Early Pregnancy Abnormalities & Abortion PDF

Title: Early pregnancy abnormalities Abortion Grade: Module: Speaker: Dr. ishraq mohammed Date: THROMBOPHILIA: ANTIPHOSPHOLIPID ANTIBODY University of Baghdad/ College of Medicine 2022-2023 SYNDROME BACKGROUND: APS is an acquired hypercoagul...

Title: Early pregnancy abnormalities Abortion Grade: Module: Speaker: Dr. ishraq mohammed Date: THROMBOPHILIA: ANTIPHOSPHOLIPID ANTIBODY University of Baghdad/ College of Medicine 2022-2023 SYNDROME BACKGROUND: APS is an acquired hypercoagulable state characterized by the persistent presence of autoantibodies against proteins bound to cell membrane phospholipids. It is associated with thrombosis (venous, arterial, or microvascular) and/or pregnancy complications such as recurrent miscarriage, late pregnancy loss, or pre-eclampsia.  University of Baghdad/ College of Medicine 2022-2023 There may be accompanying features such as thrombocytopenia, livedo reticularis, renal disease and neurologic symptoms. APS may occur in the setting of underlying autoimmune disease such as systemic lupus erythematosus (secondary APS) or may occur in isolation (primary APS). APS associated with pregnancy morbidity and no thrombosis is often termed obstetric APS.  University of Baghdad/ College of Medicine 2022-2023 THE DIAGNODIAGNOSIS OF APS: sis of APS should be made carefully and in consultation with a specialist because of the potential for false positive laboratory tests. In addition, a diagnosis of APS has important treatment implications because such patients may require long-term anticoagulant therapy. APS is diagnosed based on expert consensus criteria (revised Sapporo criteria) and requires the presence of at least one laboratory and one clinical criterion for definite APS.  University of Baghdad/ College of Medicine 2022-2023 Laboratory criteria: If laboratory testing is undertaken in a patient with a history of recent thrombosis, it should be performed after a minimum of 3 months of anticoagulant therapy has been completed. A positive result requires confirmation and documentation of persistent positivity at least 3 months later.  University of Baghdad/ College of Medicine 2022-2023 1) Lupus anticoagulant (LA) or non-specific inhibitor. These antibodies are present (positive) or absent (negative). 2) Anticardiolipin (aCL) antibody (IgG or IgM) present in medium or high titre (i.e. >40 GPL units or >99thpercentile). 3) Anti-beta2 glycoprotein-I antibody (IgG or IgM) with a titre >99th percentile.  University of Baghdad/ College of Medicine 2022-2023 Clinical criteria: 1) Vascular thrombosis: One or more clinical episodes of arterial, venous, or small vessel thrombosis, in any tissue or organ. Thrombosis must be confirmed by objective criteria (i.e. unequivocal findings on appropriate imaging studies or histopathology of microvascular thrombosis). For histopathologic confirmation, thrombosis should be present without significant evidence of inflammation in the vessel wall. Superficial venous thrombosis is not part of the criteria.  University of Baghdad/ College of Medicine 2022-2023 2) Obstetrical complications: Three or more unexplained, consecutive spontaneous abortions before the 10th week of gestation, with exclusion of maternal anatomic or hormonal abnormalities and paternal and maternal chromosomal causes, or One or more unexplained deaths of a morphologically normal fetus at or beyond the 10th week of gestation, with normal fetal morphology documented by ultrasound or by direct examination of the fetus, or One or more premature births of a morphologically normal neonate before the 34th week of gestation because of: (i) eclampsia or severe pre-eclampsia according to standard definitions or (ii) recognized features of placental insufficiency.  University of Baghdad/ College of Medicine 2022-2023 Pregnant women with antiphospholipid antibodies: It is recommended that pregnant women who meet criteria for obstetric APS without a history of venous/arterial thrombosis receive prophylacticdose LMWH/UFH combined with low-dose ASA for the duration of their pregnancy; however, it is important to note that the efficacy and safety of such management has not been validated in welldesigned clinical trials. The role of prophylactic-dose LMWH/UFH and low-dose ASA in women with persistent antiphospholipid antibodies and a single late pregnancy loss has not been well studied. Low-dose ASA is often used in pregnant women with persistent antiphospholipid antibodies to reduce the risk of pre-eclampsia.  