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RECURRENT PREGNANCY LOSS

Dr.P.M.GOPINATHMD, DGO, FMMC, FICS, FICOG, MBA (HSM)

Director of Social Obstetrics i/c ISO & KGH Chennai 600005

Recurrent Miscarriage-Definition Occurrence of 3 or more clinically

recognized consecutive ornonconsecutive pregnancy losses before

20 weeks from last menstrual period Primary- No previous full term pregnancy Secondary- At least one successful pregnancy

Incidence 15-20% of all pregnancies 11-13 % in first pregnancy 13-17 % after first abortion 38 % after two abortions

55% after three abortions

Recurent Miscarriage Etiology

Explained

Anatomic (Sporadic) Endocrine Luteal phase deficiency Uncontrolled DM PCOS

12%-16%17%-20%

Un-explained 50%

Immunological Anti phospholipid syndrome

10%-16%

Environmental Alcohol, Smoking

Genetic factors

3.5-5%

Anatomical Factors What are the congenital & acquireduterine anomalies leading to RSA?

How will you manage?

Uterine Abnormalities CONGENITAL (Mullerian Duct abnormalities) UTERINE NEOPLASMS (Growth) IATROGENIC (Acquired)

ANATOMICAL CAUSES Septate uterus Intrauterine adhesions Bicornuate ut (unequal horns) Unicornuate uterus T shaped uterus Submucous fibroids Large endometrial polyps

How they affect. Smaller Uterine Cavities Fewer suitable implantation sites Aberrations of vascularisation May be accompanied by cervical incompetence Lead to both early & later pregnancy losses

Septate Uterus Most COMMON anomaly 55% May be complete/ incomplete/segmental 25% early abortions 6.2% late abortions & Premature labors

Unicornuate Uterus 20% of anomalies Agenesis or hypoplasia of one Mullerian duct May be alone or accompanied by Rudimentary horn With presence / absence of cavity Communicating / Non communicating Associated Renal anomalies occur in 40% patients Ipsilateral to hypoplastic horn

Unicornuate Uterus Abortion Rate 51%, Premature labours, malpresentations, IUGR, Uterine rupture & ectopic pregnancies common Cervical encerclage to improve pregnancy outcome Rudimentary Horn resected to prevent dysmenorrhoea, haematometra,ectopic pregnancy

Uterus Didelphys Least common anomaly -5-7% Failure of lateral fusion of uterus &vagina Abortion rate 43%,Premature birth rate 38% Resection of Vaginal septum if there is difficulty in intercourse / vaginal delivery Strassmann Operation not indicated

Bicornuate Uterus 10% of anomalies Incomplete fusion of Uterine horns at level of fundus Two separate but communicating endometrial cavities Abortion rate 32% Preterm labour 21% Strassman Metroplasty / Place IUCD in one horn

Arcuate Uterus Near complete resorption of u-v septum Mild concave indentation at fundus ? Anomaly / ? Anatomic variant Data conflicting Abortion rates ?45% ?13% Treatment expectant

T shaped Uterus Diethylstilbestrol treatment for Premature labour started 1940 Banned 1970 69% female foetuses suffered Uterine anomaly T-Shaped uterus, small uterus, constriction rings, Cervical hypoplasia, cervical incompetence, Anterior Cervical collar, pseudopolyps 2 fold increase in abortion rates & 9 fold increase in Ectopic pregnancy rates

T SHAPED UTERUS- INFECTION MALA ARORA 17

Uterine Neoplasms Endometrial Polyps

2/8/2013

PERIOSTEALMALA ARORA ENDOMETRIAL POLYP 19

Leiomyomas (Fibroids) most common. 20-50% of reproductive womenWhen will you consider fibroids responsible ?

Preconception myomectomy to improve reproductive outcome can be considered on an individual basis It is likely to have a place only in women who have recurrent pregnancy loss, large submucosal fibroids, and no other identifiable cause for recurrent miscarriage Ouyang DW, Obstet Gynecol Clin North Am. 2006

Iatrogenic

Intrauterine adhesions ,Ashermans Syndrome Lead to Poor implantation, Decreased blood supply , infection Abortion rates 40% Preterm labour 23% Management :-Hysteroscopic excision of adhesions

HYSTEROSCOPIC CORRECTION All of the above have a good pregnancy rate post hysteroscopic correction Except ashermans syndrome

Anatomical Factors When will you label a patient as a case of incompetent Cervix?

