Presentation on theme: "The Diagnostic Evaluation and Treatment of Recurrent Pregnancy Loss"— Presentation transcript:
1 The Diagnostic Evaluation and Treatment of Recurrent Pregnancy Loss Ashim Kumar, M.D.Reproductive Endocrinology and InfertilityClinical Assistant Professor,UCLA School of MedicineFertility & Surgical Associatesof California,Encino & Thousand Oaks, CA
2 Luteal Support Progesterone +/- Estradiol Start after ovulation or egg retrievalContinue until 10 weeks gestational age
3 Early Pregnancy Reassurance Ultrasounds Pelvic rest as needed As IndicatedMonitor TSHMonitor BP
5 Recurrent Pregnancy Loss SAB: involuntary loss of pregnancy before 20wk GARPL: Three or more pregnancy losses in the first trimesterIndications to evaluate after 2 or more consecutive losses:+ FCA in prior lossNormal Karyotype on prior lossFemale > 35yrInfertilityEmotional Support is critical
6 Risk of RPL in Young Women # of Prior SAB’s% Risk of SAB in Next Pregnancyh/o prior liveborn12%124%226%332%4653%No liveborn2 or more40-45%
7 Early Pregnancy Loss Clinically unrecognized (less than 8wk GA) 30-60% of all pregnancies end in SABAt least ½ are early losses (go unnoticed)~75% of embryos with chromosomal abnormalities90% are numerical (aneuploidy/polyploidy)Rest are structural or mosaicism2/3 of the remaining 25% with normal karyotype exhibit gross structural abnormalities
13 Thrombophilias Congenital Immunologic - Antiphospholipid Syndrome Factor V Leiden MutationProtein C / Protein S DeficiencyProthrombin Gene MutationMethylenetetrahydrofolate Reductase (MTHFR) – homocysteineAntithrombin IIIImmunologic - Antiphospholipid SyndromeAnticardiolipin AntibodiesLupus Anticoagulant
14 Virchow’s Triad Stasis (Decrease flow in placental vessels) Damaged VasculatureHypercoagulable StateCancerPregnancy (Elevated Estradiol leads to increased hepatic production of clotting factors)CongenitalImmunologic
15 Genetic Meiotic Nondisjunction Balanced Translocation (5% of couples) Risk of miscarriage increases with advancing reproductive ageBalanced Translocation (5% of couples)RobertsonianReciprocalOthersMosaicismInversionChromosomally abnormal sperm do not play a role in RPL
25 Treatment Provide Emotional Support Uterus Hypercoagulable State Resect lesionHypercoagulable StateHeparinAspirinFolateGeneticPGDGeneral EndocrineCorrect hormonal imbalance
26 What Does Not Work Alloimmune Disorders Genetic Hypercoagulable State TestingHLA testingMixed lymphocyte cultureNatural killer cell assayTreatmentPaternal leukocyte immunizationIntravenous immunoglobulins (IVIG)GeneticPGDHypercoagulable StateGlucocorticoidsUterusMetroplasty
27 ConclusionThe likelihood of successful delivery is very high. The challenge is to do it an a cost-effective fashion while being sensitive to the emotional sequelae.
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