, stress, and idiopathic causes. Management may involve treating explainable causes as well as addressing prognostic factors for future live births.
Prenatal screening and diagnosis allows for the detection of fetal abnormalities before birth. It involves various screening techniques in the first and second trimester such as nuchal translucency measurement, maternal serum markers, and ultrasound exams. Invasive diagnostic tests such as amniocentesis and chorionic villus sampling allow for the analysis of fetal cells to check for genetic abnormalities. The goal of prenatal screening and diagnosis is to provide information to parents about the health of the fetus and allow for informed decision making and management planning.
This document discusses fetal growth disorders including intrauterine growth restriction (IUGR). It defines key terms like SGA, discusses causes and risk factors for IUGR like placental insufficiency. It outlines methods for detecting and monitoring IUGR fetuses including ultrasound measurements and Doppler assessments. It also presents a staging system for managing IUGR pregnancies based on ultrasound and Doppler findings with recommendations for surveillance and timing of delivery.
Infertility is defined as the failure to conceive after at least 1 year of regular unprotected sex. It affects 10-15% of reproductive-aged couples in the US. The main causes of infertility include male factors, ovulatory dysfunction, uterine abnormalities, tubal damage, cervical factors, immunological factors, and unexplained causes. Evaluation involves a medical history, physical exam, semen analysis, tests to check for ovulation and tubal patency, and imaging to check for structural abnormalities. Treatment depends on the underlying cause, and may include medications to induce ovulation, surgery to repair structural issues, assisted reproductive technologies, and lifestyle modifications.
- Recurrent pregnancy loss (RPL), defined as two or more pregnancy losses, is a serious problem that impacts women psychologically and socially.
- The causes of RPL are often unknown, but can include genetic factors, anatomical abnormalities, endocrine/metabolic issues, autoimmune disorders like antiphospholipid syndrome, and lifestyle factors.
- Evaluation of RPL involves screening for causes like thyroid abnormalities, luteal phase defects, hyperprolactinemia, antiphospholipid syndrome, uterine anomalies, and counseling regarding lifestyle modifications. Treatment depends on the underlying cause but may include thyroid supplementation, progesterone, low-dose aspirin, anticoagulants, and surgery.
Recurrent pregnancy loss: causes and diagnosis, myths and facts (evidence based)Ali Bendary
The document discusses recurrent pregnancy loss (RPL) and provides information on various potential causes. It begins by defining RPL as the loss of three or more clinically recognized pregnancies before 24 weeks of gestation. The incidence of RPL is approximately 10-15% of recognized pregnancies under 20 weeks. Extensive evaluation is not generally recommended after a single miscarriage. Potential causes discussed include epidemiological factors, antiphospholipid syndrome, anatomical abnormalities, genetic and endocrine issues, immune factors, infections, and thrombophilia. Evaluation and management depends on factors like maternal age, previous history, and clinical findings.
Controversy and consensus regarding management of recurrent pregnancy loss.pptxDrRokeyaBegum
This document discusses controversy and consensus regarding management of recurrent pregnancy loss. It provides definitions of miscarriage and recurrent pregnancy loss. It examines various potential causes of recurrent pregnancy loss including genetic, immunological, endocrine, anatomical, infectious, and male factors. For each factor, it discusses recommendations for investigation and management based on guidelines from various organizations. The document emphasizes taking a thorough history and investigating multiple potential causes through tests and scans to determine a tailored treatment plan aiming to prevent future miscarriages.
The 10 recommendations of society of maternal fetal medicine 2016Aboubakr Elnashar
The document outlines 10 recommendations from the Society for Maternal-Fetal Medicine (SMFM) on practices that should not be performed during pregnancy. The recommendations advise against routine serologic screening, inherited thrombophilia evaluation, Doppler screening for IUGR, noninvasive prenatal testing for low-risk patients, redundant aneuploidy screening, cervical length screening outside certain gestational ages, cerclage for twin pregnancies, progestogen use for multifetal gestations, activity restriction, and antenatal testing without indications in diet-controlled gestational diabetes.
