dr seema mehrotra dept of obstetrics and gynaecoloy recurrent abortions
TRANSCRIPT
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Dr Seema MehrotraDept Of Obstetrics and Gynaecoloy
Recurrent abortionsRecurrent abortions
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Defnition Defnition Recurrent abortions is traditionally
defined as three or more consecutive miscarriages occurring before 20 weeks.
May affect as many as 1% to 2% of women of reproductive age
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Some guidelines use the definition of two or more miscarriages for offering an evaluation of etiologic causes.
(ASRM 2008)
An earlier evaluation( investigation) may be indicated
fetal cardiac activity was identified prior to a loss,
Woman older than 35 years, Couple had difficulty in conceiving. (infertility)
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Risk factors for recurrent abortionsMaternal age- associated with a decline in
both the number and quality of the remaining oocyte
Previous miscarriages- risk increases with each successive pregnancy loss,40% after 3 consecutive pregnancy losses
Obesity-increases risk of both sporadic and recurrent miscarriage
Environmental factors-Cigarette smoking, caffeine and alcohol consumption,
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Causes of Recurrent Pregnancy Causes of Recurrent Pregnancy LossLoss
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◦ Repetitive first trimester losses
◦ Anembryonic pregnancies
◦ History of malformations or mental retardation
◦ Advanced maternal age
Genetic etiology less likely with late first trimester or second trimester losses
GENETIC FACTORS
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Genetic factorsParental Chromosomal abnormalities- • One of the partner carries a balanced
structural chromosomal anomaly• Most common is balanced reciprocal and
Robertsonian translocation which causes unbalanced translocation in the fetus
Embryonic Chromosomal abnormalities- • Due to abnormalities in the egg, sperm
or both .Most common- Monosomy or trisomyMainly responsible for sporadic miscarriage
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Genetic counselling
Assisted reproductive technologies, including PGD (preimplantation genetic diagnosis)
Use of either donor oocyte or donor sperm depending on the affected partner
MANAGEMENT
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Acquired or congenital anomalies
Congenital uterine anomalies: 6 - 7 % in women with RPL vs. 2 % in all women.
Pathogenesis uncertain but attributed to :
Reduced intrauterine volume
Poor vascular supply
ANATOMIC FACTORS-UTERINE FACTORS
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Congenital•Septate uterus 65 %Unicornuate uterus 50% lossUterus didelphys 40% lossBicornuate uterus 30 % lossDES exposure - many have abnormal
uterine structure (T shaped uterus+/-cervical changes)-24 %
AcquiredUterine LeiomyomasIntrauterine Adhesions(Asherman’s
Syndrome)Incompetent cervix
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Sonohysterography (SIS)◦ More accurate than HSG◦ Differentiate septate & bicornuate
uterus
Hysterosalpingogram (HSG)◦ Does not evaluate outer contour◦ Not ideal for the cavity
Hysteroscopy◦ Gold standard for Dx + Rx intrauterine
lesions
UTERINE ASSESSMENT
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Ultrasound◦ Presence and location of uterine
myomas ◦ Associated renal abnormalities
MRI◦ Differentiate septate from bicornuate
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No surgical procedure can enlarge unicornuate uterus
Available evidence suggests most pregnancies best managed expectantly with cervical cerclage reserved for those with previous second trimester pregnancy losses or evidence of progressive cervical shortening
UNICORNUATE UTERUS
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Most common developmental
anomalyPoorest outcome Miscarriage 65 %The mechanism
◦Not clearly understood
◦ Implantation on Poorly
vascularised septum
SEPTATE UTERUS
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Uterine septa not always associated with a poor pregnancy outcome but their presence in a woman with RPL is an indication for surgical correction (Hysteroscopic septoplasty,usually only incision required)
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Only surgery indicated is removal of an obstructing longitudinal vaginal septum
Unification procedures can benefit some women with numerous miscarriages or previable births
The recommended technique unifies the two fundi and leaves the two cervices intact
UTERUS DIDELPHYS
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Surgery generally considered unnecessary and best reserved for those with a well established history of otherwise unexplained recurrent pregnancy loss or previable births
Strassman abdominal metroplasty surgical procedure of choice
BICORNUATE UTERUS
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Unclear relationship between uterine leiomyomata and RPL
•Pregnancy outcomes adversely affected by submucous myomas,not by subserosal or intramural myomas under 5-7 cm in size
• Large submucosal fibroids distort the cavity or occupy a large subendometrial area
Uterine leiomyoma
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Surgery not indicated when myomas do not distort the uterine cavity or when specific symptoms are not attributable to them
Treatment options: Hysteroscopic/Abdominal
myomectomy,subtotal hysteroscopic myomectomy
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◦ Excessive curettage for pregnancy complications
◦ Traumatize basalis layer granulation tissue
◦ Insufficient endometrium to support fetoplacental growth
◦ Menstrual irregularities (hypomenorrhea, amenorrhea), cyclic pelvic pain, infertility.
