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 .

Vit B12 supplementation Low dose aspirin (75-80mg/day) Low molecular weight heparin(40mg/day) Unfractionated heparin 5000IU sc bd   .Vit B6.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.

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 .

Unexplained deaths of a morphologically normal fetus>10wks 1>.consecutive abortions < 10 wks .APAS..  DIAGNOSIS  CLINICAL CRITERIA 1>. preterm births at or before 34wks due to severe preeclampsia or placental insufficiency 3>.

.  LAB CRITERIA… Coagulation based assay detection of LA Antibody testing are Anti cardiolipin Ab Anti phosphotidylserine Ab Anti B2 Glycoprotein Ab .APAS.

APAS…MANAGEMENT: Heparin 5000IU twice daily LMWH-Enoxaparin 20-40mg /day + Low dose aspirin 75mg/day Intravenous immunoglobulin 0.3g/kg every 4 wks till 32wks .

 SEPTATE UTERUS: MC..Anatomic abnormalities.>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) .

abortion..ANATOMIC. .FIBROIDS  Usually do not cause abortion  Placental implantation over or in contact with myoma → placental abruption. . 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 .

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

6 CM CX INDEX >= 0.DURING PREGNANCY  USG CX LENGTH IO WIDTH BULGING OF MEMBRANES LUS AND IO IN Y/V/U/T SHAPE LUS < 0.52 DYNAMIC USG AND CERVICAL STRESS TEST  MRI .

WURMS Modification SHIRODKARS TRANSABDOMINAL .CERVICAL INSUFFICIENCY MANAGEMENT CERVICAL CERCLAGE ELECTIVE/PROPHYLACTIC EMERGENT/URGENT/THERAPEUTIC PROCEDURES: Mc DONALDS.BOYDS.

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 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 DISORDERS—SLE  SYSTEMIC SCLEROSIS  HEMATOLOGICAL DISORDERS .

LIFESTYLE FACTORS  SMOKING  ALCOHOL  CAFFIENE  OBESITY  STRESS .

 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 ..Lifestyle factors.

Prognosis  Genetic factors  Anatomic factors 20–80 % 60–90 %  Endocrine factors  Infectious factors >90 % 70–90 %  Apla  Unknown factors 70–90 % 40–90 % .

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