Recurrent pregnancy loss is defined as 3 or more consecutive pregnancies ending in spontaneous abortion before 20 weeks. The causes of recurrent pregnancy loss can be established in only 30-50% of cases and include genetic abnormalities, anatomic abnormalities of the uterus, endocrine disorders, autoimmune conditions, infections, and environmental factors. While extensive testing and treatments are available, the cause remains unidentified in 30-40% of recurrent pregnancy loss cases. Providing psychological support to couples experiencing recurrent pregnancy loss can help improve future pregnancy outcomes.
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Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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2. Pre- test
With regard to recurrent pregnancy loss (RPL),
1.it affects 1–3% of couples trying to conceive.
2.a diagnosis of the cause is given to most couples after
3.a prevalence of up to 20% has been reported for
syndrome in those with this diagnosis.
2
3. Investigations that should be carried out in all patients
investigated for RPL include,.
1.hereditary thrombophilia screening.
2.pelvic ultrasound scan.
3.thyroid-peroxidase antibodies.
4.parental karyotyping
3
4. Introduction
A miscarriage is the spontaneous demise of a pregnancy
in utero before the fetus reaches viability. In the UK, this
definition applies up to 23 weeks and 6 days of gestation.
Considering the differences in definitions, it is difficult to
accurately calculate the prevalence of RPL. While one in
eight recognised pregnancies end in pregnancy loss, the
prevalence of RPL is about 1–3%.
9/3/2023
RPL
4
6. Aetiology
6
A 2018 study into RPL aetiology
showed only 26% of the
patients reviewed had an
explained cause, with the rest
not given an aetiology or a
causative reason.
Chromosomal abnormalities are
the commonest cause of
pregnancy loss. They account
for around 70% of early
pregnancy losses, although
only around 20% of those
occurring between 13 and
20 weeks of gestation
10. Chromosomal abnormalities
of the fetus
Numerical chromosomal abnormalities
are commonest and include trisomy
(52%), polyploidy (21%) and monosomy
(13%). A trisomy is believed to occur as a
result of nondisjunction during maternal
meiosis I. The risk of a chromosomal
abnormality of the fetus is higher in
women older than 35 years of age, which
supports the association of aneuploidy
and increasing maternal age.
10
11. Parental chromosomal abnormalities
• Parental carriership of a
chromosomal abnormality
occurs in 2–6% of patients
with RPL. Most commonly,
these are balanced reciprocal
or Robertsonian
translocations, so have a high
chance of a healthy live birth
in a future pregnancy.
12. Congenital uterine anomalies
• Congenital uterine anomalies (CUAs) are frequently associated with
RPL patients, with a prevalence of 13.3% in those with a history of
miscarriage compared with 5.5% in an unselected population. In high-
risk populations, uterine septae are commonest. Most people with a
CUA experience a normal reproductive outcome
12
13. Chronic endometritis
• Chronic endometritis (CE) has been associated with RPL in several studies; however, the actual
prevalence is hard to describe because there is lack of consensus on the best diagnostic method. In
a 2020 observational prospective longitudinal study, which included a systematic review and
meta-analysis, use of immunohistochemistry to quantify CD138+ cells was helpful in the diagnosis
of CE and for predicting further reproductive outcomes.
• The continuing Chronic Endometritis and Recurrent Miscarriage (CERM) trial will hopefully
provide more evidence when it is completed. In this trial, women with a history of two or more
consecutive pregnancy losses and who test positive for chronic endometritis, will be treated either
with 100 mg doxycycline twice daily or a placebo for 14 days and their pregnancy outcomes will
be compared.
13
14. CERVICAL INSUFFICIENCY
14
Cervical insufficiency is associated with RPL
more commonly in the second trimester.
