ART PREGNANCY- ARE THEY DIFFERENT ? Yes they are.. Need extra vigilance.. Problems are Unique to them..

1. DR. RENU MAKWANA
MBBS, MS, FICOG
VASUNDHARA HOSPITAL LIMITED
Sec-11 Near Chopasani Housing Board,
Jodhpur (Raj.)
Phone No.: 0291-2709001 / 9002
Email: care@vasundhrahospital.com
Website:
www.vasundharahospital.com
www.vasundhrafertility.com

2. ART PREGNANCY- ARE THEY DIFFERENT ?
Yes they
are
Need extra vigilance
Problems are
Unique to them
DR RENU MAKWANA MBBS MS FICOG

6. Egg number and perinatal outcomes
• Pregnancies following ART associated with higher risk low
birth weight (LBW) and preterm birth (PTB)
(Schieve et al., Matern Child Health J 2007; McDonald et al.,
Eur J Obstet Gynecol Reprod Biol 2009)
• Is there an association between response to ovarian
stimulation and perinatal outcomes?

7. Sunkara et al., Hum Reprod 2014

10. Complete workup and counseling of couple for
medical co-morbidities and inheritable
diseases.
High order pregnancies-option for fetal
reduction should be discussed.

13. ART pregnancies are at higher risk of-
• Gestational diabetes mellitus, gestational
hypertension, preeclampsia, intra hepatic
cholestasis of pregnancy
• Placenta mediated diseases.
• Preterm labour, low birth weight, and small-
for-date infant compared with spontaneously
conceived births.

17. GDM
• Reddy et al.15 and Allen et al.16 reported that pregnancies
after ART demonstrated increased rate of GDM.
• It is suggested that insulin resistance and hyperinsulinemia
might partly explain the etiology of GDM. GDM could be
related to the relatively high prevalence of polycystic ovary
syndrome (PCOS) among patients undergoing ART.
Furthermore, insulin resistance, which is a known risk
factor for the development of GDM, has been proven in a
certain proportion of PCOS patients.
Kopp, W. Role of high-insulinogenic nutrition in the etiology
of gestational diabetes mellitus. Med Hypotheses 64, 101–
103 (2005).

18. Active demethylation might be induced by ART
while epigenetic changes were likely to be
involved in GDM.
The development of GDM is proposed to be
resulted from epigenetic modifications
Li, T. et al. IVF results in de novo DNA methylation and histone
methylation at an Igf2-H19 imprinting epigenetic switch. Mol
Hum Reprod 11, 631–640 (2005).
GDM

19. ‘ HURT ME WITH THE TRUTH, I DON’T MIND.
BUT, NEVER COMFORT ME WITH A LIE’
Soaring rates of “ At-risk” pregnancies reflects
changing profile of risk factors.
&
Changing trends in labor management in keeping
with challenges of “At-risk” pregnancies….. NEED OF
THE HOUR

21. Gestational Diabetes Complication
The rate of GDM in Asian women is 5-10 times higher than in white women
Complications of pregnancy associated with GDM
Fetal macrosomia
(16%-29%)
On cidence
Increased rates
of cesarean delivery
Increase in
hypertensive
disorders
Maternal and
Infant mortality
And morbidity

22. Screening and Monitoring
Weighing pregnant women
Early OGTT
Early screening for vascular disease
Anomaly Screening
High-Risk model of care with regular screening
for preeclampsia-early urinary protein
estimation and baseline blood pressure
measurement

23. ViciousCycle: Diabesity begets Diabesity.
Obesity-PCOD-GDM, Putting her pregnancy’At Risk
PCOS Insulin Resistance Environmental Factors
OBESITY
Hyperlipidemia Glucose
Intolerance Endothelial
Dysfunction
•Delayed pregnancy
•Risk of cesarean
deliveries
Gestational
Diabetes
Type 2
Diabetes
Macrosomia
Childhood
Obesity

24. ART PREGNANCY AND ICP
Pregnancies with ART had a higher rate of ICP
(11.4% vs. 4.3%, for with ART and no ART,
respectively) associated with increased
rates of fetal morbidity and mortality, and an
increased risk of maternal coagulopathy
Davidson, K. M. Intrahepatic cholestasis of
pregnancy. Semin Perinatol 22, 104–111 (1998).

