RECURRENT MISCARRIAGE GUIDELINES

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RECURRENT MISCARRIAGEGUIDELINES

• MAJ DR AMINA AKBAR
• MBBS, MCPS, FCPS

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DEFINITION

• A recurrent miscarriage is defined as 3 or more
  consecutive, spontaneous pregnancy losses, under
  20 week gestation from the last menstrual period

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• Primary recurrent pregnancy loss" refers to
  couples that have never had a live birth
• While "secondary RPL" refers to those who have
  had repetitive losses following a successful
  pregnancy

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TERMINOLOGY

• The medical term ' abortion' should be replaced
  with the term 'miscarriage'
• Other names Recurrent Pregnancy Loss (RPL),
• Habitual Abortions ,
• Habitual Miscarriages,
• Recurrent Abortions ,
• Recurrent Miscarriages.

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INCIDENCE

• 1015 of all clinically recognized pregnancies
  end in a miscarriage
• Recurrent miscarriage affects 0.5-2 of all women
  -- Hence, only a proportion of women presenting
  with recurrent miscarriage will have a persistent
  underlying cause for their pregnancy losses

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RISK FACTORS

• Advanced maternal age adversely affects ovarian
  function, giving rise to a decline in the number
  of good quality oocytes, resulting in
  chromosomally abnormal conceptions that rarely
  develop further
• Previous number of miscarriages

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POSSIBLE CAUSES

• Recurrent miscarriage is a heterogeneous
  condition that has many possible causes more
  than one contributory factor may underlie the
  recurrent pregnancy losses
• Each may have had a different cause

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Recurrent Miscarriage
Explained
Un-explained
Genetic factors
Infective agents
Endocrine
Enviromental factors
Anatomical factors
Immune factors
Inhereted Thrombophilic defect
Bacterial Vaginosis
Body
Cervix
C I
APS
Uterine anomalies
Paternal karyotyping
Cytogenetic Of miscarriage
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GENETIC FACTORS
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• All couples with a history of recurrent
  miscarriage should have peripheral blood
  karyotyping performed. The finding of an abnormal
  parental karyotype should prompt referral to a
  clinical geneticist.
• 35 of couples with recurrent miscarriage, one
  of the partners carries a balanced structural
  chromosomal anomaly
• 510 chance of a pregnancy with an unbalanced
  translocation.

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FETAL CHROMOSOMAL ABNORMALITIES

• This may be due to abnormalities in the egg,
  sperm or both. The  most common chromosomal
  defects are-
• Trisomy
• Monosomy
• Polyploidy

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• Chromosome Testing on Fetal (Miscarriage) Tissue
• This can only be done right at the time of
  miscarriage.
• It is an analysis of the genetic makeup of the
  fetus.
• It can indicate genetic problems that lead to
  RPL.
• Many miscarriages are caused by chromosomal
  abnormalities that are unlikely to repeat. To
  know if the problem is likely to recur, it is
  necessary to study the genetics of both parents
  as well.

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• Karyotyping of Parents
• Chromosome analysis of blood of both parents.
• It can show if there is a potential problem with
  one of the parents that leads to miscarriage, but
  often has to be done in conjunction with fetal
  testing to provide answers.

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ANATOMICAL FACTORS
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CONGENITAL ANOMALIES

• An abnormal or irregularly shaped uterus.
• Sometimes the uterus has an extra wall down its
  centre, which makes it look as if it is divided
  into
• two (bicornuate or septate uterus)
• a septate uterus Where as a partial septum
  increases the risk to 60-75 a total septum
  carries a risk for loss of up to 90.
• Today a relatively simple surgical procedure
  can remove a uterine septum
• or it may have only developed one half
  (unicornuate uterus).

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• The reported prevalence of uterine anomalies in
  recurrent miscarriage populations range between
  1.8 and 37.6.
• The prevalence of uterine malformations appears
  to be higher in women with late miscarriages
  compared with women who suffer early miscarriages
• Untreated uterine anomalies has a term delivery
  rate of only 66.
• Open uterine surgery is associated with
  postoperative infertility and carries a
  significant risk of uterine scar rupture during
  pregnancy. Therefore treatment of uterine
  anomalies in women with recurrant miscarriage
  remains controversial.

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FIBROIDS

• If fibroids are detected on the inside of the
  uterus (termed submucous fibroids) and distort
  the uterine lining, they are a significant cause
  of reproductive problems and should be removed.
  It is less clear whether fibroids in the wall of
  the uterus cause reproductive problems

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All women with recurrent miscarriage should have
a pelvic ultrasound to assess uterine anatomy and
morphology

• Two dimensional pelvic ultrasound assessment of
  the uterine cavity with (or without)
  Sonohysterography

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HYSTEROSALPINGOGRAPHY

• The routine use of hysterosalpingography as a
  screening test for uterine anomalies in women
  with recurrent miscarriage is questionable.
• It is associated with patient discomfort,
• carries a risk of pelvic infection and radiation
  exposure
• and is no more sensitive than the non-invasive
  two dimensional pelvic ultrasound assessment of
  the uterine cavity with (or without)
  Sonohysterography when performed by skilled and
  experienced personnel.