There are no recommended investigations for
cervical insufficiency outside of pregnancy,
15. HYDROSALPINX
15
• A 2019 systematic review and meta-analysis suggested that the presence
of a hydrosalpinx can increase the risk of pregnancy loss and that
treatment can reduce this risk. However, a caution: most of the women
included in the review were specifically undergoing in vitro fertilisation
(IVF), so the findings should not be generalised to people conceiving
naturally.
16. THROMBOPHILIAS
• Hereditary thrombophilias include Factor V Leiden gene mutations,
prothrombin gene mutations and deficiencies in antithrombin, protein
C and protein S. Although they may be associated with adverse
pregnancy outcomes, the evidence is weak for any association with
RPL. A 2019 review showed no evidence that treatment of hereditary
thrombophilia improves pregnancy outcomes in RPL
• Antiphospholipid syndrome (APS) is the commonest acquired
thrombophilia, with a prevalence of 5–20% in RPL patients compared
with 2% in those with a low-risk obstetric history. It has been
described as the most important treatable cause of RPL.
16
17. Thyroid abnormalities
17
It has been known for some time that
overt hypothyroidism causes an
increased risk of RPL, so should be
treated. There is no link known
between hyperthyroidism and RPL;
however, the picture has been less
clear for subclinical hypothyroidism
(elevated thyroid-stimulating hormone
[TSH] and normal free thyroxine) and
thyroid autoimmunity. Some of this lack
of clarity appears to come from newer
guidelines suggesting a new upper limit
of normal for TSH of 4.0 mlU/L rather
than the previous 2.5 mIU/L.
A systematic review and meta-analysis
in 2020 showed no association
between subclinical hypothyroidism
and RPL. Although there is an
association between RPL and thyroid
autoimmunity, evidence suggests that
treatment of these patients does not
alter their outcome.
18. • 2020 systematic review and meta-analysis
showed an association between diminished
ovarian reserves and RPL
• However, this review suggests more
evaluations are needed for any prognostic
value of carrying out anti-mϋllerian hormone
(AMH) or antral follicle counts (AFC)
• There is some association between
polycystic ovary syndrome (PCOS) and
pregnancy loss risk. This is potentially
related to hyperinsulinemia and
hyperandrogenaemia, but there is no
evidence to suggest PCOS predisposes to
RPL
• There is no clear evidence on the effect
of either prolactin deficiency or
hyperprolactinaemia on RPL.
However, there is evidence that
bromocriptine treatment of
hyperprolactinaemia increases the live
birth rate.
• Diabetes mellitus is associated
with pregnancy loss: a high
haemoglobin A1C (HbA1C) in
the first trimester increases the
risk of pregnancy loss and
fetal malformation. Well-
controlled diabetes mellitus is
not a risk for RPL.
diabetes hyperprolactinemia
POOR OVARIAN
RESERVE
PCOS
18
19. LUTEAL INSUFFICIENCY
• There is no clear definition for luteal insufficiency, and it could be caused by
several pathologies, including prolactin disorders. There are no evidence-based
investigations to identify a prognostic value for luteal insufficiency, nor any
evidence of a direct association between it and RPL.
19
20. MALE FACTOR
• There is a growing body of evidence to suggest an association between RPL and
poor-quality sperm; however, this remains a controversial subject. A 2020
systematic review and meta- analysis31 showed that an increased sperm DNA
fragmentation index (DFI) was associated with RPL but studies on treatment and
prognosis are still lacking.
20
21. Some RPL patients will never identify a reason for their pregnancy losses. Several adjuvant
treatments have been considered for these groups, with mixed outcomes. A retrospective cohort
review published in 2018,specifically looked at adjuvant treatment in RPL. It concluded that more
than two-thirds of those with RPL will have a live birth in a subsequent pregnancy, and empirical
adjuvant treatment for these patients does not appear to offer any additional benefit.
21
22. MANAGEMENT- INVESTIGATIONS
• The management of people with RPL is multifactorial and should include lifestyle
modification, psychological support and specific treatment of any identified cause.
