Recurrent miscarriage.pdf sjsisjnssiissj

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1. RECURRENT MISCARRIAGE
•It is defined as 3 or more consecutive pregnancy loss
before viability(24 weeks of gestation).

2. Epidemiology
•About 15% of all pregnancies end with miscarriage but
recurrent miscarriage affect 1-2% of women of
reproductive age.
•Increased maternal age is a risk factor mainly due to
increase in chromosomal abnormalities . Increased
paternal age also increase the risk.
•Obesity is also a risk factor as it correlate with poor oocyte
and embryo quality and reduced endometrial receptivity.

3. Causes
1.Immunological causes:
-Antiphospholipidsyndrome has a prevalence of 15% in
women with first trimester recurrent abortion.
Anticardiolipinor lupus anticoagulant antibodies cause
vascular thrombosis & placental infarcts which may lead
recurrent miscarriage.
-Systemic lupus erythmatosisknown to cause recurrent
miscarriage.
-Other immunological factors include presence of
antithyroidantibodies & the mechanism is either
autoimmune or mild thyroid insufficiency.

4. 2.Genetic factors:
-Parental chromosomal abnormalities found in 2% of
women with recurrent miscarriage. The most common is
balanced reciprocal translocation of the couple with risk of
conceiving future embryo with unbalanced translocation.
-Sperm DNA damage or fragmentation is seen in higher
degree in couples with recurrent miscarriage. It is also
seen in some subfertilemale. Factors increase this
damage is smoking, alcohol, chlamydia infection, obesity
and advanced paternal age.

5. 3.Anatomic factors:
It could be congenital like septate, bicornuateor arcuate
uterus or acquired like cervical weakness which usually
associated with second trimester abortion or preterm
labour.
Also fibroid if submucousin location may associate with
recurrent pregnancy loss bas it may impede normal
implantation.
Other acquired cause is intrauterine adhesion
(Ashermansyndrome).

6. •There is recent studies suggest a possible association of
adenomyosisand miscarriage due to impeding
implantation or increased infiltration of macrophages and
natural killer cells in the endometrial stroma.

7. 4.Endocrine factors:
-There is an association between polycystic ovary
syndrome & recurrent miscarriage. The possible
mechanism for this is luteal phase insufficiency & insulin
resistance.
-Diabetes mellitus both type 1 and 2 if poorly controlled.
-Thyroid disorders including hypo or hyperthyroidism and
thyroid autoimmune disorders all associated with
increased risk of early pregnancy loss.

8. 5-Thrombophilias:
These are either inherited or acquired.
-Inherited like factor V Leiden mutation and prothrombin
gene mutation.
-Acquired like antithrombinIII and protein s deficiency.
-Anticardiolipinand lupus anticoagulant are also
considered acquired thrombophilias.
6. Unexplained idiopathic recurrent miscarriage: It comprise
50% of the cases.

9. MANAGEMENT
•Investigations may include:
1.Screening for anticardiolipin& aniphospholipid
antibodies.
Some advice that all women with one or more second
trimester miscarriage should be screened.
Two positive tests at least 12 weeks apart of either IgG
and/or IgM( because infections cause transient positivity)
or high titer over 40g/L to ensure the diagnosis.

10. 2.Thyroid function test& antithyroidantibodies.
3.Pelvic imaging : ultrasound scanning and/or
hysterosalpingographyto look for anatomic abnormalities
of the uterus.
4.Parental karyotyping . Product of conception during
miscarriage can be sent for cytogenetic analysis to detect
unbalanced transclocation.
5.Screening for inherited thrombophilias:
Beside women with recurrent miscarraige, women with
one second trimester miscarriage should also be
screened.

11. •Treatment of recurrent miscarriage is challenging & the
followings may be offered:
1.Tender care with reassurance & psychological support &
regular ultrasound scan is helpful.
2. Antiphospholipidsyndrome may be treated with low dose
aspirin or unfractionatedlow molecular heparin or both.
Also prednisolone& i.v. immunoglobulin has been used
with limited benefit.

12. 3-Congenital uterine abnormalities can be treated by
surgery and cervical incompetence by cervical circlage.
4-Progesterone supplementation may be used in selected
cases with no evidence of routine use.

13. 5. If unbalanced chromosomal abnormalities found, the
couple should be informed about the prognosis in future
pregnancy.
Therapeutic options include to try pregnancy again with or
without prenatal diagnosis, gamete donation and lastly in
vitro fertilization with pre-implantation genetic diagnosis.

14. •Empirical treatment with aspirin for women with recurrent
miscarriage is common but no evidence of improvement if
used in all women with recurrent miscarriage.

15. Induced Abortion
Therapeutic abortion –termination of
pregnancy before time of fetal viability for
the purpose of safe guarding the health of
the mother e.g. heart disease, renal
failure,invasiveCa of cervix or breast caor
fetus having a lethal abnormality.

16. Elective (voluntary) abortion is the
interruption of pregnancy before viability at
request of the women but not for reason of
impaired maternal health or fetal disease(This
is NOTallowed).