RECURRENT MISCARRIAGE GUIDELINES RECURRENT MISCARRIAGE GUIDELINES MAJ DR AMINA AKBAR MBBS, MCPS,...
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Transcript of RECURRENT MISCARRIAGE GUIDELINES RECURRENT MISCARRIAGE GUIDELINES MAJ DR AMINA AKBAR MBBS, MCPS,...
RECURRENT RECURRENT MISCARRIAGEMISCARRIAGEGUIDELINESGUIDELINES
MAJ DR AMINA MAJ DR AMINA AKBARAKBAR
MBBS, MCPS, FCPSMBBS, MCPS, FCPS
DEFINITIONDEFINITION
A recurrent miscarriage is defined A recurrent miscarriage is defined
as as 3 or more consecutive, 3 or more consecutive,
spontaneous pregnancy lossesspontaneous pregnancy losses, ,
under 20 week gestation from the under 20 week gestation from the
last menstrual period last menstrual period
Primary recurrent pregnancy loss" Primary recurrent pregnancy loss"
refers to couples that have never had a refers to couples that have never had a
live birth live birth
While While "secondary RPL""secondary RPL" refers to those refers to those
who have had repetitive losses who have had repetitive losses
following a successful pregnancy following a successful pregnancy
TERMINOLOGYTERMINOLOGY
The medical term The medical term ' abortion' ' abortion' should be should be
replaced with the term replaced with the term 'miscarriage''miscarriage'
Other names : Recurrent Pregnancy Loss (RPL), Other names : Recurrent Pregnancy Loss (RPL),
Habitual Abortions ,Habitual Abortions ,
Habitual Miscarriages, Habitual Miscarriages,
Recurrent Abortions ,Recurrent Abortions ,
Recurrent Miscarriages. Recurrent Miscarriages.
INCIDENCEINCIDENCE
1010––15%15% of all clinically recognized of all clinically recognized
pregnancies end in a miscarriage pregnancies end in a miscarriage
Recurrent miscarriage affects Recurrent miscarriage affects 0.5-2%0.5-2% of all of all
women -- Hence, only a proportion of women -- Hence, only a proportion of
women presenting with recurrent women presenting with recurrent
miscarriage will have a persistent miscarriage will have a persistent
underlying cause for their pregnancy losses underlying cause for their pregnancy losses
RISK FACTORSRISK FACTORS
Advanced maternal age Advanced maternal age adversely adversely
affects ovarian function, giving rise to a affects ovarian function, giving rise to a
decline in the number of good quality decline in the number of good quality
oocytes, resulting in chromosomally oocytes, resulting in chromosomally
abnormal conceptions that rarely abnormal conceptions that rarely
develop furtherdevelop further
Previous number of miscarriages Previous number of miscarriages
POSSIBLE CAUSESPOSSIBLE CAUSES
Recurrent miscarriage is a Recurrent miscarriage is a
heterogeneous condition that has heterogeneous condition that has
many possible causes; many possible causes; more than one more than one
contributory factor may underlie the contributory factor may underlie the
recurrent pregnancy lossesrecurrent pregnancy losses
Each may have had Each may have had a different a different cause cause
Geneticfactors
Anatomicalfactors
EndocrineInfectiveagents
Immunefactors
InheretedThrombophilic
defect
Explained Un-explained
RecurrentMiscarriage
Enviromentalfactors
Body Cervix
Paternalkaryotyping
CytogeneticOf miscarriage
C I
Uterineanomalies
APS
BacterialVaginosis
All couples with a history of recurrent All couples with a history of recurrent miscarriage should have peripheral miscarriage should have peripheral blood karyotyping performed. The blood karyotyping performed. The finding of an abnormal parental finding of an abnormal parental karyotype should prompt referral to a karyotype should prompt referral to a clinical geneticist.clinical geneticist.
33––5% of couples with recurrent 5% of couples with recurrent miscarriage, one of the partners carries a miscarriage, one of the partners carries a balanced structural chromosomal anomaly balanced structural chromosomal anomaly
55––10% chance of a pregnancy with an 10% chance of a pregnancy with an unbalanced translocation. unbalanced translocation.
