Recurrent pregnancy loss panel discussion

definition of recurrent pregnancy loss, causes , their diagnosis and management

1. Recurrent Pregnancy Loss Panel Discussion

2. DR. NIRANJAN CHAVAN MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP, DIPLOMA IN ENDOSCOPY (USA) Professor And Unit Chief, L.T.M.M.C&L.T.M.G.H, Sion Hospital National Co-ordinator, FOGSI Medical in Pregnancy Committee (2019-2021) Chairperson, FOGSI Oncology & TT Committee (2012-2014) Secretary MOGS (2019-2020), Premises Secretary, AFG (2019-2020) Chair & Convenor, FOGSI Cell Violence Against Doctors (2015-2016) Dean and Chairman, Academia of Global Obstetrician & Gynaecologists Chief Editors, AFG Times (2015-2016) Course Coordinator of 11 batches Of MUHS recognised Certificate Course of B.I.M.I.E at L.T.M.G.H (2010-2016) Member, Oncology Committee AOFOG (2013-2015) Member, Managing Committee, IAGE (2013-2017), (2018-2020) Editorial Board, European Journal of Gynaec . Oncology (Italy) Course Coordinator of 3 batches 0f Advanced Minimal Access Gynaec Surgery (AMAS) at LTMGH (2018 -2019)

3. “………I recall nothing which in times past has caused me more anxiety and doubt, or in regard to which I have found it more difficult to get any satisfactory rules from books, than the treatment of Abortion.” - T. G. Thomas (1908 )

4. What are the common questions asked by RPL patients?

5. Patients Questions Why did it happened ? Will it happen again ? How it can be avoided ? Could have been avoided ?

6. What is the incidence of RPL?

7. Spontaneous pregnancy loss is, in fact, the most common complication of pregnancy About 70% of human conceptions fail to achieve viability estimated 50% are lost before the first missed menstrual period Most of preg . Losses are unrecognized. Actual rate of preg . Loss after implantation is 31%(by hCG assay) Clinically recognized, loss occurs in 15% before 20wks of gestation.

8. Spontaneous Abortions Normal population Chromosomal abnormality --- 50% Trisomic --------------------- 56% Polyploid -------------------- 20% Monosomic for chromosome X-- 18% Unbalanced translocations ------ 4%

9. What is the Definition of RPL?

10. Definition : 3 or more clinically recognized pregnancy losses before 20wks from LMP. Incidence: 1/300

11. 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

12. Causes of Pregnancy Loss Genetic Trisomies , 16, 21, 7,15 Monosomy X, Triploidy Parental Structural Aberrations Fetal anomalies Any incompatible with life Uterine anomalies Septate, Bicornuate Fibroids Cervical Incompetence DES Immunological causes Alloimmune ( cytokines,NK ) APL (ACA,LA) Hereditary Thrombophilia APCR, FVL FII MTHFR, Homocysteinemia Pritein C, Protein S, Antithrombin III Trauma Endocrine Luteal defficiency Thyroid dysfunction Diabetes Alloimmune Cytokines NK Infection Chlamydia Mycoplasma Toxoplasmosis Septic Abortion

13. Proposed Etiologies Genetic Factors 3.5-5% Anatomic Factors 12-16% Endocrine Factors 17-20% Infectious Factors 0.5-5% Immunologic Factors 20-50% Other Factors 10% Novak’s Gynecology 14 th ED

14. Is it important to establish the gestational age of these pregnancies ??

15. Clinical Pregnancy Loss PREEMBRYONIC < 5 WKS EMBRYONIC < 8 WKS FETAL > 8 WKS

16. Early Pregnancy Failure ( EPF) Anembryonic Pregnancy : Trophoblast has invaded the decidua Embryonic disc not developed/ resorbed after loss of viability Embryonic / Fetal demise: Embryonic disc developed :: loss of viability USG : Emb pole > 5mm without cardiac activity

17. On ultrasound do we have any milestones by which we can predict the outcome?

18. Threshold ??? MSD 20 mm without yolk sac 25mm without embryo : TAS : anembryonic pregnancy Rate of increase in MSD : parameter < 0.6 mm/day Increase of <3 mm over 5 days Increase of < 4 mm over 7 days

