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Gynaecology > 23. Management Of Reccurentiscarriages > Flashcards

23. Management Of Reccurentiscarriages Flashcards

1
Q

What is defined as recurrent miscarriage?

A

Two or more spontaneous pregnancy losses before 20 weeks of gestation.

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2
Q

What is the difference between early miscarriage and losses after 20 weeks?

A

Early miscarriage occurs before 20 weeks, while losses after 20 weeks are classified as premature deliveries, which are clinically different.

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3
Q

When are investigations commenced for recurrent miscarriages in your unit?

A

Investigations are commenced if there are:
1. Three or more first trimester losses,
2. Two or more second trimester losses,
3. A combination of 1 and 2.

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4
Q

What is the incidence of spontaneous miscarriage in pregnant women?

A

Spontaneous miscarriage occurs in 15% of pregnant women.

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5
Q

What percentage of couples trying to conceive will have two consecutive miscarriages?

A

Up to 5% of couples trying to conceive will have two consecutive miscarriages.

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6
Q

What percentage of couples trying to conceive will experience three or more miscarriages?

A

1% of couples trying to conceive will experience three or more miscarriages.

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7
Q

What is the reason for seeking specific causes for recurrent miscarriages?

A

The calculated incidence of recurrent miscarriages is greater than the chance alone, so specific causes should be sought.

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8
Q

What is the most common genetic cause of first trimester miscarriages?

A

Chromosomal aneuploidy is the most common genetic cause.

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9
Q

How often do genetic abnormalities contribute to recurrent miscarriages?

A

Genetic abnormalities contribute to 50% of first trimester and 20% of second trimester miscarriages.

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10
Q

Does finding aneuploid conceptus material after miscarriage increase the risk of subsequent miscarriage?

A

No, finding aneuploid conceptus material does not increase the risk of subsequent miscarriage with the same anomaly.

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11
Q

What structural genetic abnormalities are associated with recurrent miscarriage?

A

Structural genetic abnormalities, such as balanced translocations, are commonly associated with recurrent miscarriage.

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12
Q

What percentage of couples with 2 or more recurrent miscarriages have a structural abnormality in one or both partners?

A

3-5% of couples with 2 or more recurrent miscarriages have a structural abnormality.

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13
Q

What is the most common structural defect associated with recurrent miscarriage?

A

The most common structural defect is a balanced translocation.

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14
Q

What are the congenital uterine anomalies associated with recurrent miscarriage?

A

Septate and bicornuate uteri are the most common congenital anomalies associated with recurrent miscarriage.

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15
Q

Can uterine abnormalities always be the sole cause of recurrent miscarriage?

A

No, uterine abnormalities may be associated with satisfactory obstetric outcomes, so other causes must be explored as well.

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16
Q

What percentage of recurrent pregnancy losses are due to uterine defects as the sole cause?

A

Approximately 2% of all recurrent pregnancy losses will have uterine defects as the sole cause.

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17
Q

What other condition is often associated with congenital uterine anomalies?

A

Cervical incompetence is often associated with congenital uterine anomalies.

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18
Q

What are the acquired causes of recurrent miscarriage?

A

Acquired causes include adhesions and synechiae (Asherman’s syndrome), diethylstilboestrol (DES)-related abnormalities, fibroids, and cervical incompetence.

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19
Q

How do adhesions and synechiae (Asherman’s syndrome) lead to recurrent miscarriage?

A

Adhesions and synechiae cause recurrent miscarriage by leading to a loss of endometrial tissue, which is essential for sustaining fetal growth.

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20
Q

What is the role of Diethylstilboestrol (DES) in recurrent miscarriage?

A

DES-related abnormalities may result in recurrent miscarriage due to induced uterine malformations, though this is of historical significance as DES is no longer used in clinical practice.

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21
Q

How can fibroids cause recurrent pregnancy loss?

A

Submucous fibroids that impinge on the endometrium can cause recurrent pregnancy loss, likely due to altered endometrial blood flow.

