Recurrent pregnancy loss RANZCOG Flashcards
List two independent risk factors for recurrent miscarriage
- Maternal age (advanced)
- previous miscarriage
List the age related risk of miscarriage for
A) 12-19 y/o
B) 20-24 y/o
C) 25-29 y/o
D) 30-34 y/o
E) 35-39 y/o
F) 40-44 y/o
G) 45 +
A) 13%
B) 11%
C) 12%
D) 15%
E) 25%
F) 51%
G) 93%
The risk of miscarriage is highest when the woman is >35 y/o and the man is >40 y/o
How would you advise a woman about her risk of miscarriage if she has had previous losses?
- risk of miscarriage increases with each successive miscarriage
- risk reaches approximately 40% after 3 consecutive losses
List 3 environmental risk factors that are implicated in miscarriage risk
- alcohol intake (although association is not confirmed, there is a dose dependent effect on risk of sporadic miscarriage)
- obesity increases risk of sporadic and recurrent miscarriage
- caffeine intake - associated with miscarriage in a dose dependent manner
Anaesthetic gases for theatre staff - evidence is mixed
List 3 adverse pregnancy outcomes associated with anti phospholipid syndrome
- 3 or more consecutive miscarriages at <10/40
- 1 or more morphologically normal fetal loss >10/40
- 1 or more pre term births before the 34th week of gestation owing to placental disease
What are the proposed mechanisms by which APS leads to pregnancy loss?
- inhibition of trophoblastic function and differentiation
- activation of complement pathway at the maternal fetal interface resulting in local inflammatory response
- later in pregnancy thrombosis of the placental vasculature
Justify screening for APS in RPL
APS is one of the known causes of recurrent miscarriage, and recurrent miscarriage is one of the clinical criteria for APS
If she has positive APS antibodies, then she meets the diagnostic criteria for APS
Diagnosing APS is crucial as it is associated with adverse pregnancy and health outcomes requiring close obstetric monitoring
There is also strong evidence for using LMWH and low dose aspirin in women with APS in pregnancy to improve outcome
what percentage of recurrent miscarriages can be explained by balanced chromosomal translocation?
2-5%
most commonly a balanced reciprocal or robertsonian translocation
Embryonic miscarriages
account for 30-57% of further miscarriages
- the risk of embryonic miscarriage increases with age
- although the risk of miscarriage of normal pregnancies also increases with age
Are uterine anomalies more strongly associated with first or second trimester miscarriage?
- more common in 2nd trimester
- thought to be due to the cervical weakness associated with uterine anomalies
Are uterine anomalies more strongly associated with first or second trimester miscarriage?
- more common in 2nd trimester
- thought to be due to the cervical weakness associated with uterine anomalies
- it has been reported that women with arcuate uteri are more likely to miscarry in the 2nd trimester, while women with septet uteri are more likely to miscarry in the first trimester
Explain the association between diabetes /thyroid disease and miscarriage
- poorly controlled diabetes with a high HbA1c at booking is associated with an increased risk of miscarriage and fetal anomaly
- poorly controlled thyroid disease is associated with an increased risk of miscarriage
However well controlled Diabetes and well treated thyroid disease are not associated with miscarriage
Which inherited thrombophilia should be tested for with RPL?
- factor V leidein
- prothrombin gene mutation
- protein S deficiency
what treatment options are available for APS positive women with recurrent miscarriage?
Combination of aspirin and heparin
What type of heparin is recommended?
LMWH has less side effects and is as effective
Side effects of unfractionated heparin - osteoporosis, heparin induced thrombocytopenia