19. When shall we start investigations?

20. Clinical Investigation should be started after two consecutive spontaneous abortions, especially When fetal heart activity had been identified prior to the pregnancy loss when the women is older than 35 yrs of age when the couple has had difficulty conceiving

21. Are there any biochemical markers to predict the outcome?

22. BIOMARKERS HCG Progesterone 17 α Hydroxy progesterone Inhibin A Inhibin Pro - α C IGFBP I

23. Case 1 24 years old Mrs. MSJ married since 5 years Obstetric history: G1 – Vesicular Mole, D&E done. G2 - Missed abortion at 7 weeks, D&E not done, pills taken. G3 - Missed abortion at 6 weeks, D&E done. G4 - 6 weeks, Blighted ovum , pills given.

24. Menstrual History: Regular Medical History: N.P. Family History: N.P. Clinical Findings: Normal Hormonal Profile: Normal APLA: Negative

25. KARYOTYPING: Husband: 46XY Wife: 46XX, t(11;22) (q24:q13) GTG banding : proband shows reciprocal balanced translocation involving chr 11 & chr 22 breakage & reunion has occurred at bands 11q24 & 22q13 MFISH balanced translocation between chr 11 & chr 22 involving breakpoints 11q24 & 22q13 respectively

26. Cytogenetic Studies of the conceptus Should we always do them ?

27. 13.9% 5 Monosomy (45XO) 66.7% 24 Trisomy 13.9% 5 Triploidy 5.5% 2 Structural (Unbalanced Translocations) Aberrations in Abortus (Carp et al, 2002 )

28. Karyotype of Abortus According to Maternal Age p=0.01 (Fisher’s exact Test) for the age group 40-45 compared to the other age groups .

29. Repeat Aneuploidy Repeat Aneuploidy 8/43 (19%) Carp et al, 2004 3/30 (10%) Sullivan et al, 2005 11/73 (15.1%) Total

30. What are the RCOG guidelines?

31. RCOG guidelines Recurrent pregnancy loss may be due to an abnormal embryo, which is incompatible with life. As the number of miscarriages increases, the prevalence of chromosomal abnormality decreases If the karyotype of the miscarried pregnancy is abnormal, there is a better prognosis in the next pregnancy. karyotyping the products of conception provides useful information for counseling and future management.

32. Subsequent Pregnancy According to Karyotype of Abortus 14/37 14/21 27/71 37/60 O.R. for a live birth after aneuploidic abortion. 3.28 (95% CI = 0.94-11.9) Carp et al 2.62 (95% CI = 1.21-5.67) Ogasawa et al

33. Genetic counseling after a miscarriage In all couples with a history of recurrent miscarriage cytogenetic analysis of the products of conception should be performed if the next pregnancy fails.

34. What is the role of Parenteral karyotype ??

35. Structural genetic factor in either 2.5-8% RPL couples Commonest :balanced reciprocal/Robertsonian translocation Rarer : inversion,insertions,deletions,duplications,ring chromosome

36. Translocations Reciprocal translocations Robertsonian translocations A translocation is the transfer of genetic material from one chromosome to another.

37. Robertsonian translocations occur when two chromosomes fuse together, creating one chromosome that contains most of the original two. (4 5 chromosomes with one variant) Translocations Reciprocal translocations occur when two different chromosomes exchange segments. (46 chromosomes with two variants)

38. Robertsonian Translocation Robertsonian translocations between chromosomes 14 and 21, one of the most common combinations, are of particular clinical relevance. An individual with this translocation could have a child with three copies of chromosome 21, resulting in Down’s syndrome (trisomy 21).

39. Non Disjunction Non disjunction occurs when chromosomes fail to "disjoin" during meiosis or mitosis .

40. Non disjunction during Mitosis The incidence of trisomies increases with age. Trisomy 16, which accounts for 30% of all trisomies, is the most common. All chromosome trisomies have been reported in abortuses except for trisomy 1.