What are the different surgicalprocedures?

Role of prophylactic surgery?

USG follow up weekly in cases of prior 2nd trimester

loss Funneling of >25% cervical length and/or 20wk

Risk Factors for RMAdvanced maternal age

Affects ovarian function, giving rise to a declinein the number of good quality oocytes, resulting in chromosomally abnormal conceptions that rarely develop further.

RM risk -75% in women >45years

Previous number of miscarriages28

Spontaneous Miscarriage 10-15% of recognized pregnancies

Mostly sporadic ; 80% losses in 1st 12 wks 50-70% due to chromosomal anomaliesAutosomal trisomy 50-60% 13,16,18,21,others

Monosomy X-20% Triploidy 15% Tetraploidy-5% UnbalancedKaryotypes normal Minimal recurrence risk translocation-3-5% Parental

In Recurrent Miscarriage (RM)Fetal chromosomal abnormality in only 2532% of product of conception (POC) This may be due to abnormalities in the egg, sperm or both. The most common chromosomal defects are Trisomy, Monosomy, PolyploidySperm aneuploidy (13,18,21,X,Y ) directly influences the rate of aneuploidy in the conceptus (Carrell et al 2003)

In Recurrent Miscarriage Parental chromosomal abnormality (Balancedchromosomal rearrangements)

General population RM

6 in 1000(0.6%) 4.1-11%

*3-5% of couples with RSA are carriers of balanced chromosomal rearrangements

Parental Chromosomal AbnormalitiesTranslocation (commonest) (1in 500) Reciprocal [50%] Robertsonian [24%]

Mosaicism for a numeric aberration [12%] Inversion

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TranslocationTranslocation is exchange of chromosomal segments between two, non-homologous chromosomes.

Source-Internet

TranslocationsTwo major types Reciprocal translocation- two nonhomologous chromosomes exchange information Robertsonian translocation -two non-homologous acrocentric chromosomes break at the centromere and the long arms fuse. The short arms are often lost.

Source- Emerys book of principles of Medical Genetics

Karyotype of the abortus( fetal/placental tissue)

Peripheral blood Karyotyping of the parents in all couples with RM

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Spontaneous abortion 10-15%

Recurrent Miscarriage 1-3%

50-70% abortuses 25-30% abortuses chromosomally abnormal chromosomally abnormal Couple karyotype usually Couple karyotype may be normal rearrangement carrier Recurrence risk negligible Recurrence risk upto 50%

Successful culture requires healthy cells derived from the fetus Unsuccessful in upto 50% of cases

Maternal overgrowth of fetal cells

Poor growth of abortus tissue esp. if there is a long timeinterval from the demise until the culture is performed

Poor chromosome morphology

Whether we should do POC karyotype ????

No definite recommendations for routinely obtaining abortus karyotype (ACOG 2001) Karyotype analysis of abortus tissue for couples with a subsequent second or third pregnancy losset al 2003) (Hogge,

If abortus is aneuploid, maternal cause is excluded(ACOG, 2001)

If POC karyotype not possible, do parental karyotype

Normal Abnormal (trisomy or chromosomal rearrangement) Both requires parental karyotype

Direct parental karyotype is more cost effective No need for first abortion

Individuals with Balanced Chromosomal Rearrangement usually phenotypically normal Are at risk of having conceptus with normal balanced phenotypically normal unbalanced spontaneously aborted phenotypically malformed

Single Gene Disorders in RM Second and 3rd trimester losses Alpha Thalassemia Myotonic dystrophy X linked Dominant disorder Incontinentia Pigmenti Chondrodysplasia punctata Focal dermal hypoplasia of Goltz Rett Syndrome Aicardi Syndrome

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Single Gene Disorders in RM Hereditary thrombophilia First and later trimester losses Microthrombosis in placenta ;Impaired uteroplacental circulation Factor V Leiden gene mutation Evidence based Prothrombin G 20210A mutation inc. risk Protein C,S deficiency Antithrombin III No significant association MTHFR C677T mutation Combination of any of above-Increased risk43

