Chapter 32 Recurrent Pregnancy Loss and Thrombophilia

Question 1

sporadic pregnancy loss is common, ocuring in __ to __ of clinically recognized pregnancies

Answer 1

10-25%

Question 2

risk of miscarriage increases with age. 10% at age 20 to __ by age 40

Answer 2

10% at age 20

50% by age 40

Question 3

numerical chromosomal abnormalities explain more than 1/2 of clinically recognized pregnancy loss

Answer 3

true
trisomies most common.
likelihood of finding abnormal fetal karyotype increases with maternal age

Question 4

Recurret Pregnancy Loss (RPL) defined as:

Answer 4

3 pregnancy losses and occurs in approximately 1% of couples.

Question 5

chance of fetal aneuploidy in pts with RPL is lower than in patients experiencing a sporadic loss

Answer 5

true

Question 6

5 etiologies of recurrent pregnancy loss (RPL)

Answer 6

1. genetic
2. autoimmune: antiphospholipid antibody symdrome (APS)
3. anatomic
4. Endocrine
5. Inherited thrombophilia.
   60% of couples with RPL have no identifiable cause

Question 7

Genetic cause of RPL.

Answer 7

1. (most common) balanced reciprocal or robertsonian translocation
2. inversions, insertions, mosaicism

Question 8

evaluation of Genetic cause of RPL

Answer 8

karyotype of peripheral blood to detect structural chromosomal abnormalities (recommended for both partners)

Question 9

couples with RPL and a structural rearrangement, PGD leads to a reasonable live-birth rate with a significant reduction in the rate of miscarriage. in contrast, couples opting for no intervention may obtain acceptable live-birth rates as well, though time, additional miscarriages, and expenditure of emotional energy may be required

Answer 9

true.

Question 10

AUTOIMMUNE CAUSES OF RPL: Antiphospholipid Antibody Syndrome

Answer 10

16-20% of recurrent pregnancy loss.

Question 11

diagnosis of Antiphospholipid Antibody Syndrome:

Answer 11

lab criteria must be measured on 2 occasions 12 weeks apart.

Question 12

at least One of the clinical Criteria and One of the laboratory criteria are met

Answer 12

Clinical Criteria:
1.ONE or more unexplained deaths of morphologically normal neonate , or beyond 10th week gestation.
2. one or more premature births of morphologically normal neonate before 34th week gestation because of (a). eclampsia / severe preeclampsia or (b) placental insufficiency
3. three or more unexplained consecutive spontaneous abortions before 10th week gestation, with maternal anatomic /hormonal abnormalities and paternal and maternal chromosomal causes excluded.
LAB criteria:
1. Lupus anticoagulant present in plasma, on 2 or more occasions at least 12 weeks apart
2. anticardiolipin antibody of IgG or IgM on 2 or more occasions, 12 weeks apart
3. anti beta2 glycoprotein-I antibody of IgG or IgM

Question 13

treatment of Pts with APL syndrome

Answer 13

low dose aspirin and either fractionated or unfractionated heparin.

Question 14

ANATOMIC causes or Recurrent Pregnancy loss accounts for __ of cases

Answer 14

18%.
specific alterations include: 
1. endometrial polyps
2. submucosal fibroids
3. intramural fibroids >5cm
4. uterine anomalies, particularly septate uterus
5. asherman's syndrome

Question 15

diagnosis of anatomic causes :

Answer 15

1. sonogram
2. hysterosalpingogram
3. hysteroscopy

Question 16

Management of anatomic causes:

septate uterus:

Answer 16

septate uterus: may be related to decreased vascularity with septum tissue. optimal treatment is hysteroscopic METROPLASTY.

Question 17

fibroids:

Answer 17

submucous leiomyomas can impede implantation or result in abnormal implantations in the tissue overlying the myoma. submucosal myomas 5cm) intramural fibroids or intramural fibroids that alter the contour of uterine cavity may be a concern, consideration should be given to their removal.

Question 18

Asherman’s syndrome

Answer 18

adhesions within the uterine cavity. often associated with amenorrhea or lighter than normal menses.
Risk FActors: D&C, infection, multiple uterine surgeries
Pathophysiology: trauma to basalis layer leading to granulation tissue that ultimately forms adhesive bridges
Tx: hysteroscopic lysis of adhesions

Question 19

Endocrine Causes of RPL

Answer 19

8% cases of recurrent pregnancy loss

Question 20

Endocrine causes:

Answer 20

1. diabetes - poorly controlled. evaluate fasting glucose
2. thyroid - poorly controlled thyroid disease related to infertility and pregnancy loss. evaluate tsh
3. prolactin - elevated levels associated with irregular menstrual cycles, infertility, and possibly miscarriage. evaluate PRL level
4. Luteal Phase Defect

Question 21

Luteal Phase Defect

Answer 21

1.Progesterone is essential for embryo implantation and maintenance of pregnancy.
2.Inadequate progesterone production may occur in setting of poor follicular development or corpus luteum function.
3. Careful documentation of a short luteal phase (<8 days) or clinical evidence of prolonged spotting may be suggestive
4.Endometrial biopsies not a reliable method of dx.
5. Possible treatment strategies include ovulation induction with oral agents such as Clomid or progesterone supplementation in luteal phase.
The human luteal phase lasts between ten and sixteen days, the average being fourteen days. Luteal phases of less than twelve days may make it more difficult to achieve pregnancy

Question 22

HEMATOLOGIC CAUSES OF RPL: INHERITED THROMBOPHILIA

Answer 22

Factor V Leiden
Prothrombin gene 20210A mutation
Deficiencies in protein C
Deficiency in protein S
Antithrombin III deficiency

Question 23

Infectious Causes of RPL

Answer 23

Listeria monocytogenes
Toxoplasma gondii
cytomegalovirus
primary genital herpes
currently no role for evaluation or treatment of the asymptomatic patient.

Question 24

Lifestyle and environmental factors associated with RPL

Answer 24

caffeine - intake >200mg/ day may correlate with miscarriage

• limit caffeine to one to two cups / day
• cigarette smoking
• alcohol consumption
• prepregnancy bmi above 25