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22
Q

What is cervical incompetence and how can it contribute to recurrent miscarriage?r

A

Cervical incompetence is a condition where the cervix weakens and dilates prematurely, leading to miscarriage. However, no consensus has been reached on the diagnostic criteria for this condition.

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23
Q

When is screening for thyroid dysfunction useful in recurrent miscarriage?

A

Screening for thyroid disease is not useful unless the patient is symptomatic.

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24
Q

How does poorly controlled diabetes affect the miscarriage rate?

A

The spontaneous miscarriage rate in women with poorly controlled diabetes (high HbA1c in the first trimester) is increased 2 to 3 fold.

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25
Q

What is luteal phase defect?

A

Luteal phase defect is an abnormality where there is insufficient development of the secretory endometrium, inadequate progesterone production, or a failure of the endometrium to respond to adequate progesterone levels.

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26
Q

What is the gold standard for diagnosing luteal phase defect?

A

The gold standard is an endometrial biopsy done on two separate occasions, showing an “out of phase” endometrium, with a lag of 2 days.

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27
Q

Is there a consensus on the diagnosis or treatment of luteal phase defect?

A

No, there is no accepted consensus about the pathophysiology, method of diagnosis, or treatment of luteal phase defect.

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28
Q

Is PCOS associated with an increased chance of miscarriage?

A

The association between PCOS and an increased chance of miscarriage is controversial.

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29
Q

What hormonal factor in PCOS is implicated as a risk factor for miscarriage?

A

LH hypersecretion has been implicated as a risk factor in PCOS patients.

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30
Q

Does pre-pregnancy suppression of LH improve the chances of a successful pregnancy in PCOS?

A

No, pre-pregnancy suppression of LH has not been shown to improve pregnancy success rates in PCOS patients.

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31
Q

What other mechanisms of pregnancy loss in PCOS patients have been investigated?

A

Increased plasminogen activator inhibitor (PAI) secretion has been investigated as a potential mechanism of pregnancy loss in PCOS patients.

32
Q

What role do phospholipids play in pregnancy?

A

Phospholipids act like “glue,” helping to hold dividing cells together and are necessary for the growth of the placenta into the uterine wall.

33
Q

How are antiphospholipid antibodies related to miscarriage?

A

Antibodies to phospholipids are associated with an increased risk of miscarriage.

34
Q

What defines primary antiphospholipid syndrome?

A

Primary antiphospholipid syndrome is diagnosed in the presence of antiphospholipid antibodies and adverse pregnancy outcomes or vascular thrombosis.

35
Q

What are some adverse pregnancy outcomes in primary antiphospholipid syndrome?

A

Adverse outcomes include:
- 3 or more consecutive miscarriages before 10 weeks,
- One or more morphologically normal fetal deaths after the 10th week,
- One or more pre-term births before 34 weeks due to severe pre-eclampsia, eclampsia, or placental insufficiency.

36
Q

What defines secondary antiphospholipid syndrome?

A

Secondary antiphospholipid syndrome is diagnosed when antiphospholipid syndrome coexists with a chronic inflammatory condition like systemic lupus erythematosus (SLE).

37
Q

Which antibodies are important in diagnosing antiphospholipid syndrome?

A

The important antibodies are lupus anticoagulant (LA), anticardiolipin antibodies (ACA), and anti-beta 2 glycoprotein-1 antibodies.

38
Q

What is the pathogenesis of antiphospholipid syndrome in pregnancy?

A

The pathogenesis likely involves placental thrombosis and infarction, possibly due to decreased prostacyclin (PGI2) or platelet damage with increased adhesiveness.

39
Q

What is the prevalence of antiphospholipid syndrome in recurrent miscarriage?

A

The prevalence of antiphospholipid syndrome in recurrent miscarriage is about 15% (9% LA, 6% ACA, and 2% both).

40
Q

In which trimesters does miscarriage occur due to antiphospholipid syndrome?

