Early pregnancy complication - Recurrent miscarriage & Gestational Trophoblastic Disease Flashcards
What is the definition of recurrent miscarriage?
3+ 1st timester miscarriage
How common is recurrent miscarriage?
1% women
What is the greatest RF for recurrent miscarriage?
And other RF?
Maternal Age
Paternal age, N previous misc , black ethic BG, smoking, excision ETOH or caffeine, BMI <19 >25, antiphospholpoid, anatomical, endocrine (DM, thyroid, PCOS)
Rates of miscarriage
12-19
20-24
25-29
30-34
35-39
40-44
45+
12–19 years = 13%;
20–24 years = 11%;
25–29 years = 12%;
30–34 years = 15%;
35–39 years = 25%;
40–44 years = 51%;
45 + = 93%.
Rates of miscarriage
1 previous
2 previous
3 previous
4 previous
5 previous
6 previous
1 previous 11%
2 previous 17%
3 previous 28%
4 previous 40%
5 previous 47%
6 previous 64%
What % of women with recurrent miscarriage have antiphospholipid syndrome?
15%
Which antiphopholispid antibodies are tested?
Lupus anticaogulant
Anticardiolipin antibodies
Anti B2 glycoprotein 1 antibody
2+ve test 12 weeks apart
What other features should be present other than the antibodies to Dx aPL syndrome?
Adverse pregnancy outcomes
- 3+ miscarriage <10/40
- 1+ morphologically normal loss >10/40
- 1+ preterm birth <34/40 due to placental disease
or
vascular thrombosis
What other Ix should be completed for recurrent misc?
- aPL antibodies
- Cytogenetics on POC
If POC shows unbalanced structural chromosomal abnormlairt → parental peripheral blood karyotype both parents - Pelvis USS, if suspect uterine abnormality consider hsyteroscopy/Lap
If 2nd trimester miscarriage, what else should be tested for?
If 2nd trimInherited thrombophilias, factor V leiden, prothrombin gene mutation or protein S deficiency
What is the most common cause of sporadic and recurrent miscarriage?
Chromosomal abnormality
For sporadic 50% CA, most common trisomy 52%
In recurrent miscarriage which is the most common type of chromosomal abnormality?
Aneuploidy 40%
After 3 recurrent miscarriages, what % of 1 or both couples have a balanced translocation?
3-5%
What the chances of parents with a balanced translocation having a health child?
83%
Lower if reciprocal translocation (54%), robertsonain (34%)
If antiphospholipid syndrome, what is the Tx?
Aspirin and LMWH
What can be offered to women who have had a 2nd trimester miscarriage and suspected cervical weakness?
Cervical USS, if <25mm can offer cerlclage
Women with unexplained recurrent miscarriage have excellent prognosis for future pregnancy outcomes. What % successful pregnancy
75%
Which gestational trophoblastic disease are pre-malignant?
Complete and partial molar pregnancy
Which gestational trophoblastic disease are malignant?
Invasive mole
Choriocarcinoma
Placental site trophoblastic tumour (PSTT)
Epithelioid trophoblastic tumour (ETT)
What is the definition of complete molar?
46XX
Diploid
- 75-80% - No nucleus - single sperm duplicates
- 20-25% No nuclear - 2 sperm fertilise
What is the definition of partial molar?
69XXY
Triploid
2 sperm + nucleated egg
Incidence of GTD in UK?
1 in 714 live births
Incidence of GTD if <15yrs
1 in 500
Incidence GTD if >50yrs
1 in 8
Incidence of GTN (neoplasia)
1 in 50,000
Cure rate of GTD
98-100%
What % need chemotherapy for partial molar and complete?
Partial: 0.5-1%
Complete 13-16%
Reurrance of molar pregnancy?
After 1 and after 2
1 in 80
1 in 6.5 after 2
Where does choriocarcinoma spread to?
Haematogenous spread to lungs, brain and liver (cannon ball mets)
Common presentation of GTD?
Irregular vaginal bleeding
Positive pregnancy test
Supporting ultrasonographic evidence
Less common presentations include hyperemesis, excessive uterine enlargement, hyperthyroidism, early‐onset pre‐eclampsia and abdominal distension due to theca lutein cysts
Very rarely women can present with haemoptysis or seizures due to metastatic disease affecting the lungs or brain.
What is the definitive Dx of GTD?
Histological
Management of molar pregnancy
Surgical Mgmt with suction for complete and partial (unless if fetal size deters this and medical can be used)
Anti D
Avoid use of oxytocin infusion
→ Repeat SMM/Balloon/UAE
When should histological assessment of miscarriage be recommenced?
If no fetal parts are identified
After miscarriage/aboriton, how to rule out GTD
UPT after 3 weeks
Which women should be Ix for GTN after non molar pregnancy?
- If persistently raised HCG after an ectopic pregnancy has been excluded, or 2 x Tx with MTX
- Persistent bleeding after pregnancy event > 8 weeks after pregnancy event
When should prenatal invasive testing for karyotype be considered?
- Unclear if the pregnancy is complete mole + normal town or singleton partial molar
- Abnormal placenta such as mesenchymal hyperplasia
Referred to GTD centre
For how long should a complete molar pregnancy be followed up?
If normal bHCG within 56 days, 6 month FU from uterine removal
If not reverted to normal within 56days, 6 months from normalisation of bHCG
How long should a partial molar be followed up?
On bHCG has returned to normal on 2 samples, 4 weeks apart
When can women attempt conception again after GTD?
Without chemo
Following chemo
without: Once completed follow up
with: 1 year after chemo
If a women has GTN, they can be treated with chemotherapy what score is used to determine if the need single or multi-agent chemo?
FIGO scoring
<6 single agent IM MTX with folinic acid
> 7 Muliagent check
Draw table of FIGO
What % of women have successful future pregnancies with chemotherapy Tx GTN?
80%