41. Deletions Deletions are fragments of chromosomes that are missing. They are usually lethal when homozygous and cause abnormalities when heterozygous. Cri du Chat Syndrome Cri du chat syndrome is due to a deletion of a portion of chromosome 5. Cri du chat individuals are mentally retarded. "Cri du chat" is French for "cry of the cat". The infants cry sounds like a cat.

42. Counseling Cytogenetic data In balanced translocation there is 5-10% chance of pregnancy with unbalanced translocation Important to evaluate : carriers : >70% LBR. Possibility of PGD

43. 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. Genetic counseling after a miscarriage

44. Case 2 28 years old Mrs. XYZ married since 6 years G4P1L0A3 Obstetric history: G1 - Preterm stillbirth at 7ma abruption G2 - Missed abortion at 6 weeks G3 - Missed abortion at 8 weeks G4 - Spont . Abortion at 8 weeks

45. MENSTRUAL HISTORY: 4-5/28 Regular, Moderate, Painless MEDICAL HISTORY: History of childhood Asthma History of DM and HT in family

46. TORCH ROUTINE INVESTIGATONS WNL Toxo - IgG + ve , IgM - ve Rubella - IgG Low + ve , IgM - ve CMV - IgG Mod + ve , IgM - ve Herpes - IgG mild + ve , IgM - ve

47. Autoimmune Profile BT - 3’ 05”, CT - 4’ 25”, Platelets - 1.2 lac/ cmm PT - 13 sec (T) 11 sec ( C ) ACL - IgG - high + ve (181U) - IgM - high + ve (221U) LA - high + ve dsDNA + ve

48. TORCH Toxoplasmosis Other infections – parvovirusB19, HIV, Syphillis , hepatitis, varicella Rubella Cytomegalovirus Herpes Simplex infections

49. Distinctive features Intracranial calcifications ( Toxo , CMV) Cataracts (Rubella, HSV) Chorioretinitis ( Toxo , CMV) Bone lesions (Syphilis, Rubella) Congenital heart disease (Rubella) Microcephaly (CMV) Hydrocephalus ( Toxo ) Vesicles (HSV, VZV, Syphilis)

50. RCOG guidelines for TORCH For an infective agent to be implicated in the aetiology of repeated pregnancy loss, it must be capable of persisting in the genital tract and avoiding detection or must cause insufficient symptoms to disturb the women. Toxoplasmosis, rubella, cytomegalovirus, herpes and listeria infections do not fulfill these criteria and routine TORCH screening should be abandoned.

51. Infections & Recurrent Pregnancy Loss Tuberculosis Listeriosis Bacterial vaginosis TORCH infections Chlamydiae Syphilis Mycoplasmas Note : Late rather than early abortions Doubtful role of antibiotic prophylaxis

52. Genital Tuberculosis And RPL Genital tuberculosis ? Latent GTB Immunological Basis- ↑ Cytokines; ↑ Th1 : Th2 i.e changes ratio of cytokines towards an increase in abortogenic milieu Implantation failure- due to fibrosis & inflamation

53. Does APLA cause early pregnancy loss ????

54. Mechanism Inhibition of cytotrophoblast invasion Differentiation Thrombosis: platelets, fibrinolysis & coagulation cascade Arachidonic acid release blocked hence PGI 2 decreased Anticytokines action against IL3 Placental cell Apoptosis

55. Character Of Pregnancy Loss Typical presentation is growth retardation probably leading to fetal death in the second or third trimesters ( Lockshin , 1993). APS in 10% of unselected patients with RPL ( Tincani et al 1987) APS in 30% ( Drakely et al 1998) of patients with recurrent second trimester pregnancy loss.

56. Other Immunological Disorders SLE Higher rate of RPL APLA : 37% ≈ poor outcome Lupus flares / renal disease Counseling R AFS: (Reproductive autoimmune Failure Syndrome) 90% Cannot be dete cted by routine antibody estimate

57. Therapy in immunological disorders Aspirin & Low Molecular Heparin Antipaternal cell antibodies IV IG

58. MANAGEMENT Aspirin : 75 mg / day Prednisolone : 60 mg /day. Side effects- cushingoid features, Immunosuppressant ( miliary tuberculosis),glucose intolerance, HT, IUGR. Heparin: 5000 IU BD subcut side effects- osteoporosis, thrombocytopenia, hemorrhage. LMWH: Low molecular weight Heparin ( Dalteparin , Enoxaparin)

59. Role of IVIG in RPL 45% of miscarriages and 95% of late pregnancy losses from women experiencing RPL are chromosomally normal. Large data suggestive of the causes being immunological .