Genetic Evaluation and Testing Recommendation History of Recurrent miscarriage Clotting disorder Still birth/neonatal death

Babies with dysmorphic features Infertility Mental retardation /developmental delay

Inherited disorder

(J Gen Counsel ;14(3)2005) 44

Karyotypic abnormalities in couples with Recurrent abortions Total Couples n=742(1484 cases) Duration -12 years Chromosomal rearrangements = 52 (7% ) Structural aberrations 22 (2.9%) Reciprocal (6,8,11,18)=15 (68.2%) Robertsonian (21,22,13,14)=4 (18.1%) Inversion(4)=1 (9%) Deletion=2 Numerical anomalies (mosaics with XO,XXX, XXY)= 9 (1.2%)

Chromosomal variants (para centromeric heterochromatin/fragile sites) = 21 (3.2%)Dubey et al. Ind J Hum Genet 2005

Role of Infections

Venn diagram of the responsibilities of Reproductive Failure

EGG 80%SPERM 10%UTERUS 10%

Doubtful causes of RSA TORCH infections Endocrine and metabolic disease

Untreated adrenal hyperplasia, hypothyroidism & diabetes mellitus. Exogenous causes

Environmental factors, alcohol, street drugs, anesthesia gases etc

Its time to say goodbye to TORCH tests.Cochrane Review has categorically proven in multiple meta-analysis that none of the TORCH group of infections are responsible for RECURRENT SPONTANEOUS ABORTIONS

So which infections, if any are responsible for RSA?Female Viral infections ? ? Coxasackie B Parovo-virus B

Bacterial infections Bacterial Vaginosis Tuberculosis Chlamydia trachomatis

Male factors: Semen infections can cause anueploidy and be the reason of RSA

Genitourinary diseases prior spontaneous abortion as a risk factor for RSAConcluded infections of the maternal and/or paternal genitourinary system may be the causal factor for recurrent pregnancy loss and can also pre-determine women that are of greater susceptibility to preterm pregnancy Culi V, Konjevoda P, et al. Coll Antropol. 2009 Mar;33(1):187-92 Kamilova N, Sultanova I, et al. Georgian Med News. 2008 Nov;(164):23-7

Bacterial Vaginosis Commonest cause of vaginitis Amsel's criteria for diagnosis of BV Thin, homogeneous discharge Release of an amine (putrescine, cadaverine, & trimethylamine) or fishy odor on addition of KOH is to vaginal discharge "Clue cells" (Vaginal epithelial cells coated with coccobacilli) Vaginal pH > 4.5 Nugent score: Gram Stain of vaginal swabBacterial Vaginosis

50%Trichomona Candida s vaginalis albicans 25% 25%

BV and RSA BV one of the most frequently founded cause of spontaneous abortions and prematurity birth Diagnostics is easy and not expensive High vaginal pH is diagnostic Treatment is simple using Metronidazole/Clindamycin1. Damianov L, Damianova V. Akush Ginekol (Sofiia). 2004;43 Suppl 2:26-7. 2. Mania-Pramanik J, Kerkar SC, et al. J Clin Lab Anal. 2008;22(5):375-9. 3. Li TC, Makris M, et al. Hum Reprod Update. 2002 Sep-Oct;8(5):463-81

The influence of Chlamydia trachomatis infection on RSASpecific anti-chlamydial antibodies in 3 groups of women IgA class 7.9% (p=0.082) in group 1 (RSA group), 4.5% (p=0.236) in group 2 (1 abortion) 0% in group 3 ( no abortions)

IgG class in 21.1% (p=0.024), 36.4% (p=0.000) and in 4.4%, respectively. CONCLUSIONS: C.t. infection is an important causative agent in RSA Anti-Chlamydial antobodies included in screening testsWilkowska-Trojniel M. Adv Med Sci. 2009;54(1):86-90 Kavalier F, BMJ. 2005 Jul 16;331(7509):121-2.

Hattori Y, Nakanishi T.Am J Reprod Immunol. 2007 Oct;58(4):350-7.

Uterine cervical inflammatory cytokines, interleukin6 and -8, as predictors of RSA Both IL-6 and IL-8 in cervical mucus were significantly higher in patients who miscarried subsequently than in those who had a live birth.