University of Baghdad/ College of Medicine 2022-2023 Established genetic factors Rare genetic factors Indeterminate factors Factor V Leiden Dysfibrinogenemias Elevated Factor VIII Prothrombin G20210A Hyperhomocysteinemia Elevated Factor IX Protein C deficiency Elevated Factor XI Protein S deficiency Plasminogen deficiency Antithrombin deficiency Tissue plasminogen activator Elevated lipoprotein a Factor VII Factor XII Platelet glycoprotein Plasminogen activator inhibitor Heparin cofactor II Thrombomodulin Histidine-rich glycoprotein  University of Baghdad/ College of Medicine 2022-2023 MANAGEMENT Threatened Abortion A threatened abortion is best managed by an ultrasonic examination to determine the Of those in whom a live fetus is present, 94% will produce a live baby, although the incidence of preterm delivery in these cases may be somewhat higher tha n in those who do not bleed in the first trimester. Once a live fetus has been demonstrated to the couple on ultrasonography, management consists essentially of reassurance.  University of Baghdad/ College of Medicine 2022-2023 MANAGEMENT Threatened Abortion There is no need for admission to hospital, n is there any evidence that bed rest improves the prognosis; however, psychosocial support is important. Recently, t here has been evidence that women with vitamin D deficiency are at increased risk The mechanism is thought to be related to abnormal uterine muscle function  University of Baghdad/ College of Medicine 2022-2023 Incomplete Abortion Until bleeding has stopped or is minimal , it is best to insert an intravenous line and take blood for grouping and cross-matching, as the patient’s condition is stable, the remaining products of conception should be evacuated from the uterus using appropriate pain control. These tissues should be sent for pathologic evaluation. An incomplete abortion that is infected must be managed vigorously. Delay in treatment may result in overwhelming sepsis that may lead to excessive hemorrhage, renal and hepatic failure, disseminated intravascular coagulation (DIC), and rarely, death.  University of Baghdad/ College of Medicine 2022-2023 Missed Abortion Suspected missed abortion should be confirmed by ultrasound to minimize the risk of sepsis and DIC, and to reduce the extent of hemorrhage and the degre e of pain that accompanies the spontaneous expulsive process. In some studies vitamin D deficiency has b een associated with early pregnancy loss. A proposedmechanism is that women with vitamin D deficiency have an altered immune system. Macrophages do no t make the antibacterial peptide cathelicidin, which is important in reducing the risk of infection, as well as contributing to abnormal muscular function.  University of Baghdad/ College of Medicine 2022-2023 General Management Considerations When the patient is Rh negative and does not hav e Rh (anti-D) antibodies, prophylactic RhO-GAM should  University of Baghdad/ College of Medicine 2022-2023 Recurrent Abortion As far as the mother is concerned, it is appropriate to rule out the presence of systemic disorders such as diabetes mellitus, SLE, and thyroid disease, and it is also necessary to test for the presence of a lupus anticoagulant. Paternal and maternal chromosomes should be evaluated, and hysteroscopy or hysterography should be performed to evaluate the uterine cavity. Over half of couples with recurrent losses will have normal findings during the standard evaluation.  University of Baghdad/ College of Medicine 2022-2023 Many of the congenital abnormalities of the uterus can now be diagnosed using pelvic ultrasonography and may no longer require l aparotomy repair. for Cervical incompetence managed is the placement by cervical aofsuture (cerclage) the level the internal at of this os; suture is best placed in the first trimester, once a live fetus has been demonstrated on ultrasonography. The effectiveness of prophylactic cervical cerclage in preventing recurrent loss from cervical incompe- tence has not been conclusively established University of Baghdad/ College of Medicine 2022-2023 University of Baghdad/ College of Medicine 2022-2023 University of Baghdad/ College of Medicine 2022-2023 University of Baghdad/ College of Medicine 2022-2023  University of Baghdad/ College of Medicine 2022-2023 Thank you