Preventive medicine in obstetrics regarding pregnancy loss

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Preventive medicine in obstetrics regarding
pregnancy loss

• Dr. Mohammed Abdalla
• Domiat General Hospital

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• Can Pregnancy complications such as
• Recurrent abortion,
• Preterm labour,
• Still birth,
• Preeclampsia.
• be prevented

?
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• In the past the obstetrical art focused mainly on
  how to deal with complications .
• but now by the remarkable advance in modern
  obstetrics ,immunology, and hematology, the goal
  is how to prevent them.

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Maternal risk assessment

• Maternal risk assessment can be firstly
  identified from

history
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Maternal risk assessment

• Recurrent pregnancy loss is not just a Bad Luck
  and must be investigated .

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Maternal risk assessment

• But on other hand some conditions need no
  recurrence to be alarming, and to be
  investigated.

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any of these must invite a big question mark
one unexplained fetal deaths after ten weeks of
pregnancy
one preeclampsia or placental insufficiencies
occurring before 34 weeks
?
One previous preterm birth
one or more confirmed episodes of venous or
arterial thrombosis.
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Maternal risk assessment

• The initial attempts to predict preterm delivery
  in asymptomatic patients involved the use of
• risk factor assessment.

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Risk Factors for Preterm Birth

• -Prior cone biopsy or (LEEP)-Greater than or
  equal to 3 first trimester losses-Any second
  trimester loss-Prior preterm delivery
  (PTD)-Prior myomectomy-Cervical
  cerclage-Uterine Anomalies

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Risk Factors for Preterm Birth

• The diagnosis is usually based on a history of
  late miscarriage, preceded by spontaneous rupture
  of membranes or painless cervical dilatation.

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Risk Factors for Preterm Birth

• The diagnosis of Uterine Anomalies is usually
  found on a HSG . Differentiation between the
  uterine septum and the bicornuate uterus cannot
  be made with the HSG alone but Further evaluation
  of the fundal contour must be done with
  laparascopy, MRI, or US as therapy is very
  different.

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Etiologic view of pregnancy loss after 10wk
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pregnancy loss after 10wk

• one pregnancy loss more than 10wk. Gestation or
  pregnancy associated with late adverse outcome
• need no recurrence to be investigated.

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pregnancy loss after 10wk
95
3
2
0.5
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pregnancy loss after 10wk

• How much is thrombophilia common among general
  population

?
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Inherited thrombophilia

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thrombophilia and fetal loss

• Recent case-control studies and meta analyses
  attempted to quantify the risks associated with
  different thrombophilic defects and adverse
  clinical events in pregnancy,

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thrombophilia and fetal loss
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thrombophilia and fetal loss

• A meta analysis published in LANCET 15 march
  2003 included 31 studies published between 1975
  and 2002 (by Medline search).

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Relative risk is quantified by odd ratio
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(No Transcript)
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thrombophilia and fetal loss
Odd ratio
Odd ratio
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thrombophilia and fetal loss
Odd ratio
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Top guidelines to prevent recurrent pregnancy
loss and adverse pregnancy outcomes
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Top guidelines

• prenatal cervical length screening by
  transvaginal ultrasound is indicated for women
  identified to be at increased risk of preterm
  birth.
• Cervical shortening is associated with increased
  preterm birth risk
• (II-2 B)

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Top guidelines

• By Transvaginal ultrasound
• cervical length gt 3 cm. after 24 weeks has a high
  negative predictive value . to avoid unnecessary
  interventions.
• (II-2 B)

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Top guidelines

• Women with recurrent pregnancy loss and a uterine
  septum should undergo hysteroscopic evaluation
  and resection.
• (ACOG) grade C

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Top guidelines

• There is no clear first-line tocolytic drugs to
  manage preterm labor.
• (ACOG) grade A

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Top guidelines

• Neither maintenance treatment with tocolytic
  drugs nor repeated acute tocolysis improve
  perinatal outcome but just prolong pregnancy for
  2-7 days giving time for steroids.
• (ACOG) grade A

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Top guidelines

• If a tocolytic drug is used, Atosiban or
  nifedipine appear preferable as they have fewer
  adverse effects and seem to have comparable
  effectiveness.

(RCOG) A
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Top guidelines

• Screening for and treatment of bacterial
  vaginosis in early pregnancy among high risk
  women with a previous history of second-trimester
  miscarriage or spontaneous preterm labour may
  reduce the risk of recurrent late loss and
  preterm birth.

(RCOG) A
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Top guidelines

• (TORCH and herpes simplex virus)
• screening is unhelpful in the investigation of
  recurrent miscarriage.
• RCOG(C)

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Top guidelines

• In all couples with a history of recurrent
  miscarriage cytogenetic analysis of the products
  of conception should be performed if the next
  pregnancy fails.
• RCOG(C)

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Top guidelines

• There is insufficient evidence to evaluate the
  effect of (hCG) in pregnancy to prevent
  miscarriage.
• RCOG(C)

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Top guidelines

• There is insufficient evidence to evaluate the
  effect of progesterone supplementation in
  pregnancy to prevent a miscarriage.
• RCOG(C)

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Top guidelines

• In women with a history of recurrent miscarriage
  and APL, the future live birth rate is markedly
  improved when a combination therapy of aspirin
  plus heparin is prescribed.
• RCOG(A)

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Top guidelines

• Pregnancies associated with aPL treated with
  aspirin and heparin remain at high risk of
  complications during all three trimesters.

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Top guidelines

• Currently there is no reliable evidence to show
  that steroids improve the live birth rate of
  women with recurrent miscarriage associated with
  aPL.
• their use may provoke significant maternal and
  fetal morbidity.
• RCOG(C)

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Top guidelines

• If a diagnosis of luteal phase defect is sought
  in a woman with recurrent pregnancy loss, it
  should be confirmed by endometrial biopsy.

ACOG (B)
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Top guidelines

• low-dose aspirin, have small-moderate benefits
  when used for prevention of
• pre-eclampsia.
• Further information is required to assess which
  women are most likely to benefit, when treatment
  is best started, and at what dose.
• Cochrane Review 2005

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Top guidelines

• Antiplatelet therapy
• ( low dose aspirin)
• reduces the risk of pre-eclampsia by around 15
  for women at low or high risk .
• RCOG(B)

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Top guidelines

• The combination of aspirin and heparin is
  effective in recurrent fetal loss in APS and
  could be considered for women with inherited
  thrombophilias and history of severe
  preeclampsia, IUGR, abruptio placentae or fetal
  loss, although no controlled studies on the
  subject are currently available
• Cochrane Review 2003

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• Assessment of maternal risk and prediction of
  risk factors is the gate for prevention of
  adverse pregnancy outcomes.

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THANK YOU