Definition

Recurrent abortion has been defined as the

occurrence of three or more clinically recognized pregnancy losses before 28 weeks from the last menstrual period

Etiology
GENETIC
IMMUNOLOGICAL ANATOMICAL

ENDOCRINE
INFECTIONS LIFESTYLE FACTORS MATERNAL SYSTEMIC DISEASES UNEXPLAINED

Age factor
Maternal age:oocyte quality
Paternal factors:

Chromosomal translocation in the sperm

Poor sperm quality due to age

GENETIC
CHROMOSOMAL ABNORMALITIES

Aneuploidies Structural : Reciprocal tranlocation Robertsonian Inversions Sex chromosome mosaicism

GENETIC
SINGLE GENE DISORDERS

X-linked dominant disorders Inherited thrombophilias Factor V leiden & Activated protein C resistance prothrombin gene mutation MTHFR polymorphismHyperhomocysteinemia Sharing of HLA genes

GENETIC--MANAGEMENT

Karyotype of parents: 5% abnormal Amniocentesis at 16 wks Level II usg at 16-18 wks Use of donor oocyte/sperm & PGD Karyotype of product of conception Thrombophilia panel: Folate,Vit B6,Vit B12 supplementation Low dose aspirin (75-80mg/day) Low molecular weight heparin(40mg/day) Unfractionated heparin 5000IU sc bd

IMMUNOLOGICAL
CELLULAR
HUMORAL :ORGAN NON SPECIFIC APAS

ORGAN SPECIFIC
Anti thyroid Anti sperm Anti trophoblast

APAS
PRIMARY SECONDARY Antiphospholipid antibodies Anti cardiolipin Ab Lupus anticoagulant anti b2 Glycoprotein Ab antiphosphotidylserine Ab

APAS..
DIAGNOSIS
CLINICAL CRITERIA

1>,Unexplained deaths of a morphologically normal fetus>10wks 1>, preterm births at or before 34wks due to severe preeclampsia or placental insufficiency 3>,consecutive abortions < 10 wks

APAS..
LAB CRITERIA

Coagulation based assay detection of LA Antibody testing are Anti cardiolipin Ab Anti phosphotidylserine Ab Anti B2 Glycoprotein Ab

APASMANAGEMENT:
Heparin 5000IU twice daily LMWH-Enoxaparin 20-40mg /day + Low dose aspirin 75mg/day

Intravenous immunoglobulin 0.3g/kg every 4 wks till 32wks

Anatomic abnormalities..
SEPTATE UTERUS: MC- >60%

Hysteroscopic incision of the septum

UTERINE POLYPS:

Hysteroscopic resection
UTERINE SYNECHIAE

Trauma/Infection

 Diagnosis of uterine synechiae

Hysterosalpingogram characteristic multiple filling defects Hysteroscopy most accurate & direct diagnosis

Treatment of uterine synechiae

Lysis of adhesions via hysteroscopy Prevention of adherence : IUD Promotion of endometrial proliferation : Continuous high-dose estrogen (60-90 days)

ANATOMIC. . ..FIBROIDS
Usually do not cause abortion

Placental implantation over or in contact with myoma

placental abruption, abortion, preterm labor

location is more important than size

TREATMENT OPTIONS
SURGICAL:
MYOMECTOMY HYSTEROSCOPIC RESECTION UTERINE ARTERY EMBOLISATION MYOLYSIS PERCUTANEOUS LASER ABLATION

ANATOMIC
CERVICAL INSUFFICIENCY:20-30%

CONGENITAL ACQUIRED DYSFUNCTIONAL

CERVICAL INSUFFICIENCY
CLINICAL FEATURES : Painless cervical dilatation

Ballooning of the membranes into the vagina

Rupture of the membranes

Expulsion

 Incompetent cervix Etiology

Previous trauma to the cervix

Dilatation & curettage Conization Cauterization

Abnormal cervical development

Exposure to DES in utero

INVESTIGATIONS:
ITERCONCEPTIONAL

No.8 Hegar dilator Hysterocervicography Pull-through techniques of inflated Foley catheter balloons

DURING PREGNANCY USG CX LENGTH IO WIDTH BULGING OF MEMBRANES LUS AND IO IN Y/V/U/T SHAPE LUS < 0.6 CM CX INDEX >= 0.52 DYNAMIC USG AND CERVICAL STRESS TEST MRI

CERVICAL INSUFFICIENCY MANAGEMENT

CERVICAL CERCLAGE
ELECTIVE/PROPHYLACTIC EMERGENT/URGENT/THERAPEUTIC

PROCEDURES: Mc DONALDS;BOYDS,WURMS Modification SHIRODKARS TRANSABDOMINAL

 TRANSABDOMINAL
AMPUTATED CX CONGENITAL SHORT CX MARKED SCARRING FOTHERGILL/MANCHESTER OPERATION MULTIPLE CX DEFECTS SUBACUTE CERVICITIS PREVIOUS FAILED TRANSVAGINAL CERCLAGE

ENDOCRINE
HYPERPROLACTINEMIA
LUTEAL PHASE DEFECTS DIABETES MELLITUS

THYROID DISORDERS
PCOS

 Hypothyroidism

Iodine deficiency associated with excessive miscarriages Thyroid autoantibodies incidence of abortion

Diabetes mellitus

The rates of spontaneous abortion & major congenital malformations Poor glucose control incidence of abortion

Progesterone deficiency

Luteal phase defect Insufficient progesterone secretion by the corpus luteum or placenta Poor glucose control incidence of abortion

INFECTIONS
SPORADIC MC
ORGANISMS: Listeria Mycolplasma Ureaplasma Toxoplasma Salmonella Brucella Chlymydia Malaria Treponema CMV Rubella Tuberculosis

MATERNAL MEDICAL DISORDERS

AUTOIMMUNE DISORDERSSLE
SYSTEMIC SCLEROSIS HEMATOLOGICAL DISORDERS

LIFESTYLE FACTORS
SMOKING
ALCOHOL CAFFIENE

OBESITY
STRESS

Lifestyle factors..
Drug use and environmental factor Tobacco

Risk for euploid abortion More than 14 cigarettes a day the risk twofold greater Spontaneous abortion & fetal anomalies result from frequent alcohol use during the first 8 weeks of pregnancy Drinking twice a week abortion rates doubled Drinking daily abortion rates tripled At least 5 cups of coffee per day slightly increased risk of abortion

Alcohol

Caffeine

Prognosis
Genetic factors
Anatomic factors

2080 %
6090 %

Endocrine factors
Infectious factors

>90 %
7090 %

Apla
Unknown factors

7090 %
4090 %

Thank you