RECURRENT PREGNANCY LOSS DR.RAJALAKSHMI SRINIVASAN SPECIALIST GYNECOLOGIST ZULEKHA HOSPITAL DUBAI

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1 RECURRENT PREGNANCY LOSS DR.RAJALAKSHMI SRINIVASAN SPECIALIST GYNECOLOGIST ZULEKHA HOSPITAL DUBAI

2 RECURRENT PREGNANCY LOSS -RM Clinically recognized consecutive or non consecutive pregnancy losses before 20 to 22 weeks of gestation Early pregnancy loss in the first trimester affects 15 to 20 % of clinically recognized pregnancies with 80 % occurring in the first 12 weeks. May affect 1 to 3 % of couples trying to conceive More than half of recurrent abortions are due to non recurrent causes The risk of further miscarriage 50 % for women with three or more losses without a live born infant The chance of having a normal pregnancy 30 % - three miscarriages 25 % - four losses 5 % - five losses

3 POTENTIAL ITIOLOGY GENETIC 3.5-5% chromosomal, multifactorial, single gene ANOTOMICAL % congenital,acquired IMMUNOLOGICAL % APAS(15%, ), maternal rejection of foetal allograft THROMBOPHILIA % INFECTIONS % ENDOCRINE % OTHERS----10% drugs, hematoma, environmental, illness IDIOPATHIC----50%

4 RECURRENT PREGNANCY LOSS - RM Evaluation may be initiated taking into account the woman s age and length of time they have been trying for a pregnancy Age women > 35 yrs, men > 40yrs 50 % of recurrent miscarriages are IDIOPATHIC 3.5 to 5 % of recurrent miscarriages are due to genetic chromosomal causes- mostly balanced,reciprocal or Robertsonian translocation Chromosomal aberrations can be numerical and structural Single gene disorders are other genetic causes of RM ( alpha thalassemia major )

5 FREQUENCY OF CHROMOSOMAL ABNORMALITIES The risk of miscarriage due to fetal aneuploidy increases with maternal age. The risk of a new miscarriage is higher in the next pregnancy after a chromosomally normal than after a chromosomally abnormal miscarriage ( being lower in women with RM and those with number of previous miscarriages )

6 FREQUENCY OF CHROMOSOMAL ABNORMALITIES ANEUPLOIDY AND STRUCTURAL ABNORMALITIES Autosomal trisomy ( 13, 16,18,21, others ) : % Monosomy X : 20 % Triploidy : 15 % Tetraploidy : 5 % Unbalanced translocation : 3 to 5 %

7 FREQUENCY OF CHROMOSOMAL ABNORMALITIES STRUCTURAL ABNORMALITIES CAUSING RECURRANT ABORTIONS 1 ) Balanced translocations in the parents : reciprocal ( of long arms of chr 11 and 22, ie heterologous chr) and robertsonian ( breakage of 2 acrocentric chromosomes 13,14,15,21 and 22, ie homologous chr ) lead to unbalanced chromosomal gametes 2 ) inversion : 3 ) Y q microdeletions 4 ) mosaicism pericentric ( inv 1, 9,16 and Y ) and paracentric inversion

8 PREGNANCY OUTCOME IN BALANCED CARRIERS 3-5% have one partner with a cytogenetic abnormality REARRANGEMENT RISK OF ABNORMAL LIVEBORN RECURRANT MISCARRIAGE ROBERTSONIAN TRANSLOCATION RECIPROCAL TRANSLOCATION ( EITHER PARENT ) PERICENTRIC PARACENTRIC EITHER PARENT INVERSION % UPTO 10% 5 TO 10% UNCOMMAN 0.1 % TO 0.5 % UPTO 30% 30 TO 50 % 50 %

9 INVESTIGATIONS Karyotype of the abortus : should be reserved for couples with a subsequent second or third pregnancy loss Peripheral blood karyotyping : in all couples with RM is important because individuals with balanced chromosomal rearrangements are at risk of having conceptuses with an unbalanced chromosome complement.( risk is 10 to 30 % ) Thrombophilia screen USG anomalies, fibroids Diag hystero laparoscopy

10 MANAGEMENT OF PREGNANCY IN PARENTAL CHROMOSOMAL ABNORMALITY 1) Usg for NT and for congenital malformations at 12 to 13 weeks and 2) Amniocentesis at 16 to 18 weeks 3) Options of pre-implantation genetic diagnosis, donor gametes and adoption depending upon the case.

11 MALE FACTOR Sperm factors : oxidative stress, mitochondrial mutations and DNA damage may be a cause in recurrent loss Reactive oxygen species ( ROS ) are free radicals which cause sperm DNA damage Sperm DNA damage may lead to impaired fertilization and early pregnancy loss. Men with low sperm count ( < than 20 million / l ) and oligoasthenospermia may cause recurrent abortion Analysis of semen according to the WHO guidelines may provide modest information and ROS estimation and DNA damage analysis must be included in the diagnostic workup of couples with RSA Factors which prevent oxidative stress include lifestyle changes, minimize exposure to toxins, treatment of infections and use of anti oxidants

12 CONCLUSION MOST DISTRESSING COMPLETE EVALUATION WILL REVEAL CAUSE IN 2/3 CASE 75% OF OTHERS CAN HAVE SUCCESSFUL SUBSEQUENT PREGNANCY COUNCELLING, SUPPORT AND REASSURENCE

13 THANK YOU