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HYSTEROSCOPY

• This investigation, performed under general
  anaesthetic, examines the inside of the uterus
  with a thin
• telescope (3-5 mm in diameter) . By inserting
  this telescope through the cervix and into the
  uterus,
• the doctor can see the shape of the uterus and
  examine its lining.

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CERVICAL WEAKNESS
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• Diagnosis of cervical incompetence is based on
  history of late miscarriage preceded by
  spontaneous rupture of memb or painless cervical
  dilatation. Vaginal USG is helpful in assessing
  early features of cervical incompetence. Cervical
  cerclage is associated with potential hazards
  associated with surgery and risk of uterine
  contractions.

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ENDOCRINE FACTORS
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Routine screening for occult diabetes and thyroid
disease with oral glucose tolerance and thyroid
function tests in asymptomatic women presenting
with recurrent miscarriage is uninformative

• Well-controlled diabetes mellitus is not a risk
  factor for recurrent miscarriage, nor is treated
  thyroid dysfunction

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There is insufficient evidence to evaluate the
effect of progesterone supplementation in
pregnancy to prevent a miscarriage
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There is insufficient evidence to evaluate the
effect of human chorionic gonadotrophin (hCG) in
pregnancy to prevent miscarriage.

• Early pregnancy hCG supplementation failed to
  show any benefit in pregnancy outcome

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IMMUNE FACTORS

• One in ten women with recurrent miscarriages show
  evidence of auto immune factors on investigation
• As much as 40 percent of unexplained infertility
  may be the result of immune problems.
  Unfortunately for couples with immunological
  problems, their chances of recurrent loss
  increase with each successive pregnancy.

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ANTITHYROID ANTIBODIES

• Routine screening for thyroid antibodies in women
  with recurrent miscarriage is not recommended.

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ANTIPHOSPHOLIPID SYNDROME

• To diagnose APS it is mandatory that the patient
  should have two positive tests at least six weeks
  apart for either lupus anticoagulant or
  anticardiolipin (aCL) antibodies of IgG and/or
  IgM class present in medium or high titre.
• Adverse pregnancy outcomes include
• Three or more consecutive miscarriages before
  ten weeks of gestation
• One or more morphologically normal fetal deaths
  after the tenth week of gestation and
• One or more preterm births before the 34th week
  of gestation due to severe pre-eclampsia,
  eclampsia or placental insufficiency.

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• In women with a history of recurrent miscarriage
  and aPL, future live birth rate is significantly
  improved when a combination therapy of aspirin
  plus heparin is prescribed.
• Pregnancies associated with aPL treated with
  aspirin and heparin remain at high risk of
  complications during all three trimesters.

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INHERITED THROMBOPHILIC DEFECTS
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• Inherited thrombophilic defects,
• Including activated protein C resistance (most
  commonly due to factor V Leiden gene mutation),
  deficiencies of protein C/S and antithrombin III,
  hyperhomocysteinaemia and prothrombin gene
  mutation,
• Are established causes of systemic thrombosis

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INFECTIVE AGENTS
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• Screening for and treatment of bacterial
  vaginosis in early pregnancy among high risk
  women with a previous history of second-trimester
  miscarriage or spontaneous preterm labour may
  reduce the risk of recurrent late loss and
  preterm birth.

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ENVIRONMENTAL FACTORS
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• Exposture to noxious or toxic substances are
  known to be associated with recurrent miscarriage
  ( cigarretes,alcohol and caffeine ,anaestetic
  gases,petrolium products )

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UNEXPLAINED RECURRENT MISCARRIAGE

• In about half the women in the research studies,
  no cause could be found, so no specific treatment
  could be given.
• However, this group responded very well to a
  programme which removed as many stress factors as
  possible from their lives, resulting in an 80
  success rate with the subsequent pregnancy

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PSYCHOLOGICAL SUPPORT

• The value of psychological support in improving
  pregnancy outcome has not been tested in the form
  of a randomised controlled trial. However, data
  from several non-randomised studies8688 have
  suggested that attendance at a dedicated early
  pregnancy clinic has a beneficial effect,
  although the mechanism is unclear
• All professionals should be aware of the
  psychological sequelae associated with
  miscarriage and should provide support and
  follow-up, as well as access to formal
  counselling when necessary.

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THANK YOU