INTRAUTERINE ADHESIONS/ASHERMAN’SYNDROME/AMENORRHOEA TRAUMATICA
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Diagnosis primarily on high index of suspicion,based on history
Scanty or no withdrawl bleeding after sequential treatment with exogenous estrogen and progestin
Operative hysteroscopy primary method of treatment
Most advocate insertion of an intrauterine balloon catheter (left in place for approx 7-10 days) after adhesiolysis
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Treatment with broad spectrum antibiotic and a non-steroidal anti inflammatory drug minimize the risk of infection and uterine cramping while catheter is in place
High dose exogenous estrogen for approx 4 weeks after surgery encourage rapid endometrial re-epithelialization and proliferation with a progestin in the final week
Recurrence rates 20-60%
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Cervical insufficiency/Cervical incompetenceDefnition- Inability of the cervix
to retain a pregnancy in the second trimester,in the absence of uterine contractions.
Presents as acute, painless dilatation of the cervix which causes recurrent mid trimester pregnancy loss
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◦ CongenitalMullerian tube defects (bicornuate uterus,
septate uterus, unicornuate uterus)Diethylstilbestestrol exposure in uteroAbnormal collagen tissue(Ehlers Danlos
syndrome, Marfans syndrome ) Acquired Forceful mechanical cervical dilatations Cervical lacerations Cervical cone or LEEP procedure
Cervical insufficiency- Causes
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Usually made in three different settings;Women who present with sudden onset of Symptoms and signs of cervical insufficiency (acute presentation)
Women who present with history of second trimester loss consistent with diagnosis of cervical incompetence (historical diagnosis)
Women with endovaginal ultrasound findings consistent with cervical incompetence (ultrasound diagnosis)
DIAGNOSIS
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Acute PresentationWomen present between 18 and 22 weeks with
pelvic or rectal pressure of recent onset,Increased mucous vaginal discharge, and no
contractions.
Historical DiagnosisWomen gives history of painless cervical
dilatation treated with cerclage in the second trimester of a previous pregnancy.
History of ruptured membranes without contractions in second trimester of pregnancy
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Ultrasound Diagnosis (Transvaginal )-Following USG features are suggestive of cervical in competence
Cervical length<3cm
Internal os width>1.5cm in first trimester >2.0cm in second trimester
Bulging/funneling of membranes into internal os and endocervical canal.
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During Interconceptional Period Passage of no. 8 Hegar’s dilator beyond internal
os without resistance and pain and absence of internal os snap on withdrawl in premenstrual phase.
hystero-cervicography; funnel shape shadow in premenstrual phase.
Foley’s catheter no.16 passed into uterine cavity and bulb filled with 2cc normal saline can be pulled out easily.
Shirodkar’s test; passage of uterine sound without resistance or pain is ‘diagnostic’ of an incompetent cervix.
Foley’s catheter bulb filled with radiopaque dye inserted in uterine cavity and X-ray taken with traction on catheter.buib seen lying in endocervical canal.
