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25 Cards in this Set
- Front
- Back
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Define recurrent pregnancy loss
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typical: >=3 repeat losses of clinically recognized pregnancies < 20wks
ASRM: >=2 repeat losses as above. full work-up after 3rd loss. |
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What is risk of miscarriage after:
1 previous miscarriage? 2 previous miscarriages? 3 previous miscarriages |
1: 15-20%
2: 25-30% 3: 30-35% |
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List potential etiologies for recurrent pregnancy loss
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Parental chromosomal anomalies (2-4%)
Anti-phospholipid antibody syndrome Uterine anomalies Unexplained Cervical insufficiency (mid-trimester loss/PTB) ?Male factor Thrombophilia (controversial/disproven) Autoimmune Celiac Disease Endocrine (PCOS, diabetes) Environment, toxins Thyroid antibodies (anti-TPO Abs) in euthyroid women |
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Early embryonic losses are most likely caused by?
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Genetic factors/chromosomal abnormalities
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Which have a higher likelihood of karyotype anomaly - sporadic first trimester losses or recurrent first trimester losses?
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Sporadic (50%)
Recurrent (25%) |
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What is the most common type of parental chromosomal defect seen in RPL?
What are two other types that are seen commonly? Is the woman or man more likely to harbour the chromosomal abnormality? |
Reciprocal-balanced translocation (50%)
Robertsonian-balanced (25%) X-chromosome mosaicism (10%) Woman (2:1) |
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What are two management options for couples with a known balanced translocation?
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Expectant - still high odds they will have a normal child
IVF w/ PGD |
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List uterine factors that have been implicated in RPL
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Congenital anomalies
Synechiae (Asherman's syndrome) Large fibroids Large polyps Undervascularized areas (e.g. previous artery ligation/embolization) |
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What congenital anomaly of the uterus is most associated with RPL?
What is the proposed mechanism? Is surgical correction generally felt to decrease risk for RPL? |
Septate uterus (also bicornuate from Williams gyne)
Hypovascularization Yes - small studies support this. |
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What surgical procedure can correct a bicornuate uterus?
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Metroplasty (Jones, Thompkins, etc.)
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Is bicornuate uterus more associated with early or late losses?
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Late
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What acquired uterine defect is strongly linked to RPL?
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Adhesions (synechiae)
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Give two methods used to try and prevent adhesion re-formation following hysteroscopic lysis of uterine synechiae
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Foley catheter bulb (~10days, give abx)
Estrogen then Progesterone (Estrace 2mg, Provera 10mg) |
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When might uterine fibroids be considered a potential cause of RPL?
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Distortion of uterine cavity
(submucous fibroid, large myometrial fibroid) Compression of tubal interstitium (proposed) |
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What percentage of women with RPL have positive APL antibodies?
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5-15%
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Regarding APLA and fetal loss, are they more likely to be late (>10wks) or early (<10wk) losses?
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Late losses.
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What are the three mechanisms by which APL antibodies are believed to cause RPL?
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Thrombosis
Inflammatory Abnormal placentation antibodies interfere with decidualization/invasion |
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For what obstetrical indications should antiphospholipid antibodies be tested for?
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1 x fetal loss > 10wks GA
>=3 embryonic losses Prior PTB/IUFD < 34wks GA pre-eclampsia or FGR |
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History RPL w/ 2 x 12week losses.
+aCL antibody, no clot history. Four weeks pregnant. Management? |
Dating ultrasound
ASA 81mg Offer unfrac or LMWH subq daily (Williams Gyne says better evidence for unfractionated versus LMW heparin in RPL - UTD doesn't make a distinction) |
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has IVIg been shown to be effective at treating idiopathic RPL?
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No.
(Not recommended) |
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Has ASA, heparin, or both, been demonstrated to increase live-birth rate in women with unexplained RPL?
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No
Large trials have shown that after ruling out women with e.g. aPL, uterine anomalies, etc., that these treatments do not improve outcomes. They are not recommended. |
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List the highest-yield investigations for a women presenting with RPL
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Karyotype (2-4%)
Uterine imaging SHG, HSG, TV-US, MRI, hysteroscopy aPLA levels aCL, LA, aB2-glycoprotein 1 Thyroid TSH, +/- TPO Abs Other tests to consider (minimal/no evidence) Thrombophilia screen Infection screen OGTT/diabetes screen Celiac screen (tTG Abs) Ovarian reserve Endo biopsy (culture, histology) |
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What is luteal-phase defect and is it associated with RPL?
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"Desynchronization" between endometrial "phase" and ovulation such that the implantation window is skewed - endometrium is not receptive to implantation at time it should be.
This is graded histologically by biopsy and has been shown to have low intra and inter-observer reproducibility. There is no evidence for luteal phase defect being associated with RPL. |
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What percentage of women presenting with RPL will be idiopathic (unexplained?) following work-up?
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~50%
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What treatments might you offer a couple with unexplained RPL?
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Vaginal progesterone (200mg PV TID)
seems to be benign, there is limited evidence Reassurance most will achieve a normal pregnancy Semenalysis not listed in textbooks, but do talk about male factor Lifestyle not proven but seems reasonable No smoking No EtOH |