FETAL CHROMOSOMAL FETAL CHROMOSOMAL ABNORMALITIESABNORMALITIES
This may be due to abnormalities in This may be due to abnormalities in
the egg, sperm or both. Thethe egg, sperm or both. The most most
common chromosomal defects are:-common chromosomal defects are:-
Trisomy:Trisomy:
MonosomyMonosomy
PolyploidyPolyploidy
Chromosome Testing on Fetal (Miscarriage) Chromosome Testing on Fetal (Miscarriage)
TissueTissue
This can only be done right at the time of This can only be done right at the time of
miscarriage.miscarriage.
It is an analysis of the genetic makeup of the It is an analysis of the genetic makeup of the
fetus. fetus.
It can indicate genetic problems that lead to RPL. It can indicate genetic problems that lead to RPL.
Many miscarriages are caused by chromosomal Many miscarriages are caused by chromosomal
abnormalities that are unlikely to repeat. To know abnormalities that are unlikely to repeat. To know
if the problem is likely to recur, it is necessary to if the problem is likely to recur, it is necessary to
study the genetics of both parents as well.study the genetics of both parents as well.
Karyotyping of ParentsKaryotyping of Parents
Chromosome analysis of blood of both Chromosome analysis of blood of both
parents.parents.
It can show if there is a potential problem with It can show if there is a potential problem with
one of the parents that leads to miscarriage, one of the parents that leads to miscarriage,
but often has to be done in conjunction with but often has to be done in conjunction with
fetal testing to provide answers.fetal testing to provide answers.
CONGENITAL ANOMALIESCONGENITAL ANOMALIES An abnormal or irregularly shaped uterus.An abnormal or irregularly shaped uterus.
Sometimes Sometimes the uterus has an extra wall down its centre, which
makes it look as if it is divided into it is divided into
two (bicornuate or septate uterus) (bicornuate or septate uterus)
a septate uterus Where as a partial septum increases the risk a septate uterus Where as a partial septum increases the risk
to 60%-75%; a total septum carries a risk for loss of up to 90%. to 60%-75%; a total septum carries a risk for loss of up to 90%.
Today a relatively simple surgical procedure can remove a Today a relatively simple surgical procedure can remove a
uterine septum uterine septum
or it may or it may have only developed one half (unicornuate uterus)(unicornuate uterus). .
The reported prevalence of uterine anomalies The reported prevalence of uterine anomalies in recurrent miscarriage populations range in recurrent miscarriage populations range between 1.8% and 37.6%. between 1.8% and 37.6%.
The prevalence of uterine malformations The prevalence of uterine malformations appears to be higher in women with appears to be higher in women with late late miscarriages miscarriages compared with women who suffer compared with women who suffer early miscarriagesearly miscarriages
Untreated uterine anomalies Untreated uterine anomalies has a term has a term delivery rate of only 66%. delivery rate of only 66%.
Open uterine surgery Open uterine surgery is associated with is associated with postoperative infertility and carries a postoperative infertility and carries a significant risk of uterine scar rupture during significant risk of uterine scar rupture during pregnancy. Therefore treatment of uterine pregnancy. Therefore treatment of uterine anomalies in women with recurrant anomalies in women with recurrant miscarriage remains controversial.miscarriage remains controversial.
FIBROIDSFIBROIDS If fibroids are detected on the inside of the If fibroids are detected on the inside of the
uterus (termed submucous fibroids) and uterus (termed submucous fibroids) and
distort the uterine lining, they are a distort the uterine lining, they are a
significant cause of reproductive problems significant cause of reproductive problems
and should be removed. It is less clear and should be removed. It is less clear
whether fibroids in the wall of the uterus whether fibroids in the wall of the uterus
cause reproductive problems cause reproductive problems
All women with recurrent All women with recurrent miscarriage should have a miscarriage should have a pelvic ultrasound to assess pelvic ultrasound to assess uterine anatomy and uterine anatomy and
morphologymorphology
Two dimensional pelvic ultrasound Two dimensional pelvic ultrasound
assessment of the uterine cavity assessment of the uterine cavity
with (or without) with (or without)
SonohysterographySonohysterography
HYSTEROSALPINGOGRAPHYSTEROSALPINGOGRAPHYHY
The routine use of hysterosalpingography as The routine use of hysterosalpingography as a screening test for uterine anomalies in a screening test for uterine anomalies in women with recurrent miscarriage is women with recurrent miscarriage is questionablequestionable..