• Ideally, patients should attend as a couple to the RPL clinic. The first consultation
should include a full medical, obstetric and family history with information on the
lifestyle of both male and female partners, such as smoking, excessive alcohol
consumption, excessive exercise, being overweight or underweight.
25. USG
• Commonly, 2D pelvic transvaginal ultrasound scans are used as a first-line
investigation for uterine anomalies. These, as well as hysterosalpingography, are
good screening tests in low-risk women; however, 3D pelvic ultrasound is
recommended to diagnose and classify CUAs accurately.
• Magnetic resonance imaging (MRI), laparoscopy and hysteroscopy can all be
considered on an individual basis for complex CUAs or acquired uterine
anomalies.
26. THROMBOPHILIA
• Investigations for hereditary thrombophilias should only be carried out in the
presence of additional risk factors, including a strong personal or family history of
thrombosis or thrombophilia, or in the context of research.
• Diagnosis of APS requires a clinical manifestation (vascular thrombosis or
pregnancy morbidity) and the presence of at least one antiphospholipid antibody
(aPL) on two or more occasions at least 12 weeks apart. The commonly screened
aPLs are lupus anticoagulant (LA), anticardiolipin antibodies (ACA, IgG and
IgM) and b2 glycoprotein I antibodies (ab2GPI, IgG and IgM)
26
27. ENDOCRINOLOGY
• A TSH assessment is recommended to screen for hypothyroidism, followed by a
thyroxine (T4) assessment if TSH levels are greater than 4.0 mIU/L. An HbA1C
test should be used to investigate for diabetes mellitus, particularly if there are
considerable risk factors or any clinical evidence suggestive of diabetes mellitus.
If there are any clinical signs of hyperprolactinaemia
(oligomenorrhea/amenorrhea), then a prolactin level test should be requested
27
28.
29. MALE FACTOR
• There is a growing body of evidence to suggest an association between RPL and
poor-quality sperm; however, this remains a controversial subject. A 2020
systematic review and meta- analysis31 showed that an increased sperm DNA
fragmentation index (DFI) was associated with RPL, but studies on treatment and
prognosis are still lacking.
29
30. INFECTIONS
• Severe infections have been associated with spontaneous pregnancy losses, but their role in RPL is
unclear. Investigations for infection would be prudent if clinical signs and symptoms are present.
Routine screening for chronic endometritis has no evidence base, but samples taken for research is
reasonable.
• It is advisable to offer rubella immunity screening to RPL patients, as it is to patients undergoing
infertility investigations
30
31. IMMUNE
• A systematic review and meta-analysis explored associations between RPL and NK cells in both
peripheral blood and endometrial samples. However, any prognostic value or treatment options
remain unclear and should only be offered in the context of clinical research. Several other
immunological tests, including those for human leukocyte antigen (HLA), anti- histocompatibility
(anti-HY) antibodies and cytokines also have various weak associations with RPL, but no evidence-
based proven prognostic value or treatment is available
31
36. CHROMOSOMAL
36
Patients with chromosomal abnormalities should be referred for
genetic counselling. Although the option of preimplantation
genetic testing (PGT) has been shown to reduce the number of
pregnancy losses, there is no overall difference in the live birth
rate
The STAR (Single Embryo Transfer of Euploid
Embryo) study, a multinational multicentre randomised
controlled trial published in 2019, showed no
improvement in pregnancy outcomes from the use of
in vitro fertilisation (IVF) in combination with PGT for
aneuploidy screening (PGT-A).
37. 37
There is evidence to show improved live birth rates after treatment for fibroids that distort
the uterine cavity.
There is a lack of evidence for a direct association, or that treatment improves outcomes,
for other acquired uterine malformations such as polyps and uterine adhesions.
There is evidence that hysteroscopic septal division reduces pregnancy loss rates,
resulting in live births. However, owing to a lack of high-quality evidence of the efficacy and
safety of surgical treatment, this should only be offered on an individual basis by
experienced specialists.
