1 / 100

RECURRENT PREGNANCY LOSS

RECURRENT PREGNANCY LOSS. Dr.P.M.GOPINATH MD, DGO, FMMC, FICS, FICOG, MBA (HSM) Director of Social Obstetrics i/c ISO & KGH Chennai 600005. Recurrent Miscarriage-Definition.

meara
Download Presentation

RECURRENT PREGNANCY LOSS

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. RECURRENT PREGNANCY LOSS Dr.P.M.GOPINATH MD, DGO, FMMC, FICS, FICOG, MBA (HSM) Director of Social Obstetrics i/c ISO & KGH Chennai 600005

  2. Recurrent Miscarriage-Definition • Occurrence of 3 or more clinically recognized consecutive or nonconsecutive pregnancy losses before 20 weeks from last menstrual period • Primary- No previous full term pregnancy • Secondary- At least one successful pregnancy

  3. Incidence • 15-20% of all pregnancies • 11-13 % in first pregnancy • 13-17 % after first abortion • 38 % after two abortions • 55% after three abortions

  4. Recurent Miscarriage Etiology Explained • Anatomic (Sporadic) 12%-16% • Endocrine 17%-20% • Luteal phase deficiency • Uncontrolled DM • PCOS • Immunological 10%-16% • Anti phospholipid syndrome • Environmental • Alcohol, Smoking • Genetic factors 3.5-5% Un-explained 50%

  5. Anatomical Factors • What are the congenital & acquired • uterine anomalies leading to RSA? • How will you manage?

  6. Uterine Abnormalities • CONGENITAL (Mullerian Duct abnormalities) • UTERINE NEOPLASMS (Growth) • IATROGENIC (Acquired)

  7. ANATOMICAL CAUSES • Septate uterus • Intrauterine adhesions • Bicornuateut (unequal horns) • Unicornuate uterus • T shaped uterus • Submucous fibroids • Large endometrial polyps

  8. How they affect……. • Smaller Uterine Cavities • Fewer suitable implantation sites • Aberrations of vascularisation • May be accompanied by cervical incompetence Lead to both early & later pregnancy losses

  9. Septate Uterus • Most COMMON anomaly 55% • May be complete/ incomplete/segmental 25% early abortions 6.2% late abortions & Premature labors

  10. Unicornuate Uterus • 20% of anomalies • Agenesis or hypoplasia of one Mullerian duct • May be alone or accompanied by Rudimentary horn With presence / absence of cavity Communicating / Non communicating • Associated Renal anomalies occur in 40% patients Ipsilateral to hypoplastic horn

  11. Unicornuate Uterus • Abortion Rate 51%, Premature labours, malpresentations, IUGR, Uterine rupture & ectopic pregnancies common • Cervical encerclage to improve pregnancy outcome • Rudimentary Horn resected to prevent dysmenorrhoea, haematometra,ectopic pregnancy

  12. Uterus Didelphys • Least common anomaly -5-7% • Failure of lateral fusion of uterus &vagina • Abortion rate 43%,Premature birth rate 38% • Resection of Vaginal septum if there is difficulty in intercourse / vaginal delivery • Strassmann Operation not indicated

  13. Bicornuate Uterus • 10% of anomalies • Incomplete fusion of Uterine horns at level of fundus • Two separate but communicating endometrial cavities • Abortion rate 32% Preterm labour 21% • Strassman Metroplasty / Place IUCD in one horn

  14. Arcuate Uterus • Near complete resorption of u-v septum • Mild concave indentation at fundus • ? Anomaly / ? Anatomic variant • Data conflicting Abortion rates ?45% ?13% • Treatment expectant

  15. T shaped Uterus • Diethylstilbestrol treatment for Premature labour started 1940 Banned 1970 • 69% female foetuses suffered Uterine anomaly • T-Shaped uterus, small uterus, constriction rings, • Cervical hypoplasia, cervical incompetence, Anterior Cervical collar, pseudopolyps • 2 fold increase in abortion rates & 9 fold increase in Ectopic pregnancy rates