25. The exogenous sex hormones, GnRH-a and Gn
may affect the sex hormones secretion
through hypothalamic-pituitary-gonadal axis
and other mechanisms. So the hormone-
related complications like GDM, PE and ICP
may occur.
Tallo CP, Vohr B, Oh W, Rubin LP, Seifer DB, Haning RV Jr. Maternal and
neonatal morbidity associated with in vitro fertilization. J
Pediatr. 1995;127:794–800

26. ART CONCEPTION
• Biochemical pregnancy loss rates -
11% to as high as 35%
• The risk of ectopic pregnancy including
heterotopic is increased at least 2-fold
in patients who conceive after IVF–ET
Talaulikar, V. S. & Arulkumaran, S. Reproductive outcomes
after assisted conception. Obstet Gynecol Surv 67, 566–583
(2012).

27. ART CONCEPTION
Late pregnancy loss (after 12 weeks
gestation) -2 and 4% which is higher than
that of spontaneously conceived
pregnancies -1%
• Multiple pregnancies -10 times higher
than 3% in general population.
Reynolds MA, Schieve LA, Martin JA, Jeng G, Macaluso M.
Trends in multiple births conceived using assisted reproductive
technology, United States, 1997-2000. Pediatrics. 2002;111:1159–
1162

28. Risk factors of EUP
• Tubal diseases- 3.6%
• H/O PID
1. Previous EUP
2. Documented tubal pathology
3. Higher transfer volume of culture media during ET
4. Different hormonal milieus resulting from ovulation
induction protocols, particularly clomiphene citrate
(high estrogen levels increase tubal peristalsis)
• ANKUM ETAL

29. HETEROTOPIC PREGNANCY
• Spontaneous pregnancies- 1 in 200- 1 in
30000,ART- 1 in 100 pregnancies
• Risk factors of heterotopic pregnancy
1. Distorted pelvic anatomy
2. Greater number of embryos transferred
While scanning for intrauterine
pregnancy always scan adnexa too

30. Placenta-mediated pregnancy
complications
• ART singleton pregnancies were associated with
significantly higher odds of placenta previa (OR,
2.25, 95% CI 1.75–2.89),placenta abruption (OR,
4.43, 95% CI 2.28–8.61), and placental adherence
(OR, 2.21, 95% CI 1.71–2.84
• Intrauterine operation and manipulation of
embryonic cells in ART might be related to
abnormalities of location, development and
function of the placenta
Shevell, T. et al. Assisted reproductive technology and pregnancy
outcome. Obstet Gynecol 106, 1039–1045 (2005).

31. Placenta-mediated pregnancy
complications
Romundstad et al. compared the risk of
placenta previa between consecutive
pregnancies in the same mother, where one
sibling was conceived spontaneously and the
other by IVF, and found that placenta previa
occurred six times more often in singleton
pregnancies after ART
Romundstad, L. B. et al. Increased risk of placenta previa in pregnancies
following IVF/ICSI; a comparison of ART and non-ART pregnancies in the
same mother. Hum Reprod 21, 2353–2358 (2006).

32. The pregnant women have a strong willingness
to rescue the newborn in the assisted
reproductive pregnancy
Risk of venous
thromboembolism
Bone loss
Thrombo
prophylaxis

33. Neonatal Outcomes in IVF, ICSI and
Spontaneously Pregnant Groups.
Neonatal Outcomes in IVF, ICSI and Spontaneously
Pregnant Groups.; ICSI, intracytoplasmic sperm
injection. IVF group (3204 infants) consisted of 1450
cases of singleton gestation and 877 cases of twin
gestation; ICSI group (419 infants) consisted of 209
cases of singleton gestation and 105 cases of twin
gestation; Control group (5371 infants) consisted of
5193 cases of singleton gestation and 89 cases of twin
gestation. Bonferroni corrected p-value = 0.016.
aSignificantly different from control group (P < 0.016).
bSignificantly different from ICSI group (P < 0.016).