A

Miscarriage may occur in the first trimester (65%) or second trimester (35%).

41
Q

What is the fetal loss rate in cases of antiphospholipid syndrome?

A

The fetal loss rate in antiphospholipid syndrome is 80%.

42
Q

What are antinuclear antibodies (ANA) and how are they related to recurrent miscarriage?

A

ANA react against normal components of the cell nucleus and are associated with autoimmune diseases. In recurrent miscarriage, ANA may indicate an underlying autoimmune process affecting placental development, but elevated levels can also occur in the general population without pregnancy loss.

43
Q

Are antinuclear antibodies (ANA) recommended for routine evaluation in recurrent miscarriage?

A

No, measuring ANAs is not recommended as part of the evaluation for recurrent miscarriages, as elevated levels can also occur in individuals without pregnancy loss.

44
Q

What is the role of alloimmune factors in recurrent miscarriage?

A

An abnormal maternal immune response to placental or fetal antigens has been implicated in recurrent pregnancy loss. However, treatment modalities for this need further research before being recommended.

45
Q

What is thrombophilia?

A

Thrombophilia is a hereditary condition involving a disturbance in natural anticoagulants, leading to an increased tendency for thromboembolic disease, especially in young adults under 50.

46
Q

How is thrombophilia related to recurrent miscarriage?

A

Thrombophilia has been implicated in recurrent second trimester miscarriage, likely due to retroplacental thromboses and subsequent placental infarction.

47
Q

Which anticoagulant proteins are typically involved in thrombophilia-related recurrent miscarriage?

A

The abnormalities often involve protein C, protein S, and antithrombin III (ATIII).

48
Q

Which organisms have traditionally been implicated in recurrent miscarriage?

A

Mycoplasma, ureaplasma, listeria, toxoplasmosis, and chlamydia have traditionally been implicated, but none have been unequivocally proven to be associated with recurrent miscarriage.

49
Q

How is bacterial vaginosis linked to recurrent miscarriage?

A

The presence of bacterial vaginosis in the first trimester has been associated with an increased risk of second trimester miscarriage and preterm delivery.

50
Q

How can bacterial vaginosis impact women with a history of preterm birth?

A

In women with a previous history of preterm birth, detecting and treating bacterial vaginosis early in pregnancy may help prevent further preterm birth.

51
Q

What is hyperhomocysteinaemia and how is it related to recurrent miscarriage?

A

Hyperhomocysteinaemia is an abnormality in folate metabolism, leading to methionine intolerance and high homocysteine levels, which have been shown to be associated with recurrent miscarriage.

52
Q

How is Wilson’s disease related to recurrent miscarriage?

A

Wilson’s disease, a rare condition, is associated with a high miscarriage rate due to the embryotoxic effect of copper.

53
Q

What is the effect of smoking and alcohol on recurrent miscarriage?

A

Smoking and alcohol consumption appear to have a very small effect on the overall group with recurrent miscarriage. Only heavy users seem to have a slightly increased risk.

54
Q

How does radiation affect the risk of recurrent miscarriage?

A

Radiation has been associated with an increased risk of recurrent miscarriage, as seen after the Chernobyl disaster.

55
Q

What is the first step in assessing a patient with recurrent pregnancy loss?

A

The work-up begins with a detailed history and examination.

56
Q

What aspects of history are important in assessing recurrent miscarriage?

A

Key aspects include previous pregnancies, gynaecological history, medical history, family history, and social history.

57
Q

What types of examination are required for the assessment of recurrent miscarriage?

A

Both general and gynaecological examinations are necessary.

58
Q

What chromosomal tests are conducted in the work-up for recurrent miscarriage?

A

Karyotyping of both mother and father, and chromosomal analysis of the abortus are performed.

59
Q

What are the key haematological investigations for recurrent miscarriage?

A

Key tests include:
- Lupus anticoagulant (APTT, KCT, DRVVT)
- Anticardiolipin antibodies (ACA)
- Factor V Leiden
- Possibly protein C, protein S, and antithrombin levels.