60. Immunotherapy Passive, with immunoglobulin NK Cells down-regulated by IVIG (Ruiz et al, 1996) Down regulation associated with improved outcome Cytokine balance altered by IVIG ( Bakimer , et al, 2000)

61. IVIG after > 5 Abortions (Carp et al, 2007) OR = 2.1 (95% CI 1.01-4.37)

62. Defects in Coagulation Factors

63. Thrombophilia Nonpregnant Risk of DVT Method of testing Factor V Leiden (G1691A) 3 to 8 fold DNA analysis Factor II Prothrombin (20210A) 3 fold DNA analysis Protein S deficiency 2 fold Activity assay Antithrombin deficiency 25 to 50 fold Activity assay Protein C deficiency 10 to 15 fold Activity assay Acquired activated Protein C resistance 1.7 fold Anti coagulant response With activated protein C MTHFR (C677t or A1298C) Questionable Fasting homocysteine If + ve DNA testing Acquired hyperhomocysteinemia 2.5 to 4 fold Fasting homocysteine Ormethionine loading

64. Treatment Strategy Correction of hyperhomocysteinemia LMWH

65. Case 3 35 yrs , A3 with history of previous 3 missed abortions A1- 8 weeks missed abortion A2- 7 wks missed aboretion A3-10 wks missed abortion

66. investigations Hb - 10 gm% Urine R/M-N LFT, RFT - N VDRL, HIV - ve Bl gr - O + ve , husband - B + ve Day 2 progesterone levels- 2ng/ml Day 8 progesterone level—8.7ng/ml

67. Endometrial biopsy done which was suggestive of endometrial lag of >3 days USG suggestive of lack of endometrial echogenicity on 7th postovulatory day and leutinised unruptured follicle and leuteal cyst formation

68. What is luteal phase defect? Diagnostic criteria for leuteal phase defect? Role of progesterone and HCG? Other hormonal defects to cause RPL?

69. Role of Endocrinologic factors ???

70. Luteal Phase Defect LPD Lag of 2days in histological development of endometrium Mid luteal Progesterone < 10ng/Ml Abnormal expression of endometrial progesterone receptors or α V β 3 integrin : biomarker of uterine receptivity : D20-21 Progesterone Clomiphene citrate

71. Role of Progesterone & HCG Conversion of TH1 to TH2 response Progesterone induced blocking factor (PIBF) Reduction of NK cells activity

72. Defective ovarian function High D 3 FSH > 20 IU/L Low D 3 inhibin B < 0.6 units/ml Low D 3 Estradiol < 20 pg / ml Low antral follicle count < 5 Low antimullerian hormone < 15pmol /L

73. Other hormonal defect responsible for RPL?

74. Hypothyroidism Untreated hypothyroidism Sensitive TSH assay Antibodies  ►► Antimicrososmal antithyroglobin R/O hypothyroidism During Pregnancy hypothyroidism

75. Hyperprolactinemia Dopamine agonists Insufficient folliculogenesis Oocyte maturation LPD H P O A X I S

76. Insulin Resistance DM Poor glycemic control PCOD Increased insulin resistance

77. Case 4 29 year old Mrs. X working as computer professional married since last 5 years History of primary infertility, K/c/o PCOS, conceived after ovulation induction with clomiphene citrate and IUI

78. Past obstetric history - G3P0L0A3 G1 - Missed abortion at 2 ma 2 years back G2 - Spont . Ab at 3 ma 1 year back G3 - Spont . Ab at 3 ma 6 months back Menstrual History 4-5/30 Regular, moderate, painful

79. Investigations Hb - 9.8 gm% Urine R/M - NAD FBS - 92 mg%, PLBS - 104 mg% RFT, LFT - WNL, Pap smear - N XRC - NAD HSA- 20 million per cc, 60- 70% motility