Other rare virusesCoxsackie B virus (CBV) & RSA

Parvovirus B19

Is it time to look at the sperm?

Consequences of fertilisation by sperm with nuclear DNA damageNo DNA Repair Fertilisation Failure

DNA Repair Fertilisation

Partial DNA Repair Fertilisation

Normal offspring

?Abnormal offspring

SEMEN CULTURE Male accessory gland infection with E coli /Staph aureus /

Bacteria ride on the sperm tails into uterinecavity Produce low grade endometritis

Possible role of male factors in recurrent pregnancy loss Amongst male partners of women with RSA 3 (4%) had varicocele, 23 (30.6%) had infection, 1 (1.3%) immunological and 1 (1.3%) had genetic abnormality Sperm motility, viability and sperm function tests were significantly lower in the RPL group as compared to the control group (P = 0.000) Male factor might be a contributing factor towards RPL Both the partners should be evaluated Infection treated in both Saxena P, Misro MM et al. Indian J Physiol Pharmacol. 2008 Jul-Sep;52(3):274-82

Conclusion Problems of Research in RSA The cause of individual abortion may be different

More than one factor may exist Thorough investigation often fails to reveal a cause Infections must be ruled outFertil Steril. 2010 Mar 1;93(4):1234-43. Epub 2009 Mar 31

Conclusions TORCH group DOES NOT cause RSA Infections in both partners need to be evaluated in cases of RSA Therefore the genetic counseling of couples should include thorough medical examination and evaluation for infections

Antiphospholipid Antibody Syndrome and Recurrent Pregnancy Loss

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Autoimmune etiology Secondary to autoimmune disease such as SLE, Polyarteritis nodosa, etc Primary Antiphospholipid Syndrome (PAPS) refers to the association of adverse pregnancy outcome and presence of antiphospholipid antibodies

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Which antibodies ? A number of antibodies have been studied The antibodies with the greatest significance and association with obstetric events are Lupus anticoagulant (LA) Anticardiolipin antibodies (ACL IgG and ACL IgM)

Others have such as 2glycoprotein-I, antiphosphatidylserine antibodies, annexin, etc may not be obstetrically significant65

Incidence About 1% of couples have recurrent miscarriages Antiphospholipid antibodies are found in about 2% of a Caucasian population. Not studied in a general Asian / Indian population 5 20% of women with recurrent miscarriages have antiphospholipid antibodiesMacLean AS et al, BJOG 1994 Rai RS et al, Hum Reproduction 1995 Balasch J et al, Hum Reproduction 1996

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Statistical Distribution Prevalence of antiphospholipid antibodies in various categories of women was studiedWomen with 3 or more early fetal losses Women with normal pregnancy outcome Women who have not been pregnant (includes women not desiring pregnancy and infertile women)

16%

7%

3%Parke AL et al, Arch Rheumat 1991

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Diagnosis of PAPS Based on clinical and laboratory criteria One obstetric or thrombotic criteria and one laboratory criteria should be present to diagnose PAPS Other autoimmune disease has to be ruled out to make the diagnosis of PAPSWilson A et al, International Consensus statement on APS,Arthritis Rheumatol 199968

Obstetric Criteria Three or more consecutive spontaneous abortion before the 10th week of gestation One or more unexplained fetal death at or beyond the 10th week of gestation

Severe preeclampsia or placental insufficiency (IUGR) necessitating birth before the 34th week of gestation69

Vascular Thrombosis Criteria Unexplained venous thrombosis Unexplained arterial thrombosis Small vessel thrombosis in any tissue or organ, without significant evidence of inflammation

of the vessel wall

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Laboratory Criteria Anticardiolipin antibody IgG or IgM isotype in medium to high titers by standardized ELISA assay Lupus anticoagulant present A positive test has to be repeated on at least one more occasion six weeks apart to fulfill the laboratory criteria71

Lupus anticoagulant testing Screen with demonstration of prolonged phospholipid dependent coagulation screening test (eg: activated partial thromboplastin time, kaolin clotting time, diluted Russells viper venom time, dilute prothrombin time) Failure to correct the prolonged screening test by mixing with normal platelet-poor plasma Shortening or correcting the prolonged screening test by addition of excess phospholipids Exclusion of other coagulopathies if clinically 72 indicated

