Recurrent pregnancy loss

1. Recurrent pregnancy loss Spontaneous pregnancy loss is the most common complication of pregnancy-70% of all human conceptions fail to achieve viability. Recurrent abortion –occurrence of 3 or more clinically recognised pregnancy losses before 20 weeks of gestation. Risk for subsequent pregnancy loss is estimated to be 24% after 2 clinically recognised losses,30% after 3 losses & 40—50 % after 4 losses. Clinical investigation for pregnancy loss should be initiated after 2 consecutive spontaneous abortions,especially if fetal cardiac activity is identified before any of the pregnancy losses,woman>35 yrs or the couple has difficulty in conceiving.

2. History • h/o consanguinity-single gene defects may cause RPL –revealed by a detailed family history. • Inherited thrombophilias can cause RPL-hyperhomocystinemia,activated protein c resistance,mutations in factor 5 leidein,protein C,S,antithrombin 3 • Parental chromosomal abnormalities like balanced translocations can cause RPL-cannot be ruled out by family history or prior term births.

3. History • h/o foul smelling vaginal discharge-suggestive of bacterial vaginosis .infection with ureaplasma,prevotella,b-hemolytic streptococcus,mycoplasma,gardenella,chlamydia have been implicated • Bacterial vaginosis-recurrent 2nd trimester loss.

4. History • HSV,CMV cause direct infection of the fetus,placenta-resulting villitis & tissue destruction-pregnancy disruption • Aqquired anatomic abnormalities-intrauterine adhesions,endometriosis,uterine fibroids.endometrium over fibroid/synechiae-inadequately vascularised-abnormal placentation-spontaneous pregnancy loss. • h/o any purulent discharge pv-endometritis,submucous fibroid polyp

5. History • h/o mass abdomen-fibroids,chocolate cysts • h/o pressure symptoms of fibroid-constipation & increased frequency of micturition • Exposure while in utero to maternal ingestion of diethyl stilbesterol-hypoplasia/anatomical abnormalities of uterus,cervix and vagina,incomplete mullerian duct fusion,incomplete septum resorption,cervical incompetence. • Presence of intrauterine septum-60% risk of spontaneous abortion-embryo implants on poorly developed endometrium over septum-1st tri abortion

6. History • h/o excessive vaginal mucoid discharge,wetness may be suggestive of cervical incompetence-mostly 2nd tri abortions. • h/o exposure to any medications –anti progestins,antineoplastic agents,inhalational anaesthetics • h/o exposure to ionising radiation/environmental toxins-heavy metals. • h/o pain abdomen,bleeding/spotting pv in present pregnancy

7. Menstrual history • h/o menorrhagia-fibroid(submucous),uterine malformations • h/o metrorrhagia-infected submucous fibroid polyp • h/o dysmenorrhoea-endometriosis,adenomyosis • h/o dyspareunia-endometriosis

8. Menstrual history • h/o irregular short cycles-luteal phase defect-inadequately/improperly timed endometrial changes at implantation sites. • In LPD -^ LH levels –causes premature aging of oocyte and dys-synchronus maturation of endometrium-recurrent preg.loss. • h/o irregular cycles with prolonged periods of amenorrhoea-PCOD,,hyperprolactinemia,uterine synechiae • PCOS-^ LH levels,^ androgen levels,insulin resistance-pregnancy loss

9. Obstetric history To be taken in detail in chronological order of events • Time after marriage the patient conceived,whether she undertook any treatment for infertility • At what gestational age the prior pregnancy loss occurred-whether it was associated with pain/bleeding,whether it was followed by a check curettage • Whether there was sudden painless loss of watery fluid pv followed by expulsion of the fetus • Whether fetus was alive/dead if born alive how long it lived • If IUD-fresh/macerated • Sex/wt of the fetus • h/o recurrent malpresentations in prior pregnancies –may suggest uterine malformations

10. PAST HISTORY- • h/o chronic HT,DM,TB, • Overt DM-hyperglycemia-embryotoxic,advanced IDDM-vascular complicatios-compromised blood flow to uterus. • h/o hyper/hypothyroidism-thyroid disease-ovulatory dysfunction,LPD. • Metabolic demands of early pregnancy mandates ^ requirement of thyroid hormones,so hypothyroidism-recurrent preg.loss. • In clinically euthyroid patients-presence of antithyroid antibodies may be associated with RPL-due to generalised autoimmunity/impaired ability of thyroid to meet demands of pregnancy.

11. h/o connective tissue disorders,h/o thrombotic events-suggestive of APAS-causes 3-5% of RPL. • Past surgical history-D&C,MTP,check curettage,amputation of cervix/cone biopsy-cervical incompetence • h/o surgeries myomectomy/metroplasty • FAMILY HISTORY-of recurrent spontaneous abortions,chronic medical conditions,thrombotic events • PERSONAL HISTORY-h/o smoking,tobacco chewing,alcohol consumption/drugs-cocaine

12. Examination • Obesity,hirsuitism,acanthosis,thyroid enlargement • galactorrhoea-hyperprolactinemia • Pallor-menorrhagia • p/a-irregular contour of uterus may suggest fibroids with pregnancy,bicornuate uterus • Cystic swellings with fixity/tenderness-endometriosis • malpresentations may be present • P/S may show myomatous polyp protruding through the os. • Bluish black puckered spots may be seen in the posterior fornix-endometriosis • Congenital anatomical abnormalities may be revealed.

13. Examination • Whether cervix scarred-amputation/conisation • Any signs of infection-tender swollen red vagina in bacterial vaginosis.discharge from cervix-endometritis • Estrogenisation of the tissues can be made out. • During pregnancy-whether the os is open,if open whether membranes are bulging thruogh os.periodic inspection of the cervix from 10th week onwards may be done weekly-dilatation of internal os with herniation of membranes will be diagnostic. • In interconceptional period-passage of no6-8 hegar’s dilators beyond the internal os without pain or resistance and absence of snap of internal os on withdrawing it especially in the premenstrual phase is suggestive of cervical incompetence. • Bimanual pelvic examination-enlarged irregular firm uterus-fibroid,retroverted fixed uterus,b/l forniceal tenderness/mass &cobblestone feel of uterosacrals –endometriosis • In adenomyosis-assymetrical enlargement of uterus with tenderness