Diagnosis
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Shirodkar operation
McDonald operation
Abdominal cerclage
Espinosa Flores operation
Wurm operation
SURGICAL TREATMENT
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Circlage OperationPrinciple- A non absorbable encircling suture is placed
around the cervix at the level of internal osOperates by interfering with the uterine
polarity and the adjacent lower segment from being taken up.
Timing of operationElective cerclage-In proven cases around 14
weeks or at least 2 weeks earlier than the lowest period of previous wastage as early as 10th week.
Emergency cerclage- when the cervix is dilated and the membranes are bulging.
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Contraindications for cerclage
Intrauterine infectionsRuptured membranesHistory of vaginal bleedingSevere uterine irritabilityCervical dilatation >4 cm
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Cerclage operationShirodkar operation- opening the anterior
fornix and dissecting away the adjacent bladder before placing the suture submucosaly, tied interiorly and the knot buried by suturing the anterior fornix mucosal opening
Mac Donald technique- requires no bladder dissection and the cervix is closed by purse string sutures around the cervix
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ComplicationsSlipping or cutting through the
sutureChorioamniotisRupture of the membraneAbortion /Preterm labour
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Post operative adviceBed restTocolysisTo avoid intercourseReport in case of leaking,
bleeding, and painStitch should be removed at 38
weeks or earlier when the labour starts
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Endocrine factors that may predispose to an increased risk of pregnancy loss include :
Thyroid diseaseDiabetes mellitusPolycystic ovary syndrome Luteal phase deficiency
ENDOCRINE FACTORS
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Associated with isolated as well as RPLPatients with hypothyroidism even
subclinical have an increased rate of spontaneous miscarriage
Subjects have concomitant reproductive abnormalities including ovulatory dysfunction and luteal phase defect
Association between antithyroid antibody positivity and RPL unclear
Hypothyroidism
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◦ Poorly controlled (↑Blood glucose &
HbA1c levels in 1st trimester) ↑ risk for loss.
◦ Miscarriage risk rises with the level of HbA1c
◦ Well-controlled - No ↑ risk.
Diabetes mellitus
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Polycystic Ovarian Syndrome
Characterized by excessive production of androgens by the ovaries which interferes with the reproductive, endocrine, and metabolic functions.
Woman presents with oligo/anovulation,Hyperandrogenism,and polycystic ovaries on ultrasound
Increased risk of miscarriage in PCOS is due to insulin resistance, hyperinsulinaemia, and hyperandrogenemia
Metformin treatment can reduce the risk of miscarriage in PCOS woman
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Luteal Phase deficencyThere is inadequate growth and function
of the corpus luteum which is essential for maintenance of pregnancy during the first 7 to 9 weeks of gestation
Life span of corpus luteum is shortened and there is inadequate progestrone secretion
As a result there is inadequate secretory changes in the endometrium which hinder implantation
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• Gold standard for diagnosing LPD is endometrial biopsy but not preferred due to invasive nature
• An abnormally short luteal phase duration (less than 13 days ),best defined by the interval from detection of the midcycle LH surge to the onset of menses ,is the most objective and reliable diagnostic criterion.
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Role of progesterone in recurrent abortionsThere is insufficient evidence to evaluate the
effect of progesterone supplementation in pregnancy to prevent a miscarriage
Progesterone is responsbile for the immune cascade of pregnancy and is called immunomodulater
Therefore in the absence of any factor ,progesterone is given till the placenta takes over the luteal function
Type of progesterone- natural micronized progesterone/dyhydrogesterone
Route-oral/vaginal/intramuscularDose-600-800mg per day vaginally or orally
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No infectious agent has been proven to cause recurrent pregnancy loss
Certain infections have been associated with spontaneous loss◦ Toxoplasma gondii, Chlamydia
trachomatis,Ureaplasma urealyticum,Mycoplasma hominis,Listeria monocytogenes,Campylobacter species
◦ Rubella, HSV, CMV can directly infect the foetus and the placenta
• Bacterial vaginosis in the first trimester can cause 2nd trimester miscarriage and preterm delivery
Infections
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Immunologic factorsAutoimmune-directed to self
tissue/cells
Alloimmune- directed to foreign antigen
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Alloimmune
An immune response to placental and fetal antigen
Normally pregnancy(foreign tissue graft) is tolerated by the maternal immune system through formation of antigen blocking antibodies
Couples that share similar types of HLA, there is inadequate formation of blocking antibodies
Maternal production of cytotoxic antibodies
• Maternal immune system mounts an immune response to the implanting pregnancy and a spontaneous abortion occurs.