Pitfalls in diagnosis of PAPS Usually an overdiagnosed syndrome Not meeting clinical and the strict laboratory criteria Not repeating the laboratory test at 6 weeks Non standardized ELISA for ACL antibodies Interlaboratory variations for phospholipid dependent coagulation tests used for screening for lupus anticoagulant73

False results in PAPS Improperly collected and processed samples Temporal and trimester wise fluctuations VDRL positive patients who may or may not have syphilis General infections and inflammations Coagulopathies and anticoagulant medication users (including aspirin, heparin)74

Goals for treating PAPS Avoid early pregnancy loss Normalize placental and fetal circulations to prevent early birth from obstetric complications such as preeclampsia and growth restriction Prevent maternal vascular thrombosis in pregnancy and postpartum

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Women with PAPS without a history of thrombotic events (most women with RPL) Prophylactic therapies such as aspirin, heparin in pregnancy and 6 to 8 weeks postpartum

Women with PAPS with history of thrombotic events (past or present)

Full anticoagulation with heparin (or warfarin) in pregnancy and postpartum

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Aspirin alone v/s Aspirin + Heparin Recent metaanalysis shows that the combination of Aspirin + Heparin is better than Aspirin alone in achieving live births in women with recurrent pregnancy loss and antiphospholipid antibodiesMak A et al, Rheumatology (Oxford) 2010

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Is Heparin + Aspirin really better? The metaanalysis was based on data from five trials involving 334 patients across non uniform care platforms Overall live birth rates were 74.27 and 55.83% in the combination and aspirin alone groups RR 1.301; 95% CI 1.040, 1.629 Number needed to treat is 5.6

There is no placebo group for comparison Another metaanalysis showed that LMW heparin + Asprin does not significantly improve birth rates. The benefits is present only with unfractionated heparinZikas PD et al, Obstet Gynecol 2010 78

Clinical Tips for using Heparin There is controversy as to whether LMW Heparin is effective in preventing recurrent pregnancy loss Consider costs, convenience and compliance before initiating therapy Therapy should be started when fetal cardiac activity is demonstrated and continued throughout pregnancy and postpartum Heparin in prophylactic doses needs to be stopped for about 24 hours around the time of labor and delivery79

Clinical Tips for using Heparin Heparin in prophylactic doses can not be monitored and does not require monitoring by coagulation parameters Do a platelet count at 3 days, 1 week and bimonthly when the patient is on heparin Standard doses Unfractionated heparin 5000 units sc bd Enoxaparin 40 mg sc daily or in two doses80

Full Anticoagulation : Practical Preconception : Warfarin Switch to Heparin when fetal cardiac activity is demonstrated

Warfarin should be considered in the second trimester Switch back to Heparin at 34 to 36 weeks After delivery : Warfarin81

What not to do for PAPS Steroid therapy should be avoided for PAPS because it significantly increases morbidity (hypertension, diabetes, preterm births) without any demonstrable benefit Immunoglobulin therapy is experimental and not for clinical use at present82

RECOMMENDED INVESTIGATIONS1. 2. 3. 4. 5. 6.Grade A (FOR ALL PATIENTS) Hysterosalpingography/ Hysteroscopy APTT/ dRVVT/ Lupus anticoagulant IgG & IgM anticardiolipin antibodies TSH / Prolactin / Testosterone / HbA1C/ 2 hrs Post Prandial INSULIN Karyotyping of both parents & If possible abortus

RECOMMENDED INVESTIGATIONSGrade B (FOR SELECTED PATIENTS) 1. ANDROGENS, LH, FSH IN PATIENTS WITH IRREGULAR MENSTRUATION 2. SERUM PROGESTERONE 3. EB FOR DATING & TB PCR, CULTURE 4. SERUM HOMOCYSTEINE LEVELS / THROMBOPHILIA SCREEN 5. HVS / WET PREP & pH / KOH Whiff test 6. SEMEN CULTURE / TB PCR

ANTI PHOSPHOLIPID SYNDROME LOW DOSE ASPIRIN pre preg clinic HEPARIN after ultrasound viability Low molecular weight heparin Intravenous immunoglobulins Corticosteroids only used in aps associated with sle Warfarin if previous arterial thrombosis in second & third trimester