60
Q

Which infections are screened for in recurrent miscarriage?

A

The infection screen includes HIV, VDRL, bacterial vaginosis, and culture for ureaplasma urealyticum.

61
Q

What endocrine tests are done for recurrent miscarriage?

A

Endocrine testing includes fasting blood sugar, thyroid function tests, late luteal phase endometrial biopsies, and PCOS work-up if diagnosed.

62
Q

What anatomical investigations are conducted during the work-up?

A

Anatomical tests include:
- Transvaginal ultrasound (preferably 3-dimensional)
- Hysteroscopy, laparoscopy, or hysterosalpingogram
- MRI if uterine abnormalities are suspected
- Hager test.

63
Q

Are immunological investigations for alloimmune abnormalities recommended for routine use?

A

Investigating and treating alloimmune abnormalities should be restricted to research settings.

64
Q

What additional testing might be required during the work-up?

A

Further testing depends on findings from the history, examination, and the investigations listed above.

65
Q

How should genetic abnormalities be managed in recurrent miscarriage?

A

Management includes providing explanation and acceptance, using donor gametes (sperm or oocytes), or considering adoption. Prenatal screening should be offered to all translocation carriers.

66
Q

How should congenital anatomical abnormalities be managed in recurrent miscarriage?

A

Conservative management is recommended unless the abnormality is associated with recurrent pregnancy loss.
- Septate uterus: best treated with hysteroscopic resection of the septum.
- Other abnormalities: consider open metroplasty procedures.
- Prophylactic cerclage may be recommended in some cases.

67
Q

How should acquired anatomical abnormalities be managed?

A

Asherman’s syndrome: hysteroscopic adhesiolysis followed by high-dose oestrogens with or without IUCD use.

Fibroids: myomectomy if the fibroid is submucosal or impinges on the endometrial cavity.

Cervical incompetence: cerclage indicated.

68
Q

How should diabetes mellitus be managed in women with recurrent miscarriage?

A

Insulin-dependent diabetics have an increased risk, so tight control before conception and throughout pregnancy is important.

69
Q

How should thyroid disease be managed in recurrent miscarriage?

A

Treatment is only indicated if there is a proven underlying thyroid disorder.

70
Q

How is luteal phase defect managed in recurrent miscarriage?

A

Management includes progesterone supplementation (oral, IM, or vaginal pessary), and possibly HCG therapy, which stimulates the corpus luteum to produce progesterone. However, there is no conclusive evidence that progesterone therapy improves outcomes.

71
Q

How should PCOS be managed in recurrent miscarriage?

A

The use of oral antidiabetic agents is typically considered in PCOS patients.

72
Q

How is antiphospholipid syndrome managed in recurrent miscarriage?

A

Treatment includes low-dose aspirin (1mg/kg/day) from 6-36 weeks and heparin 5000IU subcutaneously twice a day. Recent studies suggest that a combination of aspirin and heparin may be more effective than aspirin alone. Low molecular weight heparins are preferred due to a better side-effect profile.

73
Q

How are other collagen diseases (ANA) managed in recurrent miscarriage?

A

Management follows the protocol specific to the underlying disease.

74
Q

How are presumed alloimmune disorders treated in recurrent miscarriage?

A

Since diagnosing alloimmune causes is difficult, many suggest empiric treatment in otherwise “undiagnosed” cases.

75
Q

How is thrombophilia managed in recurrent miscarriage with no history of DVT?

A

Heparin 5000IU subcutaneously from early pregnancy to term, followed by warfarin therapy post-delivery for three months.

76
Q

How is thrombophilia managed in recurrent miscarriage with a history of DVT?

A

Full heparinization throughout pregnancy, warfarin post-delivery for three to six months, and wearing elastic stockings throughout pregnancy. Low molecular weight heparin is preferred for its better side-effect profile.

Gynaecology (27 decks)

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