80. USG Uterus: Anterior wall intramural fibroid measuring 1.5 X 1.2 cm, Submucosal fibroid from posterior wall 2.1 X 2.2 cm ET - 7 mm Rt Ovary - N Lt Ovary clear cyst 3 X 4 cm, POD - N

81. AUTOIMMUNE PROFILE: Platelets - 2 lacs, BT CT - N, LA - N, ACL-N Diagnostic Laparoscopic findings - Uterus - N Rt. Ovary - N Lt. Ovary - cyst, B/L Fallopian tubes - patent

82. Diagnostic Hysteroscopy Findings Submucosal fibroid

83. Dr. Sanjay Gupte What is the role of other Anatomical factors?

84. Anatomic factors Mullerian anomalies Septum Bicornuate unicornuate IU Adhesions Submucous fibroid Intramural fibroid ??? Small uterine cavity

85. HSG of unicornuate uterus

86. A : before surgery B : after surgery HSG of bicornuate uterus

87. Partial septate uterus Complete septate uterus HSG of septate uterus

88. Uterine Leiomyoma II Sx - asymptomatic - menorrhagia pelvic pain or pressure Dx - bimanual examination - USG or HSG Tx - myomectomy under laparotomy - hysteroscopic myomectomy

89. HSG of DES exposure

90. Case 5 33 year old married since 10 years G5 P0 L0 A4 6 weeks amenorrhea Family and personal history not contributory

91. Obstetric History G1-2ma missed abortion S/E done 9 yrs back G2- 2ma MTP done i /v/o h/o antimalarial drugs taken 8 years back G3 - 2ma missed abortion S/E done 2 years back G4 - 2ma missed abortion S/E done 1 1/2 years back G5 - PP

92. Investigation Hb - 10 gm% Urine R/M-N LFT, RFT - N VDRL, HIV -ve Bl gr - O +ve, husband - B +ve HSA - N

93. Hysteroscopy- Asherman’s syndrome

94. Asherman’s syndrome: Uterine Synechiae Ex - mechanical trauma - infection - estrogen deficiency (?) Sx - mestrual disorder - infertility - pregnancy loss Dx : HSG or Hysteroscopy Tx - hysteroscopic dissection - IUD or pediatric Foley catheter - estrogen-progesterone HSG before Tx HSG after treatment

95. Case-6 History indicated: h/o repeated STL (second trimester losses) or PTB, Painless cervical dilatation, Precipitate labor USG indicated: cervical length < 15 mm? cervical length reduction 1 mm / week Physical examination indicated: shortening of cervix detected on manual examination in 2 nd trimester

96. Incompetent Cervix

97. Dr Shirodkar said that cerclage is for “women who abort repeatedly between the forth and seventh month… where one can by repeated internal examinations…find that the cervix is gradually yielding”

98. Conclusion Cerclage is beneficial in 2 or more STL/PTB Beneficial if cervical length is 15mm or less or internal os > 5 mm Not useful in twins or placenta previa

99. Cerclage Nomenclature Old nomenclature New nomenclature - Prophylactic-Elective - History indicated - Therapeutic-Salvage - Ultrasound indicated - Rescue-Emergency - Physical examination - Urgent - Combined

100. Intervensions

101. CLINICAL PROTEOMICS IN SPONTANEOUS ABORTIONS

102. Progesterone Temptations of its use RU486 Immunomodulatory action ???? Pregnancy support

103. Role of NK cells RPL: high activity of NK cells at the uterine lining as well as peripheral blood NK cells lead to release of pro-inflammatory cytokines. These lead to placental blood vessel clotting and subsequent pregnancy loss. CD8 type T cells Th2 cytokines are protective against NK cytokine-dependent miscarriage .