ANATOMICAL CAUSES Hysteroscopic evaluation Intrauterine adhesiolysis

Septum resection Removal of submucous fibroids and polyps CERVICAL CERCLAGE if indicated

INFECTVE CAUSES Screening and treatment of bacterial vaginosis Screening and treatment of occult genital tuberculosis Chlamydia screening & treatment

ENDOCRINAL FACTORS Polycystic ovaries ? metformin Luteal phase defects progesterone / Duphaston Thyroid replacement therapy Optimising HbA1c levels Correct hyperprolactinaemia

THROMBOPHILIA SCREEN POSITIVE LOW MOLECULAR WEIGHT HEPARIN UNFRACTIONATED HEPARIN (From 6 weeks to 36 weeks of pregnancy)

HAEMATOLOGICAL Folic acid, vitamin b6, vitamin b12 in hyperhomocystinaemia Low dose aspirin Heparin or LMWH Full dose heparin in case of DVT WARFARIN if arterial thrombosis

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ALLOIMMUNE CAUSESProgesterone therapy Evidence for use

Dydrogesterone in the reduction of recurrent spontaneous abortionEl-Zibdeh MY El-Zibdeh MY. Dydrogesterone in the reduction of recurrent spontaneous abortion. J Steroid Biochem Mol Biol 2005; 97: 431-434

MethodsRandomised, controlled study Pregnant women (< 35 years old) who had experienced at least 3 consecutive miscarriages with the same partner Only women for whom no explanation could be found for their recurrent miscarriages were included. 180 Women of which: 82 Received dydrogesterone 50 Received hCG 48 Received no additional treatment (control)

TreatmentWomen randomised to: Oral dydrogesterone 10 mg b.i.d. Intramuscular human chorionic gonadotrophin (hCG) 5000 IU every 4 days No additional treatment Randomisation according to the day of the week they attended clinic

Treatment started as soon as possibleafter confirmation of pregnancy and continued until 12th gestational week All women received standard supportive care: multivitamin supplements and recommended bed rest

El-Zibdeh MY

Dydrogesterone in the reduction of recurrent spontaneous abortionResults Conclusion

El-Zibdeh MY. Dydrogesterone in the reduction of recurrent spontaneous abortion. J Steroid Biochem Mol Biol 2005; 97: 431-434

Dydrogesterone reduced the chances of spontaneous pregnancy loss in women with recurrent miscarriage Dydrogesterone was well tolerated and had no unwanted effects on the delivery or outcome of pregnancy

EVIDENCE - DydrogesteroneProgressive increase in PIBF cells with increasing concentrations of dydrogesterone.J Szekeres Bartho 9th World Congress of Gynecological Endocrinology, Hong Kong, December 2001

Dydrogesterone

Progesterone (P) Receptor Activation

Progesterone Induced Blocking Factor

Embryo Protective Immunomodulation

Dydrogesterone inhibits the production of the Th1 cytokines IFN-g and TNF-a from lymphocytes and up-regulates the production of the Th2 cytokines IL-4 and IL-6, inducing a Th1 to Th2 cytokine shift.Raj Raghupathy et al. BJOG 2005;112:1-6

Protection of Fetus

Th1

Dydrogesterone has an immunomodulatory capability and appears to induce a maternal cytokine shift from Th1 cytokine dominance towards a Th2 bias.Raj Raghupathy et al. BJOG 2005;112:1-6

Th2

ROLE OF TENDER LOVING CARE

DESTRESS & REASSURE Psycho-neuro-immunology Stress affects immune system Changes th2 response in endometrium to th1 response Hypothalamus affects endocrine system Adrenaline release reduces placental blood flow

DIAGNOSTIC IVF / ICSI with PGDPICKS UP ANEUPLOIDY IN EMBRYOS

SURROGACY If diagnostic IVF & PGD confirm normal gametes / embryos All treatment modalities have failed

Conclusion / Problems of RPL The cause of individual abortion may be different

More than one factor may exist Thorough investigation often fails to reveal a causeFertil Steril. 2010 Mar 1;93(4):1234-43. Epub 2009 Mar 31

THANK YOUfor your valuable time