  16. T SHAPED UTERUS- INFECTION MALA ARORA

  17. Uterine Neoplasms • Endometrial Polyps

  18. PERIOSTEAL ENDOMETRIAL POLYP MALA ARORA

  19. Leiomyomas (Fibroids) most common…. 20-50% of reproductive women When will you considerfibroids responsible ?

  20. Preconception myomectomy to improve reproductive outcome can be considered on an individual basis • It is likely to have a place only in women who have recurrent pregnancy loss, • large submucosal fibroids, and no other identifiable cause for recurrent miscarriage Ouyang DW, Obstet Gynecol Clin North Am. 2006

  21. Iatrogenic… Intrauterine adhesions ,“Asherman’s Syndrome” • Lead to Poor implantation, • Decreased blood supply , • infection Abortion rates 40% Preterm labour 23% Management :-Hysteroscopic excision of adhesions

  22. HYSTEROSCOPIC CORRECTION • All of the above have a good pregnancy rate post hysteroscopic correction • Except ashermans syndrome

  23. Anatomical Factors • When will you label a patient as a case of incompetent Cervix? • What are the different surgical procedures? • Role of prophylactic surgery?

  24. USG follow up weekly in cases of prior 2nd trimester loss • Funneling of >25% cervical length and/or <2.5 cms cervical length before 24 weeks of pregnancy • Cervical cerclage reduces the rate of preterm birth Carp et al, 2007 • Emergency cerclage: beneficial if no infection or uterine contractions

  25. Genetic Etiology • Chromosomal 3.5%-5% • Fetal chromosomal abnormalities • Parental balanced chromosomal rearrangement • Single gene disorders • Alpha thalassemia major • Thrombophilia • X linked dominant disorders

  26. Risk Factors for Karyotypic abnormalities Gestational age Higher in early gestation 90% in anembryonic preg/Blighted ova 50% at 8-11wk 30% at 16-19 wk 6-12% >20wk

  27. Risk Factors for RM • Advanced maternal age • Affects ovarian function, giving rise to a decline in the number of good quality oocytes, resulting in chromosomally abnormal conceptions that rarely develop further. • RM risk -75% in women >45years • Previous number of miscarriages

  28. Spontaneous Miscarriage • 10-15% of recognized pregnancies • Mostly sporadic ; 80% losses in 1st 12 wks • 50-70% due to chromosomal anomalies • Autosomal trisomy 50-60% • 13,16,18,21,others • Monosomy X-20% • Triploidy –15% • Tetraploidy-5% • Unbalanced translocation-3-5% Parental Karyotypes normal Minimal recurrence risk

  29. In Recurrent Miscarriage (RM) • Fetal chromosomal abnormality in only 25-32% of product of conception (POC) • This may be due to abnormalities in the egg, sperm or both. • The  most common chromosomal defects are Trisomy, Monosomy, Polyploidy • Sperm aneuploidy (13,18,21,X,Y ) directly influences the rate of aneuploidy in the conceptus (Carrell et al 2003)

  30. In Recurrent Miscarriage • Parental chromosomal abnormality (Balanced chromosomal rearrangements) • General population 6 in 1000(0.6%) • RM 4.1-11% *3-5% of couples with RSA are carriers of balanced chromosomal rearrangements

  31. Parental Chromosomal Abnormalities • Translocation (commonest) (1in 500) • Reciprocal [50%] • Robertsonian [24%] • Mosaicism for a numeric aberration[12%] • Inversion

  32. Translocation Translocation is exchange of chromosomal segments between two, non-homologous chromosomes. Source-Internet

  33. Translocations  Two major types Reciprocal translocation-two non-homologous chromosomes exchange information Robertsonian translocation -two non-homologous acrocentric chromosomes break at the centromere and the long arms fuse. The short arms are often lost. Source- Emery’s book of principles of Medical Genetics