• Routine test for Human leukocyte antigen type and anti-paternal cytotoxic antibody and use of immunotherapy not beneficial
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Autoimmune
Systemic lupus erythematosus - Risk for loss is 20%,mostly in 2nd and 3rd trimester of pregnancy and associated with antiphospholipid antibodies
Antiphospholipid syndrome (APA) -5%of women with RPL may have APA.
APA induces microthrombi at placentation site.Altered vascularity affects developing embryo and induces abortion
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Autoimmune AbnormalitiesAutoimmune Abnormalities Antiphospholipid Antibody Syndrome • The most treatable cause of RPL which is well
accepted and evidence based.
• Up to 15–20% of women with recurrent pregnancy loss have antiphospholipid antibodies (aPL).
• In 5% second or third trimester losses occur.
• About 5-10% of all pregnancies are complicated by preeclampsia or fetal growth restriction and up to 75% into preterm births.
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Antiphospholipid Syndrome Antiphospholipid Syndrome Criteria Criteria (Sydney revision of Sapporo (Sydney revision of Sapporo criteria -2006)criteria -2006)
CLINICAL CRITERIA
Vascular Thrombosis-arterial or venous
Pregnancy Morbidity:
a) 1 or more death of normal fetus at > 10 wks
b)1or more premature birth at < 34 wks due to severe preeclampsia or placental insufficiency
c) >3 consecutive abortions
at <10wks with other causes being ruled out
LABORATORY CRITERA
Anti-Cardiolipin IgG and IgM
Lupus anticoagulant (LAC)
Anti β2-glycoprotein1 IgG and IgMmedium - high titer(40 GPL or MPL or higher than 99th percentile) at least 12 wks apart
Positive test should be repeated at least 12 apart
Definite APS: 1 Clinical + 1 Lab criteria
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When to start treatmentWhen to start treatmentHeparin with low dose aspirin is
preferred regime .
Aspirin is started when pregnancy is being attempted or documented.
Heparin is started as soon as cardiac activity is documented on TVS.
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1. Unfractionated Heparin 5000-10000 IU subcutaneous twice a day Or Low molecular weight Heparin is better option
+
2. Low dose Aspirin (75-85mg/day)
APLA/APS-Treatmentdose
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Pregnancy is a hypercoagulable state
Women with heritable or acquired thrombophilic disorders have significantly increased risks of pregnancy loss
INHERITED THROMBOPHILIAS
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Coagulation factors:
Factors that favour clotting when increased
Fibrinogen Factors VII,VIII,X• Factors that favour clotting when
decreased Antithrombin III Protein C Protein S
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Inherited thrombophilic defects• Activated protein C resistance (most
commonly due to factor V Leiden gene mutation)
• Deficiencies of protein C/S and antithrombin III
• Hyperhomocystenemia- Probably interference in embryonic development through defective chorionic villous vascularization
• Prothrombin gene mutation- Higher plasma prothrombin concentrations, augmented thrombin generation
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Mechanism of actionThrombosis on maternal side of the
placenta impaired placental perfusion
•Late fetal loss, IUGR, abruption, or PIH
Relationship with early loss is less clear
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The combined use of low-dose aspirin (75-80mg/dl) and subcutaneous unfractionated heparin (5000unit twice daily)
Antithrombotic Therapy
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History◦ Pattern and trimester of pregnancy losses
and whether a live embryo or fetus was present
◦ Exposure to environmental, toxins or drugs◦ Known gynecological or obstetrical infections◦ Features associated with APS◦ Chronic illness-Diabetes
mellitus,hypertension,thyroid
Evaluation
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History◦ Family history of RPL or syndrome
associated with embryonic or fetal loss◦ Previous diagnostic tests and
treatments
Evaluation
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Physical◦ General physical exam◦ Pelvic exam
Evaluation
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Etiology Investigation Genetic/Chromosomal---------------Karyotype both partners
Anatomical------------------------------HSG or Sonohysterography or USG
Endocrine-------------------------------TSH
Luteal phase duration, Blood sugar
