Recurrent Miscarriage (RPL) PDF

Recurrent miscarriage(RPL) Dr.A Rahman Khalid  Definition & incidence It is defined as 3 or more consecutive losses before 20 weeks of clinically confirmed pregnancies. Work up usually indicated after 2 loses (no need to be consecutive). It affect 1% of all women....

Recurrent miscarriage(RPL) Dr.A Rahman Khalid  Definition & incidence It is defined as 3 or more consecutive losses before 20 weeks of clinically confirmed pregnancies. Work up usually indicated after 2 loses (no need to be consecutive). It affect 1% of all women. Risk of 2 consecutive losses is 5%. Risk of 3 or more consecutive losses is 1%. The independent risk factors are: 1. Age. (due to ↑ aneuploidy) (in ˃ 40 years the risk is 50%). 2. Number of previous miscarriages. RPL can be divided to: 1. Primary RPL: in women who have no previous viable pregnancy. 2. Secondary RPL: in women who have had previous live birth (has better prognosis).  Etiology 1. Genetic causes Occur in 3-5% of all couples. Usually One partner carries Chr. Abn. The commonest are: o Balanced reciprocal translocation. o Robertsonian translocation. The carrier is usually phenotypically normal but, 50-75% of the gametes will be unbalanced.  Genetic causes Karyotyping done to all Pts & especially imp. To detect in: o Young ladies with RPL. o Marriage in 1st degree relatives. If there is abnormal Karyotype → refer the couple to geneticist for counseling. Cytogenetic analysis (karyotyping) of the products of conception done if the next pregnancy Fail.  2. Congenital abnormalities of the uterus Associated with 2nd trimesteric miscarriage. Found in 10-30% of women with RPL. (compared to 7% in general population). It include: all fusion anomalies + Asherman’s synd., polyps & fibroids. Uterine malformation is usually ass. With cervical weakness. Routine use of HSG as a screening test in cases of RPL is not recommended as it is ass. With: pt. discomfort, radiation exposure & ↑ risk of PID + the fact that it is not more sensitive than the T/V scan when performed by expert scanner.  Congenital abnormalities of the uterus So, all women with RPL should have pelvic U/S to assess anatomy & morphology. 3D U/S is promising & may replace the need for diagnostic laparoscopy & hysteroscopy. Surgical correction of uterine anomalies should be attempted in women with RPL.  3. Cervical weakness It is a cause of 2nd trimester miscarriage & preterm labor. Usu. Over diagnosed & it has no diagnostic test & the diagnosis is usu. based on the Hx. Cerclage is associated with the hazards of surgery & may stimulate uterine contractions so,→ should be considered in small highly selected group. T/V scan assessment of the cervix may help in prediction of preterm labor.  4. Polycystic ovary syndrome Patients of PCO has 20% risk of miscarriage. Metformin may↓ the risk of miscarriage.  5. Diabetes, obesity & thyroid dysfunction If controlled are not associated with RPL so, routine screening of DM in asymptomatic pts. with RPL is not recommended. Clinical & subclinical thyroid dysfunction is associated with RPL. Strict control of any endocrine abnormality should be attempted before pregnancy.  6. Luteal phase insufficiency The use of progesterone to prevent miscarriage has no sufficient support. ∆ of luteal phase insufficiency is difficult. But, progesterone helps in prevention of preterm labor → given bet. 16-24 wks. In pts. with Hx. Of PTL before 34 wks. Oral progesterone is less effective (rapid metabolism). Vaginal & I/M routes are more effective (both are equally effective).  7. Antiphospholipid syndrome 5-20% of Pts with RPL will test +ve for APL Abs. Abs form against vascular endothelium & platelets → vasoconstriction & thrombosis → placental infarcts & abortion.  Antiphospholipid syndrome APLs clinical criteria for ∆: a. 1 or more episodes of vascular thrombosis. b. 3 or more consecutive miscarriages before 10 weeks. c. 1 or more miscarriage (morphologically normal) after 10 weeks. d. 1 or more preterm birth before 34 wks. Due to severe preeclampsia , eclampsia or placental insufficiency.  Antiphospholipid syndrome  Lab criteria For Δ: is 2+ve Anti body tests at least 6 -12 weeks apart of either: o Anti cardiolipin anticoagulant Abs (detected with ELISA). o Lupus anticoagulant Abs (Dilute Russell’s Viper venom time test).  Antiphospholipid syndrome Rx.: aspirin + LMWT heparin (aspirin alone ↑the live birth rate to 40% but, using both aspirin & heparin will ↑the live birth rate to about 70%). Unfractionated heparin can also be used with Aspirin in Rx. LMWT heparin has less S.E. than unfractionated heparin (bleeding, thrombocytopenia & osteopenia). Steroids & immune therapy will not improve the live birth rates.  8. Inherited thrombophilia They are established causes of thrombosis but, its association with RPL is questionable. Routine screening is not recommended in absence of risk factors.  9. Infections TOURCH & other infections: may cause sporadic miscarriage but, not RPL. So, their screening is not helpful in Pts with RPL. Bacterial vaginosis: its screening & Rx. Is limited to the ↑risk group (those with Hx of 2nd trimester abortion or spontaneous Preterm labor). N/B: Bacterial vaginosis has no proved association with 1st trimester loses. Chlamydia (STIs): screening & Rx. Is controversial.  10. hyperprolactinemia, stress & exercise All are not causes of RPL. Routine testing of prolactin level is not indicated in women with regular cycles.  11. Unexplained RPL Has excellent prognosis with supportive care alone which may reach to 50-75% live birth without any drug Rx. (prognosis worsen with ↑maternal age & ↑number of loses). Empirical Rx. Is unnecessary & should be resisted.  Work up Indicated after 2 losses (no need to be consecutive) 1. History:  The characteristics of the miscarriage → anembryonic, live embryo, GA… etc.  Hx of congenital abnormality.  Menstrual irregularity or galactorrhea.  Hx of thrombosis, Hx of instrumentation. 2. Examination:  General examination → signs of endocrine disorders e.g. hirsutism, galactorrhea…. etc.  Pelvic examination → for cervical pathology or uterine malformation.  Mental health evaluation.  Work up 3. Tests done in the initial evaluation: i. U/S (both T/A & T/V) → for uterine & renal abnormalities. (3D U/S if available is accurate as MRI in diagnosing uterine anomalies). ii. APL Abs. iii. TSH & thyroid Abs. iv. Hb A1c. v. Prolactin level (in Pts with irregular cycles). vi. Karyotype.  Work up 4. Additional tests may be done depending on the suggested ∆: i. Sonohysterography (saline infusion Sonohysterography) (SIS) → for uterine anomalies. ii. HSG → cannot differentiate septate & bicornouate uterus because it does not evaluate the outer contour of the uterus. iii. Hysteroscopy & laparoscopy → standard for ∆ & Rx (not included in the initial evaluation because it is invasive & expensive). iv. MRI → can differentiate septate & bicornouate uterus (less expensive & less invasive than laparoscopy).  Treatment principles Optimizing lifestyle factors. Control of underlying medical conditions. Pregnancy planning with preconception counseling. Genetic counseling if indicated. Surgical or nonsurgical treatments depending on etiology. Frequent visits to monitor pregnancy and answer concerns. If loss recurs, consider cytogenetic studies of products. Psychological support and counseling.  Treatment Specific managements:  PCO → metformin  APLs → aspirin + LMWT heparin  Obesity → Wt. reduction  Adjust thyroid function & hyperprolactinemia. THANK YOU