  34. Diagnosis • Karyotype of the abortus ( fetal/placental tissue) • Peripheral blood Karyotyping of the parents in all couples with RM

  35. Karyotype of Products of Conception • Successful culture requires healthy cells derived from the fetus • Unsuccessful in upto 50% of cases • Maternal overgrowth of fetal cells • Poor growth of abortus tissue esp. if there is a long time interval from the demise until the culture is performed • Poor chromosome morphology

  36. Whether we should do POC karyotype????

  37. Karyotype of Products of Conception • No definite recommendations for routinely obtaining abortus karyotype (ACOG 2001) • Karyotype analysis of abortus tissue for couples with a subsequent second or third pregnancy loss (Hogge, et al 2003) • If abortus is aneuploid, maternal cause is excluded (ACOG, 2001) • If POC karyotype not possible, do parental karyotype

  38. Karyotype of Products of Conception • Normal • Abnormal (trisomy or chromosomal rearrangement) Both requires parental karyotype Direct parental karyotype is more cost effective No need for first abortion

  39. Why Karyotype of the Parents ?? • Individuals with Balanced Chromosomal Rearrangement usually phenotypically normal • Are at risk of having conceptus with • normal • balanced phenotypically normal • unbalanced • spontaneously aborted • phenotypically malformed

  40. Single Gene Disorders in RM • Second and 3rd trimester losses • Alpha Thalassemia • Myotonic dystrophy • X linked Dominant disorder • IncontinentiaPigmenti • Chondrodysplasiapunctata • Focal dermal hypoplasia of Goltz • Rett Syndrome • Aicardi Syndrome

  41. Single Gene Disorders in RM • Hereditary thrombophilia • First and later trimester losses • Microthrombosis in placenta ;Impaired uteroplacental circulation • Factor V Leiden gene mutation Evidence based Prothrombin G 20210A mutation inc. risk • Protein C,S deficiency • Antithrombin III No significant association • MTHFR C677T mutation • Combination of any of above-Increased risk

  42. Genetic Evaluation and Testing Recommendation • History of • Recurrent miscarriage • Clotting disorder • Still birth/neonatal death • Babies with dysmorphic features • Infertility • Mental retardation /developmental delay • Inherited disorder (J Gen Counsel ;14(3)2005)

  43. Karyotypic abnormalities in couples with Recurrent abortions Dubey et al. Ind J Hum Genet 2005 • Total Couples n=742(1484 cases) • Duration -12 years • Chromosomal rearrangements = 52 (7% ) • Structural aberrations 22 (2.9%) • Reciprocal (6,8,11,18)=15 (68.2%) • Robertsonian (21,22,13,14)=4 (18.1%) • Inversion(4)=1 (9%) • Deletion=2 • Numerical anomalies (mosaics with XO,XXX, XXY)= 9 (1.2%) • Chromosomal variants (para centromeric heterochromatin/fragile sites) = 21 (3.2%)

  44. Role of Infections

  45. EGG 80% Venn diagram of the responsibilities of Reproductive Failure SPERM 10% UTERUS 10%

  46. Doubtful causes of RSA • TORCH infections • Endocrine and metabolic disease • Untreated adrenal hyperplasia, hypothyroidism & diabetes mellitus. • Exogenous causes • Environmental factors, alcohol, street drugs, anesthesia gases etc

  47. Its time to say goodbye to TORCH tests……. Cochrane Review has categorically proven in multiple meta-analysis that none of the “TORCH” group of infections are responsible for RECURRENT SPONTANEOUS ABORTIONS TORCHTESTS

  48. So which infections, if any are responsible for RSA? Female • Viral infections ? ? • Coxasackie B • Parovo-virus B • Bacterial infections • Bacterial Vaginosis • Tuberculosis • Chlamydia trachomatis Male factors: • Semen infections can cause anueploidy and be the reason of RSA

More Related