Immunological--------------------------Anticardiolipin Antibody ,Lupus
anticoagulant , Anti-β2- glycoprotein 1
antibody Thrombophilias-------------------------Antithrombin III, Protein C,
Protein S, prothrombin gene,
factor V leiden,prothrombin gene mutation,Activated protein C resistance
Infectious-------------------------------- Endocervical swab to detect infection
INVESTIGATIONS
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Tests NOT useful◦ ANA◦ Maternal anti-paternal leukocyte
antibodies◦ Mixed lymphocyte maternal-paternal
cell cultures◦ HLA genotyping◦ Immunophenotype panels (CD56, CD16)
Evaluation
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PreconceptionCounselling of the couple-after 3
consecutive miscarriages chance of a successful pregnancy is high(70%)
1.Folic acid2.Correct nutritional deficiencies3.Empiric antibiotics 4.Luteal support
◦ Natural progesterone
Management of Patient with Idiopathic Recurrent abortions
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Post conception :1. Reassurance and Tender loving Care (TLC)2. Prophylactic aspirin 3. Prophylactic cervical circlage
◦ If history of repeated D & E4. Anticardiolipin antibodies [ IgM ]5. Steroids for pulmonary maturity6. Monitor closely near term [ NST, USG ]
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Multiple Choice Questions
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Q1. The uterine anomaly most commonly implicated in the etiology of recurrent abortions is
Septate uterusUnicornuate uterusUterus DidelphysArcuate uterus
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A1
Septate uterus- 65%
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Q2 . Most common paternal chromsomal abnormality responsile for recurrent pregnancy loss is
TrisomyMonosomyBalanced reciprocal translocationTriploidy
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A2
Balanced reciprocal translocation
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Q3. All are causes of recurrent pregnancy loss except
PCOSDiabetesThyroid dysfunctonAnaemia
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A3.
Anaemia
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Q4 .Risk factors for recurrent abortions include
Maternal agePrevious miscarriagesObesityAll of the above
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A4
All of the above
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Q5. Asherman Syndrome presents as
AmenorrheaInfertilityRecurrent abortionsAll of the above
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A5.
All of the above
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Q6. Causes of incompetent cervical os include all except
Cervical lacerationCervical conizationAbnormal collagen tissueCervical intraepithelial neoplasia
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A6
Cervical intrepithelial neoplasia
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Q7 Gold standard for diagnosing luteal phase deficency is
Endometrial biopsySerum ProgestroneSerum estrogenSerum prolactin
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A7
Endometrial biopsy
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Q8. Ultrasound features suggestive of cervical incompetence include
Cervical length<3 cmInternal os width>1.5 cmBulging of membranes into
internal osAll of the above
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A8
All of the above
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Q9. Clinical criteria for diagnosing antiphospholipid syndrome include all except
History of vascular thrombosis> 3 consequtive abortions at <10 weeksDeath of congenitally malformed fetus at
>10 weeksPremature birth at <34 weeks due to
severe preeclampsia or placental insufficency
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A9
Death of congenitally malformed fetus at >10 weeks
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Q10. Antibodies tested for diagnosing antiphospholipid syndrome include all except
Anticardiolipin antibodyLupus anticoagulantAnti β2 glycoproteinMaternal antiplatelet leukocyte antibodies
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Q10Maternal antiplatelet leukocyte antibodies
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Q11.What is the treatment of choice for APLA
HeparinLow dose aspirinHeparin + low dose aspirinHeparin + warfarin
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A11.
Heparin + low dose aspirin
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Thank you