34. Wang, Y. A., Sullivan, E. A., Healy, D. L. & Black, D. A. Perinatal outcomes
after assisted reproductive technology treatment in Australia and New
Zealand: single versus double embryo transfer

35. Birth defects and ART
Birth defects include fetal malformations
determined by ultrasound, chromosomal
abnormalities and malformation found after birth
such as strephenopodia, hexactylia and so on.
A meta-analysis of birth defects in children
conceived by IVF and ICSI was published in
2012.It reported that there was a significantly
increased risk of birth defects in infants conceived
by ART, but ICSI did not increase the risk
compared with IVF.

36. Birth defects and ART
Another study in 2012 shows that treatment with ART is
associated with increased risks of cardiovascular,
musculoskeletal, urogenital, and gastrointestinal
defects and cerebral palsy.
The effect of ART on the nervous system was relatively
obvious compared with the effects on eyes, ears, face,
and neck, which may suggest that the earlier
developed systems were more sensitive to birth
defects by ART.
Davies MJ, Moore VM, Willson KJ, Van Essen P, Priest K, Scott H, et al. Reproductive
technologies and the risk of birth defects. N Engl J Med. 2012;366:1803–1813

37. Birth defects and ART
These could be due either to ART procedures
themselves or to the underlying infertility in
the couples seeking treatment, or to both .
Bonduelle M, Van Assche E, Joris H, Keymolen K, Devroey P, Van Steirteghem A, et
al. Prenatal testing in ICSI pregnancies: incidence of chromosomal anomalies in
1586 karyotypes and relation to sperm parameters. Hum Reprod. 2002;17:2600–
2614.

38. IAP-FOGSI ART Babies
Developmental delay- 4
fold increased risk
1. Prematurity
2. Multiple Pregnancies
3. Congenital
Malformations
4. Imprinting disorders
Multiple pregnancies- 27%
LBW- 27.4%
Preterm birth- 30.3%

41. DIAGNOSIS
• Usg - TVS for measuring cervical
length.

42. COMPLICATIONS
• RDS
• IVH
• NEC
• ROP
• APNOEA
• INFECTIONS
• JAUNDICE
• HYPOTHERMIA
• ANEMIA

43. NECROTISING ENTEROCOLITIS

44. RESPIRATORY DISTRESS SYNDROME
Antenatal steroids

45. INTRAVENTRICULAR HEMOPRRHAGE
Magsulf
Neuroprophylaxis

46. Y chromosome microdeletion

47. CHD- TETRALOGY OF FALLOT
Fetal echocardiography

48. IMPRINTING DISORDERS
• Genomic imprinting
• specialized epigenetic mechanism silences one
parental allele, while enabling gene expression from
the other parental allele.
• Genomic imprinting required for
• normal development, and disrupted imprinting is
associated with significant pathologies including:
• Angelman syndrome,
• Prader–Willi Syndrome (PWS),
• and Beckwith–Wiedemann Syndrome (BWS)

50. Prediction of Preterm labour, PIH,USG Fetal Surveillance in
High Risk Pregnancy
YES ..ART PREGNANCIES ARE
DIFFERENT !
& UNIQUE AS WELL !!!

51. Multidisciplinary team work
• Good antenatal care with screening .
• Antenatal steroids for lung maturation
• Magnisium sulfate for neuroprotection
• Delayed cord clamping
• Infection prevention and screening for IEM
• In high order pregnancy- option for fetal reduction.
• Quality neonatal care
• Preparedness to handle maternal complications

52. Our Strength
Department of Gynecology & Obstetrics