Recurrent pregnancy loss

1
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 4050 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,womangt35 yrs or the couple has difficulty
  in conceiving.

2
History

• h/o consanguinity-single gene defects may cause
  RPL revealed by a detailed family history.
• Inherited thrombophilias can cause
  RPL-hyperhomocystinemia,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.

3
History

• h/o foul smelling vaginal discharge-suggestive
  of bacterial vaginosis .infection with
  ureaplasma,prevotella,b-hemolytic
  streptococcus,mycoplasma,gardenella,chlamydia
  have been implicated
• Bacterial vaginosis-recurrent 2nd trimester loss.

4
History

• HSV,CMV cause direct infection of the
  fetus,placenta-resulting villitis tissue
  destruction-pregnancy disruption
• Aqquired anatomic abnormalities-intrauterine
  adhesions,endometriosis,uterine
  fibroids.endometrium over fibroid/synechiae-inadeq
  uately vascularised-abnormal placentation-spontane
  ous pregnancy loss.
• h/o any purulent discharge pv-endometritis,submuco
  us fibroid polyp

5
History

• 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

6
History

• h/o excessive vaginal mucoid discharge,wetness
  may be suggestive of cervical incompetence-mostly
  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

7
Menstrual history

• h/o menorrhagia-fibroid(submucous),uterine
  malformations
• h/o metrorrhagia-infected submucous fibroid polyp
• h/o dysmenorrhoea-endometriosis,adenomyosis
• h/o dyspareunia-endometriosis

8
Menstrual history

• h/o irregular short cycles-luteal phase
  defect-inadequately/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

9
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

10

• 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
  disease-ovulatory 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.

11

• h/o connective tissue disorders,h/o thrombotic
  events-suggestive of APAS-causes 3-5 of RPL.
• Past surgical history-DC,MTP,check
  curettage,amputation of cervix/cone
  biopsy-cervical 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

12
Examination

• Obesity,hirsuitism,acanthosis,thyroid enlargement
• galactorrhoea-hyperprolactinemia
• Pallor-menorrhagia
• p/a-irregular contour of uterus may suggest
  fibroids with pregnancy,bicornuate uterus
• Cystic swellings with fixity/tenderness-endometrio
  sis
• malpresentations may be present
• P/S may show myomatous polyp protruding through
  the os.
• Bluish black puckered spots may be seen in the
  posterior fornix-endometriosis
• Congenital anatomical abnormalities may be
  revealed.

13
Examination

• Whether cervix scarred-amputation/conisation
• Any signs of infection-tender swollen red vagina
  in bacterial vaginosis.discharge from
  cervix-endometritis
• Estrogenisation of the tissues can be made out.
• 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
  hegars 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 uterus-fibroid,retroverted fixed uterus,b/l
  forniceal tenderness/mass cobblestone feel of
  uterosacrals endometriosis
• In adenomyosis-assymetrical enlargement of uterus
  with tenderness