Transcript Recurrent pregnancy loss

Recurrent pregnancy loss
Spontaneous pregnancy loss is the most common
complication of pregnancy-70% of all human
conceptions fail to achieve viability.
Recurrent abortion –occurrence of 3 or more clinically
recognised pregnancy losses before 20 weeks of
gestation.
Risk for subsequent pregnancy loss is estimated to be
24% after 2 clinically recognised losses,30% after 3
losses & 40—50 % after 4 losses.
Clinical investigation for pregnancy loss should be
initiated after 2 consecutive spontaneous
abortions,especially if fetal cardiac activity is identified
before any of the pregnancy losses,woman>35 yrs or
the couple has difficulty in conceiving.
History
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h/o consanguinity-single gene defects may
cause RPL –revealed by a detailed family
history.
Inherited thrombophilias can cause RPLhyperhomocystinemia,activated protein c
resistance,mutations in factor 5 leidein,protein
C,S,antithrombin 3
Parental chromosomal abnormalities like
balanced translocations can cause RPL-cannot be
ruled out by family history or prior term births.
History
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h/o foul smelling vaginal dischargesuggestive of bacterial vaginosis .infection
with ureaplasma,prevotella,b-hemolytic
streptococcus,mycoplasma,gardenella,chla
mydia have been implicated
Bacterial vaginosis-recurrent 2nd trimester
loss.
History
 HSV,CMV cause direct infection of the
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fetus,placenta-resulting villitis & tissue
destruction-pregnancy disruption
Aqquired anatomic abnormalitiesintrauterine
adhesions,endometriosis,uterine
fibroids.endometrium over
fibroid/synechiae-inadequately
vascularised-abnormal placentationspontaneous pregnancy loss.
h/o any purulent discharge pvendometritis,submucous fibroid polyp
History
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h/o mass abdomen-fibroids,chocolate cysts
h/o pressure symptoms of fibroid-constipation &
increased frequency of micturition
Exposure while in utero to maternal ingestion of diethyl
stilbesterol-hypoplasia/anatomical abnormalities of
uterus,cervix and vagina,incomplete mullerian duct
fusion,incomplete septum resorption,cervical
incompetence.
Presence of intrauterine septum-60% risk of
spontaneous abortion-embryo implants on poorly
developed endometrium over septum-1st tri abortion
History
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h/o excessive vaginal mucoid discharge,wetness
may be suggestive of cervical incompetencemostly 2nd tri abortions.
h/o exposure to any medications –anti
progestins,antineoplastic agents,inhalational
anaesthetics
h/o exposure to ionising radiation/environmental
toxins-heavy metals.
h/o pain abdomen,bleeding/spotting pv in
present pregnancy
Menstrual history
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h/o menorrhagiafibroid(submucous),uterine malformations
h/o metrorrhagia-infected submucous
fibroid polyp
h/o dysmenorrhoeaendometriosis,adenomyosis
h/o dyspareunia-endometriosis
Menstrual history
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h/o irregular short cycles-luteal phase defectinadequately/improperly timed endometrial
changes at implantation sites.
In LPD -^ LH levels –causes premature aging of
oocyte and dys-synchronus maturation of
endometrium-recurrent preg.loss.
h/o irregular cycles with prolonged periods of
amenorrhoea-PCOD,,hyperprolactinemia,uterine
synechiae
PCOS-^ LH levels,^ androgen levels,insulin
resistance-pregnancy loss
Obstetric history
To be taken in detail in chronological order of events
 Time after marriage the patient conceived,whether she
undertook any treatment for infertility
 At what gestational age the prior pregnancy loss
occurred-whether it was associated with
pain/bleeding,whether it was followed by a check
curettage
 Whether there was sudden painless loss of watery fluid
pv followed by expulsion of the fetus
 Whether fetus was alive/dead if born alive how long it
lived
 If IUD-fresh/macerated
 Sex/wt of the fetus
 h/o recurrent malpresentations in prior pregnancies –
may suggest uterine malformations
PAST HISTORY h/o chronic HT,DM,TB,
 Overt DM-hyperglycemia-embryotoxic,advanced
IDDM-vascular complicatios-compromised blood
flow to uterus.
 h/o hyper/hypothyroidism-thyroid diseaseovulatory dysfunction,LPD.
 Metabolic demands of early pregnancy mandates
^ requirement of thyroid hormones,so
hypothyroidism-recurrent preg.loss.
 In clinically euthyroid patients-presence of
antithyroid antibodies may be associated with
RPL-due to generalised autoimmunity/impaired
ability of thyroid to meet demands of pregnancy.
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h/o connective tissue disorders,h/o thrombotic
events-suggestive of APAS-causes 3-5% of RPL.
Past surgical history-D&C,MTP,check
curettage,amputation of cervix/cone biopsycervical incompetence
h/o surgeries myomectomy/metroplasty
FAMILY HISTORY-of recurrent spontaneous
abortions,chronic medical conditions,thrombotic
events
PERSONAL HISTORY-h/o smoking,tobacco
chewing,alcohol consumption/drugs-cocaine
Examination
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Obesity,hirsuitism,acanthosis,thyroid enlargement
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galactorrhoea-hyperprolactinemia
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Pallor-menorrhagia
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p/a-irregular contour of uterus may suggest fibroids with
pregnancy,bicornuate uterus
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Cystic swellings with fixity/tenderness-endometriosis
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malpresentations may be present
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P/S may show myomatous polyp protruding through the os.
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Bluish black puckered spots may be seen in the posterior fornixendometriosis
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Congenital anatomical abnormalities may be revealed.
Examination
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Whether cervix scarred-amputation/conisation
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Any signs of infection-tender swollen red vagina in bacterial
vaginosis.discharge from cervix-endometritis
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Estrogenisation of the tissues can be made out.
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During pregnancy-whether the os is open,if open whether membranes are
bulging thruogh os.periodic inspection of the cervix from 10th week onwards
may be done weekly-dilatation of internal os with herniation of membranes
will be diagnostic.
In interconceptional period-passage of no6-8 hegar’s dilators beyond the
internal os without pain or resistance and absence of snap of internal os on
withdrawing it especially in the premenstrual phase is suggestive of cervical
incompetence.
Bimanual pelvic examination-enlarged irregular firm uterusfibroid,retroverted fixed uterus,b/l forniceal tenderness/mass &cobblestone
feel of uterosacrals –endometriosis
In adenomyosis-assymetrical enlargement of uterus with tenderness