Transcript peripartum cardiomyopathy - Austin Perinatal Associates

RECURRENT AND MIDTRIMESTER PREGNANCY LOSS
David L. Berry, M.D.
Austin Perinatal Associates
Seton Medical Center OB Grand Rounds
September 19, 2011
“MISCARRIAGE” OR
“SPONTANEOUS ABORTION”
Spontaneous loss of a conceptus < 20 weeks
 30% of all pregnancies
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– 1/3 recognized (usu. > 10 weeks)
– 2/3 isolated elevated hCG and < 10 weeks
Increased with maternal age < 18 or > 35
 Increased with increased # of previous losses
 80% unexplained, 20% explained
 Only ½ of explained losses are aneuploidy
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PSYCHOLOGY OF RECURRENT
PREGNANCY LOSS
All patients feel broken and unworthy
 All partners feel inadequate and helpless
 With 80% unexplained, any theoretic
explanation will be sought and grasped
onto as gospel
 This industry is so poorly understood,
there is significant abuse of these
desperate patients
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RECURRENT PREGNANCY LOSS
(RPL)
3 or more consecutive, unexplained
spontaneous abortions
 Occurs in 1% of couples
 Two consecutive losses occur in 5%
 Must differentiate timing (early vs. late)
 Structural, hormonal, chromosomal,
implantation, anomaly, placental,
circulatory, cervical
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RECURRENT PREGNANCY LOSS
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Early losses (< 10 weeks) associated with fetal
structural/chromosomal abnormalities, uterine defects
(scarring/fibroids/septa), and luteal phase defects
Frequently early losses are idiopathic
Phospholipid syndromes associated with 16 – 20 week
IUFD’s, PIH and IUGR at < 34 weeks and maternal
thrombosis more so than early losses
5 – 15% of RPL have anti-phospholipid Ab syndrome
RECURRENT PREGNANCY LOSS
Uterine malformations (10 – 25%)
 Parental balanced translocations (3 – 6%)
 Maternal thyroid disease and diabetes
 Mycoplasma/Ureaplasma screening are of
questionable utility
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EVALUATION FOR RPL
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Historical information is VITAL
– Anembryonic and < 10 weeks
– +FHR seen followed by bleeding
– History of familial disease or previous
aneuploid fetus is useful
– Previous D&C or Hysteroscopy useful
– REMEMBER: Symptoms of miscarriage do
not show for 4 weeks post embryonic demise
EVALUATION FOR RPL
Anembryonic may be structural uterine
or fetal anomaly/aneuploidy
 +FHR and spontaneous bleeding and
cramping is likely luteal phase defect
 Mid-trimester IUFD may be placental,
fetal or anti-phospholipid syndrome
 Mid-trimester delivery of a well-grown
fetus is frequently cervical insufficiency
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WORK-UP FOR RPL
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For < 10 week losses, karyotype on POC’s or on
parents, HSG
For losses involving bleeding/cramping, Day 21
Progesterone may help (not predictive of future cycles)
For Mid-trimester IUFD - LAC, ACA, and Beta 2
Glycoprotein I may be helpful
– Factor V Leiden and Prothrombin gene mutation are less
diagnostic from a fetal standpoint
RPL – TREATMENT OPTIONS
If HSG indicates filling defects –
Hysteroscopy is indicated
 If parental balanced translocation is
identified, IVF with PGD ($50 – 100,000)
 Consider treatment of both partners for
mycoplasma/ureaplasma(?)
 For all unexplained losses, consider ASA and
progesterone supplements until 12 weeks(?)
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RPL TREATMENT OPTIONS
For cramping/bleeding history, treat with
Progesterone replacement from +UPT
until 10 – 12 weeks
 Vaginal progesterone 200 mg BID
 No need for Progesterone levels
 Early (6 – 8 week ultrasound)
 Follow up ultrasound q 1 – 2 weeks until
12 weeks of pregnancy
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ANTIPHOSPHOLIPID SYNDROME
Abnormal aPTT + DRVVT
 ACA IgG or IgM (> 40 GPL/MPL units)
 Anti Beta-2 glycoprotein I (>99th centile)
 ALL OF THE ABOVE MUST BE + ON
TWO OCCASIONS AT LEASE 12
WEEKS APART AND MAY NOT BE
THE CAUSE OF PREVIOUS LOSSES!
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WHO SHOULD BE TESTED FOR
APL ANTIBODY SYNDROME?
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Any patient with a history of unexplained
arterial or venous thrombosis
Any patient with an unexplained fetal death
(> 10 weeks) of a morphologically normal
fetus on exam or ultrasound
History of < 34 week birth from IUGR or
severe preeclampsia/eclampsia
Patient with 3 or more early losses with
normal chromosomes and hormones
TREATMENT FOR APL
SYNDROME
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Focus on prevention of thrombosis, 3rd
trimester IUGR and prevention of preeclampsia > pregnancy loss
Prophylactic anticoagulation (usu. Lovenox
+ ASA) until 6 weeks PP
Prednisone, IVIG controversial
Expert opinion support increased AP testing
Observe for future thromboses
Avoid estrogen containing OCP’s
MISCONCEPTIONS ABOUT RPL
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A single loss or even two early losses are
“abnormal”
Low + ACA, + ANA or + FVL or other
thrombophilias are CAUSATIVE of RPL
Hysteroscopy will “cure” or “fix” the cause so it
will not recur
Frequent progesterone and hCG values are
helpful
TRUTHS ABOUT RPL
Psychological and emotional support are
imperative
 Even unexplained losses deserve a “plan”
 Treatment of true APL Antibody
Syndrome is with Heparin/Aspirin
 Treatment of FVL and Prothrombin gene
mutations and other thrombophilias are
maternal treatments, not fetal
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CERVICAL INSUFFICIENCY
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No known cause of cervical failure
Poor association between prior cervical
surgeries and cervical insufficiency
LEEP and CKC more causative of stenosis
ACOG recommends > or = 3 losses with
painless dilatation to consider cerclage
ACOG states up to 16.6% complication from
elective cerclage
TREATMENT OF CERVICAL
FAILURE
Simple, easy, outpatient procedure
 12 – 14 week Modified McDonald
cerclage
 Use 5 mm Mersilene
 Do NOT tie over Hegar/Hank’s dilator
 As high and as tight as possible
 Remove electively at 36 weeks
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AUSTIN PERINATAL OUTCOMES
FOR CERCLAGE
Over 900 procedures performed
 One (0.1%) transient anesthetic
complication
 0% procedurally related losses
 99% Survival Rate
 96% Term Rate (4% prematurity)
 Compared to the uncomplicated term
rate is 88% (12% prematurity)
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RESCUE CERCLAGE
Reserved for specific circumstances
 Highly risky (up to 50% complication)
 Not clinically proven in controlled study
 Patients discovered incidentally
 Exclusions include bleeding, contractions,
infection, PROM, dynamic changes or >
2 X 2 cm BOW outside the external os
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TREATMENT OPTIONS FOR
MIDTRIMESTER IUFD
Pre-medicate with Cytotec 200mcg q 4 hrs
 Cytotec p.o. or p.v.
 200 mcg tabs do not dissolve vaginally
 100 mcg tabs do not dissolve in high pH
 30 cc Foley catheter + high dose Pitocin
 Hemabate 250 mcg I.M. q 4 hours
 Intra-amniotic Hemabate (10 mL)
 D&E
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