Recurrent miscarriage

Question 1

Define recurrent miscarriage

Answer 1

> 3 consecutive pregnancies that end in miscarriage of the fetus before 24 weeks gestation

Question 2

What percentage of women of reproductive age suffer from recurrent miscarriage?

Answer 2

1-2%

Question 3

List some causes of recurrent miscarriage

Answer 3

Antiphospholipid syndrome

Genetic factors - parental chromosomal rearrangements or embryonic chromosomal abnormalities

Endocrine - DM, thyroid disease and PCOS

Anatomical factors - uterine malformations, cervical weakness or acquired uterine abnormalities

Infective agents

Inherited thrombophilias

Question 4

What does antiphospholipid syndrome refer to?

Answer 4

Association between antiphospholipid antibodies and vascular thrombosis or pregnancy failure/complication

Question 5

What percentage of women with recurrent miscarriage have antiphospholipid syndrome

Answer 5

15%

Question 6

What is the live birth rate for women with antiphospholipid syndrome and no pharmacological intervention

Answer 6

10%

Question 7

Describe parental chromosomal rearrangements

Answer 7

In approx 2-5% of couples with recurrent miscarriage, one of the partners carries a balanced reciprocal or robertsonian 1 chromosomal translocation. They are phenotypically normal but their pregnancies are at an increased risk of miscarriage, secondary to an unbalanced chromosomal arrangement

Question 8

How many miscarriages in recurrent pregnancy loss does embryonic chromosomal abnormalities account for

Answer 8

30-57%

Question 9

What does a high HBA1c at conception increase the risk of?

Answer 9

Miscarriage and foetal malformation

Question 10

Describe the mechanisms by which PCOS is thought to increase risk of miscarriage

Answer 10

Insulin resistance
Hyperinsulinemia
Hyperandrogenaemia

Question 11

List some uterine malformations

Answer 11

Septate
Bicornuate
Arcuate

Question 12

What is an arcuate uterus?

Answer 12

Dip at the top

Question 13

What is a septate uterus?

Answer 13

Has a membrane (septum) dividing the inner portion of the uterus

Question 14

What is a bicornuate uterus?

Answer 14

Uterus appears heart shaped

Question 15

Describe cervical weakness and how it may lead to miscarriage

Answer 15

Where cervix begins to efface and dilate before pregnancy reaches term

Question 16

What is the classic history of cervical weakness

Answer 16

Second trimester miscarriage

Preceded by spontaneous rupture of membranes or painless cervical dilatation

Question 17

List some acquired uterine abnormalities

Answer 17

Adhesions

Fibroids

Question 18

What is the name of the syndrome which involves adhesions?

Answer 18

Ashermans

Question 19

What is Ashermans syndrome?

Answer 19

scar tissue on uterus or cervix causing the walls to stick together and reduces the size of the uterus

Question 20

Which infective agent increases risk of second trimester miscarriage?

Answer 20

Bacterial vaginosis

Question 21

Which inherited thrombophilias increase the risk of second trimester pregnancy loss

Answer 21

Factor V leiden
Prothrombin gene mutation
Deficiencies of protein C/S and antithrombin 111

Question 22

List 3 risk factors for recurrent miscarriage

Answer 22

Advanced maternal age

Number of previous miscarriages

Lifestyle

Question 23

What blood tests would you order when investigating recurrent miscarriage?

Answer 23

Antiphospholipid antibodies

Inherited thrombophilia screen - factor V leiden, prothrombin gene mutation and protein S deficiency

Question 24

What is required for a diagnosis of antiphospholipid syndrome?

Answer 24

2 positive tests, 12 weeks apart for either lupus anticoagulant, anticardiolipin antibodies or anti-B2 glycoprotein antibodies

Question 25

What genetic tests would you order for recurrent miscarriage?

Answer 25

Cytogenetic analysis - examines for any chromosomal abnormalities in the POC of >3rd miscarriage

Parental peripheral blood karyotyping - indicated when testing POC reports unbalanced structural chromosomal abnormality. Done on both parents

Question 26

What imaging is done in recurrent miscarriage?

Answer 26

Pelvic ultrasound - assess uterine anatomy. If anomalies suspected then further investigations such as hysteroscopy, laparoscopy or 3d pelvic US

Question 27

Describe the management for recurrent miscarriage caused by genetic abnormalities

Answer 27

Couples with abnormal parental karyotype should be referred to a clinical geneticist

Prognosis of risk of future pregnancies

Familial chromosomal studies

Preimplantation genetic screening with IVF if unexplained recurrent miscarriage

Question 28

What is the management of recurrent miscarriage caused by cervical weakness?

Answer 28

Cervical cerclage

or serial cervical sonographic surveillance

Question 29

What is cervical cerclage?

Answer 29

Suture is placed to close the cervix

Question 30

When might cervical cerclage be indicated?

Answer 30

Previous poor obstetric history >3 X 2nd trimester losses

Cervical length shortening on USS

Symptomatic women with premature cervical dilation and exposed foetal membranes in the vagina

Question 31

List the complications of cervical cerclage

Answer 31

Bleeding
Membrane rupture
Stimulating uterine contractions

Question 32

How are women with antiphospholipid syndrome managed in pregnancy

Answer 32

Low dose aspirin and low molecular weight heparin therapy