104. How does the fetus escape rejection by NK cells??

105. Following trophoblastic invasion the fetal semi-allograft induces PgR in γ / δ T cells. This enhances the interaction with high levels of progesterone Progesterone causes expression of PIBF

106. PIBF Inhibits NK-cell cytologic activity Th1 cytokines(IL2 and interferon γ ) Favors Th2 cytokines(IL4, IL5 and IL10) This inhibits cellular immune response and promotes humoral response

107. Supporting evidence Much less PIBF expression was found in women who eventually lost their pregnancies than in healthy pregnant women * However no such difference was found in aborters or non- aborters in patients aggressively treated with progesterone ** * Liddell HS et al * * Brigham SA et al

108. Difficulties….. Determining the role of progesterone in preventing RPL is difficult due to difficulty in determining who has progesterone deficiency When does the problem start ??? Luteal phase or will the need of progesterone increase with advancement of pregnancy

109. Spectrum theory ??? The spectrum of progesterone deficiency Prevention of embryonic implantation Early loss : chemical pregnancy Blighted ovum Viable but missed before 1 st trimester 2 nd trimester loss Preterm delivery

110. Benefits of Progesterone It is better to treat a woman with a benign treatment that is later found not to be effective than not treat her, have her miscarry and later find studies showing unequivocally that with such treatment definitely reduces the risk of miscarriage . - Shulman (2008 yearbook )

111. Role of HCG ??

112. Intervention : hCG HCG is the hormone responsible for CL support in early pregnancy If pregnancy is failing levels of HCG may be low resulting in low progesterone. Rather than giving progestrone HCG could be used directly in order to stimulate natural hormone to reduce ab normal fetal effects .

113. Evidence Study Treatment Control Odds ratio Quenby & Farquharson 6/41 10/39 0.39(0.13-1.20) Svigos 1/13 9/15 0.11(0.02-0.05) Harrison 0/10 7/10 0.05(0.01-0.32) Harrison 6/36 8/31 0.58(0.18-1.87) Total 13/95 34/85 0.26(0.14-0.52) Early smaller studies showed HCG to be beneficial Larger trials : weaknesses HCG v/s placebo for recurrent miscarriages : miscarriages per treated pregnancy

114. HCG is not a panacea to all patients of RPL Beneficial in particular group How to diagnose these patients? irregular cycles : more benefits HCG or Pr : HCG more natural

115. Comparison of Protocols Investigation/ treatment RCOG ACOG ESHRE Progesterone/ HCG supplement ---insufficient evidence--- Bacterial vaginosis ---insufficient evidence--- Thrombophilias ---insufficient evidence--- Anticoagulant for ---insufficient evidence--- Thrombophilia TFTs NR NR R OGCT NR NR R TORCH NR NR NR Immunotherapy NR NR insuf.evidence

116. Summary of Evaluation And Management of RPL

117. Evaluation and Management RPL 1 Factor Diagnostic Evaluation Abnormal result Therapy Immunologic LA,AC IgG / M ß2GlyproI Phosphotydylserine Embryotoxicity assay Immunophenotyping 15- 20% ASA Heparin IV Immunoglobulin Parental structural chromosome rearrangement Cytogenetic analysis of both the partners 2.5% -8% Genetic counseling Donor gametes PGD

118. Evaluation and management RPL 2 Factor Diagnostic Evaluation Abnormal result Therapy Endocrinologic Endometrial biopsy Midluteal Progesterone TSH ,PRL,FBSL 8-12% Progesterone Levothyroxine Bromocrytine / cabergoline,metformin ,insulin Anatomic Hysteroscopy HSG sonohysterography 15-20% Hysteroscopic metroplasty Adhesiolysis myomectomy

119. Evaluation and management RPL 3 Factor Diagnostic Evaluation Abnormal result Therapy Thrombophilic Factor V Leiden Prothrombin gene Fasting homocysteine Antithrombin activity? Protein C activity? Protein S activity? 8-12%? Low molecular weight or fractionated Heparin Folic acid Microbiologic Endometrial biopsy Cervical /vaginal cultures? 8-10 % Antibiotics

120. Evaluation and management RPL 4 Factor Diagnostic Evaluation Abnormal result Therapy Psychologic Mental status evaluation Support group Counseling psychiatrist Iatrogenic Review tobacco ,alcohol, caffeine use Review exposure to toxins,chemicals 5% Genetic counseling Donor gametes PGD

121. Thank you