It is associated with patient discomfort, It is associated with patient discomfort, carries a risk of pelvic infection and carries a risk of pelvic infection and
radiation exposure radiation exposure and is no more sensitive than the non-and is no more sensitive than the non-
invasive two dimensional pelvic ultrasound invasive two dimensional pelvic ultrasound assessment of the uterine cavity with (or assessment of the uterine cavity with (or without) Sonohysterography when without) Sonohysterography when performed by skilled and experienced performed by skilled and experienced personnel. personnel.
HYSTEROSCOPYHYSTEROSCOPYThis investigation, performed under general This investigation, performed under general
anaesthetic, examines the inside of the uterus anaesthetic, examines the inside of the uterus
with a thinwith a thin
telescope (3-5 mm in diameter) . By inserting this telescope (3-5 mm in diameter) . By inserting this
telescope through the cervix and into the uterus,telescope through the cervix and into the uterus,
the doctor can see the shape of the uterus and the doctor can see the shape of the uterus and
examine its lining.examine its lining.
Diagnosis of cervical incompetence is based on Diagnosis of cervical incompetence is based on
history of late miscarriage preceded by history of late miscarriage preceded by
spontaneous rupture of memb or painless spontaneous rupture of memb or painless
cervical dilatation. Vaginal USG is helpful in cervical dilatation. Vaginal USG is helpful in
assessing early features of cervical assessing early features of cervical
incompetence. Cervical cerclage is associated incompetence. Cervical cerclage is associated
with potential hazards associated with surgery with potential hazards associated with surgery
and risk of uterine contractionsand risk of uterine contractions..
Routine screening for occult Routine screening for occult diabetes and thyroid disease diabetes and thyroid disease
with oral glucose tolerance and with oral glucose tolerance and thyroid function tests in thyroid function tests in asymptomatic women asymptomatic women
presenting with recurrent presenting with recurrent miscarriage is uninformativemiscarriage is uninformative
Well-controlled diabetes mellitus is not a Well-controlled diabetes mellitus is not a
risk factor for recurrent miscarriage, nor risk factor for recurrent miscarriage, nor
is treated thyroid dysfunction is treated thyroid dysfunction
There is insufficient evidence There is insufficient evidence
to evaluate the effect of to evaluate the effect of
progesterone supplementation progesterone supplementation
in pregnancy to prevent a in pregnancy to prevent a
miscarriagemiscarriage
There is insufficient evidence to There is insufficient evidence to evaluate the effect of human evaluate the effect of human
chorionic gonadotrophin (hCG) chorionic gonadotrophin (hCG) in pregnancy to prevent in pregnancy to prevent
miscarriagemiscarriage..
Early pregnancy hCG supplementation Early pregnancy hCG supplementation
failed to show any benefit in pregnancy failed to show any benefit in pregnancy
outcome outcome
IMMUNE FACTORSIMMUNE FACTORS
One in ten women with recurrent miscarriages One in ten women with recurrent miscarriages
show evidence of auto immune factors on show evidence of auto immune factors on
investigationinvestigation
As much as As much as 40 percent 40 percent of unexplained infertility of unexplained infertility
may be the result of immune problems. may be the result of immune problems.
Unfortunately for couples with immunological Unfortunately for couples with immunological
problems, their chances of recurrent loss problems, their chances of recurrent loss
increase with each successive pregnancyincrease with each successive pregnancy..
ANTITHYROID ANTIBODIESANTITHYROID ANTIBODIES
Routine screening for thyroid Routine screening for thyroid
antibodies in women with antibodies in women with
recurrent miscarriage is not recurrent miscarriage is not
recommendedrecommended..
