Case-5

ñ
ô 30yrs old woman attends the EPAU and is diagnosed
with a silent (missed) first trimester miscarriage .she
is very upset as ,she had 2 other miscarriage at 8,10
wks during last year

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 Q1 -Discuss the management
of this woman´s miscarriage?
ñ
ô • Pt should be treated with empathy and
sympathy
ô • Options:
ô • Expectant : no intervention ,take few weeks
ô • Medical ;80% effective
ô • Surgical evacuation: after cx ripening ,at same
day ,hospital admission ,anaesthesia, tissue for
karyotyping may help in management of future
pregnancy
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 Q2 –What is your management and
investigation should be performed
for recurrent miscarriage?
ñ

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 Proper detailed history of:
ô 1.Age of the patient and her partner
ô 2.previous pregnancies should be obtained including
gestational ages of miscarriages and details of ultrasound scans
and treatments ,h\o preterm labour or IUGR , Previous
cytogenetic results
ô 3.Menstrual History
ô 4.A past gynaecological history is important to ascertain any
subfertility issues , any surgical procedure on the cervix , and
any clinical features of systemic or endocrine disease.
ô 5.A full past medical history is needed particularly noting any
personal or family history of thrombosis
ô 6.A detailed drug history should be taken including details of
over-the-counter medications and confirmation of folic acid use.
Antidepressant use and periconceptual non-steroidal anti-
inflammatory drugs
ô 7.Social history should be taken in a sensitive manner and
include caffeine intake, smoking, alcohol, cannabis and cocaine
use.
ô 8.Medical disease to be ruled out ; DM, SLE

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 ñ
Examination:
ô •BMI
ô •Thyroid swelling
ô •Evidence of galactorrhea
ô •Clinical features of hyperandrogenemia
ô Abdominal examination
ô •Per vaginal examination : A per speculum and a
bimanual pelvic examination will identify local infection,
uterine size and shape and any gross uterine anomaly. A
per speculum will also identify a torn cervix, or a grossly
short cervix
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 Investigations
ñ
ô •Parental blood for karyotyping (In 2-5% of couples with recurrent
miscarriage one partner carries a balanced structural chromosomal
anomaly)
ô •Cytogenetic analysis of product of conception at time of miscarriage
ô •three-dimensional pelvic u\s and HSG ((uterine septate and bicornuate
uterus are found in between 1.8% and 37.6% of women with recurrent
miscarriage) ,uterine fibroid
ô •Thrombophillia screening(factor V Ledine ,prothrombin gene mutation
,protein S
ô •Lupus anticoagulant
ô •Anticardiolipin antibodies IgG and IgM (Antiphospholipid antibodies
are present in 15% of women with recurrent miscarriage)
ô •Bacterial vaginosis screening in pt with 2nd trimester loss (not in early
pregnancy)
ô •Hysteroscopy(endometrial factors )
ô •Laparoscopy
ô •Luteal phase endometrial biopsy
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 ñ
ô General advice and support:
ô •psychological support
ô •reduce wt , stop smoking and alcohol
ô •healthy diet
ô •a preconceptual folic acid supplementation
ô •It is important to ensure
ô •any chronic condition, such as diabetes, thyroid disease
and epilepsy is as stable as possible and that the
treatments used are safe for use in pregnancy.
ô If there is specific cause of RPL should be treated

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 ñ
Q3 - How should a woman with
APLS be managed in her next
pregnancy?

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 ñ
ô •Untreated pt with APLS has only 10% chance of
spontaneously delivering a baby at term
ô •Low dose aspirin as soon as PT +ve (success rate
increase to 40%)
ô •Aspirin plus LMWH once daily increase success
rate to 70%
ô •ANC should be in EPAU by consultant for
psychological support and u\s scan
ô •Regular antenatal visit (high risk for
PET,IUGR,PTL)
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 ñ
ô Q4- How to manage pt with abnormal karyotyping?

ô •Referral to clinical geneticist for genetic counselling

ô •Natural pregnancy with prenatal diagnostic test
ô •pregnancy by ARPT with Preimplantation genetic
diagnosis

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