38. Acquired thrombophilia
38
The use of unfractionated heparin (UFH) or low-molecular- weight
heparin (LMWH) combined with low-dose aspirin has been shown to
improve live birth rates and birthweights in RPL patients. LMWH has
the benefit of once-daily administration and a superior safety profile
for thrombocytopaenia and osteopenia over UFH.
A recommended treatment plan for APS patients is to start low-dose
aspirin and a prophylactic dose of LMWH from a first positive
pregnancy test. However, these patients should be recommended to
discuss plans for pregnancy in advance with their specialist.
39. Immunological treatments
• A systematic review and meta-analysis published in 2018 showed no improvement in the live birth
rate when looking at the role of immunotherapy for RPL. Use only in the context of research is
recommended
39
40. Endocrinological treatment
• If diabetes mellitus, thyroid disease, or hyperprolactinaemia are not well controlled, then gaining
preconceptual advice
• and input from specialists with an interest in pregnancy care is recommended. A TSH level of <4.0
mIU/L should be targeted, with no additional treatment for euthyroid women with thyroid peroxidase
antibodies.
• A 2009 systematic review and meta-analysis showed no effect of metformin on the pregnancy loss
risk for PCOS patients.
40
41. Male factor
• Although no specific evidence-based treatment for male factors is available, giving lifestyle
modification advice, such as on smoking, obesity and excessive exercise, to improve sperm DNA
damage is recommended.
• A 2019 Cochrane review looked at antioxidant use for male subfertility. Although this was low-quality
evidence, it suggested antioxidant supplementation in subfertile males may improve life birth rates.
Individual assessment for use could be consider, although this has not been directly examined with
RPL.
41
42. Unexplained pregnancy loss
• For several years, progesterone has been given empirically for unexplained pregnancy
loss. Indeed, a 2019 Cochrane review suggested that progesterone supplementation for
RPL may reduce the rate of pregnancy loss in further pregnancies.
• This information should be communicated to patients at high risk of pregnancy losses. If a
joint decision is reached to treat with progesterone, then we propose the use of the
following regimes of vaginal micronised progesterone: Women with vaginal bleeding and
a history of one or more previous pregnancy loss(es):400 mg twice dailystarting at the
time of presentation with vaginal bleeding and continued until 16 completed weeks of
gestation
• Women with a history of three or more previous pregnancy loss(es): 200 mg twice daily
starting at the time of presentation with vaginal bleeding and continued until 12
completed weeks of gestation; but if any vaginal bleeding, then increasing to 400 mg
twice daily and continued until 16 completed weeks of gestation
42
43. General treatments
• Lifestyle advice should include limiting alcohol and caffeine intake, stopping smoking, and
maintaining a and healthy weight/body mass index (BMI). If maternal BMI is ≥30, then high-dose
folic acid should be recommended. A discussion about vitamin D supplementation is recommended,
both pre-conceptually and during pregnancy.
• As well as offering potential treatments, it is important to discuss individualised psychological
support and lifestyle advice that can be offered to both partners in an RPL couple. Planning future
pregnancies should include offering early pregnancy ultrasound scans and ensuring patients have
appropriate contact numbers for early pregnancy units. Patients should be reassured that, despite a
diagnosis of RPL, around 70% of patients will achieve a live birth in their next pregnancy.
43
44.
45. The proportion of positive test results from RPL
investigations is the same when assessing those with,
1.either three or two previous pregnancy losses.
2.consecutive and non-consecutive pregnancy losses.
45
46. With regard to chromosomal abnormalities
1. most spontaneous pregnancy losses are euploid.
2. chromosome segregation errors in oocytes is the
maternal age being an independent risk factor for
46
47. With regard to chromosomal abnormalities of the fetus,
1.they account for most pregnancy losses before 12weeks
2.they account for most pregnancy losses between 13 and
gestation.
3.trisomy is the most common numerical abnormality
•
47