ANTIPHOSPHOLIPID ANTIPHOSPHOLIPID SYNDROMESYNDROME
To diagnose APS it is mandatory that the To diagnose APS it is mandatory that the patient should have two positive tests at patient should have two positive tests at least six weeks apart for either lupus least six weeks apart for either lupus anticoagulant or anticardiolipin (aCL) anticoagulant or anticardiolipin (aCL) antibodies of IgG and/or IgM class present antibodies of IgG and/or IgM class present in medium or high titre.in medium or high titre.
Adverse pregnancy outcomes include Adverse pregnancy outcomes include Three or more consecutive miscarriages Three or more consecutive miscarriages
before ten weeks of gestationbefore ten weeks of gestation One or more morphologically normal fetal One or more morphologically normal fetal
deaths after the tenth week of gestation anddeaths after the tenth week of gestation and One or more preterm births before the 34th One or more preterm births before the 34th
week of gestation due to severe pre-week of gestation due to severe pre-eclampsia, eclampsia or placental eclampsia, eclampsia or placental insufficiency. insufficiency.
In women with a history of recurrent In women with a history of recurrent
miscarriage and aPL, future live birth miscarriage and aPL, future live birth
rate is significantly improved when a rate is significantly improved when a
combination therapy of aspirin plus combination therapy of aspirin plus
heparin is prescribed.heparin is prescribed.
Pregnancies associated with aPL Pregnancies associated with aPL
treated with aspirin and heparin remain treated with aspirin and heparin remain
at high risk of complications during all at high risk of complications during all
three trimesters.three trimesters.
Inherited thrombophilic defects,Inherited thrombophilic defects,
Including activated protein C resistance (most Including activated protein C resistance (most
commonly due to factor V Leiden gene commonly due to factor V Leiden gene
mutation), deficiencies of protein C/S and mutation), deficiencies of protein C/S and
antithrombin III, hyperhomocysteinaemia and antithrombin III, hyperhomocysteinaemia and
prothrombin gene mutation,prothrombin gene mutation,
Are established causes of systemic Are established causes of systemic
thrombosis thrombosis
Screening for and treatment of bacterial Screening for and treatment of bacterial
vaginosis in early pregnancy among vaginosis in early pregnancy among
high risk women with a previous history high risk women with a previous history
of second-trimester miscarriage or of second-trimester miscarriage or
spontaneous preterm labour may spontaneous preterm labour may
reduce the risk of recurrent late loss reduce the risk of recurrent late loss
and preterm birth.and preterm birth.
Exposture to noxious or toxic substances are Exposture to noxious or toxic substances are
known to be associated withknown to be associated with recurrent recurrent
miscarriage ( cigarretes,alcohol and miscarriage ( cigarretes,alcohol and
caffeine ,anaestetic gases,petrolium products )caffeine ,anaestetic gases,petrolium products )
UNEXPLAINED UNEXPLAINED RECURRENT RECURRENT
MISCARRIAGEMISCARRIAGE In about half the women in the research In about half the women in the research
studies, studies, no cause no cause could be found, so no
specific treatment could be given.
However, this group responded very well to a However, this group responded very well to a
programme which removed as many programme which removed as many stress stress
factorsfactors as possible from their lives, resulting in as possible from their lives, resulting in
an 80% success rate with the subsequent an 80% success rate with the subsequent
pregnancy pregnancy
PSYCHOLOGICAL SUPPORTPSYCHOLOGICAL SUPPORT The value of psychological support in improving The value of psychological support in improving
pregnancy outcome has not been tested in the form of a pregnancy outcome has not been tested in the form of a
randomised controlled trial. However, data from several randomised controlled trial. However, data from several
non-randomised studiesnon-randomised studies86–88 have suggested that 86–88 have suggested that
attendance at a dedicated early pregnancy clinic has a attendance at a dedicated early pregnancy clinic has a
beneficial effect, although the mechanism is unclearbeneficial effect, although the mechanism is unclear
All professionals should be aware of the All professionals should be aware of the
psychological sequelae associated with miscarriage psychological sequelae associated with miscarriage
and should provide support and follow-up, as well and should provide support and follow-up, as well
as access to formal counselling when necessary.as access to formal counselling when necessary.