Presentation is loading. Please wait.

Presentation is loading. Please wait.

The Diagnostic Evaluation and Treatment of Recurrent Pregnancy Loss Ashim Kumar, M.D. Reproductive Endocrinology and Infertility Clinical Assistant Professor,

Similar presentations


Presentation on theme: "The Diagnostic Evaluation and Treatment of Recurrent Pregnancy Loss Ashim Kumar, M.D. Reproductive Endocrinology and Infertility Clinical Assistant Professor,"— Presentation transcript:

1 The Diagnostic Evaluation and Treatment of Recurrent Pregnancy Loss Ashim Kumar, M.D. Reproductive Endocrinology and Infertility Clinical Assistant Professor, UCLA School of Medicine Fertility & Surgical Associates of California, Encino & Thousand Oaks, CA

2 Luteal Support Progesterone +/- Estradiol Progesterone +/- Estradiol Start after ovulation or egg retrieval Start after ovulation or egg retrieval Continue until 10 weeks gestational age Continue until 10 weeks gestational age

3 Early Pregnancy Reassurance Reassurance Ultrasounds Ultrasounds Pelvic rest as needed Pelvic rest as needed As Indicated As Indicated Monitor TSH Monitor TSH Monitor BP Monitor BP

4 Prenatal Testing Screening Screening 1 st Trimester – Nuchal Fold + Serum 1 st Trimester – Nuchal Fold + Serum 2 nd Trimester – Triple/Quadruple Screen 2 nd Trimester – Triple/Quadruple Screen Diagnostic Diagnostic 1 st Trimester – Chorionic Villus Sampling 1 st Trimester – Chorionic Villus Sampling 2 nd Trimester – Amniocentesis 2 nd Trimester – Amniocentesis

5 Recurrent Pregnancy Loss SAB: involuntary loss of pregnancy before 20wk GA SAB: involuntary loss of pregnancy before 20wk GA RPL: Three or more pregnancy losses in the first trimester RPL: Three or more pregnancy losses in the first trimester Indications to evaluate after 2 or more consecutive losses: + FCA in prior loss Normal Karyotype on prior loss Female > 35yr Infertility Emotional Support is critical

6 Risk of RPL in Young Women # of Prior SABs % Risk of SAB in Next Pregnancy h/o prior liveborn 012% 124% 226% 332% 426% 653% No liveborn 2 or more 40-45%

7 Early Pregnancy Loss Clinically unrecognized (less than 8wk GA) Clinically unrecognized (less than 8wk GA) 30-60% of all pregnancies end in SAB 30-60% of all pregnancies end in SAB At least ½ are early losses (go unnoticed) At least ½ are early losses (go unnoticed) ~75% of embryos with chromosomal abnormalities ~75% of embryos with chromosomal abnormalities 90% are numerical (aneuploidy/polyploidy) 90% are numerical (aneuploidy/polyploidy) Rest are structural or mosaicism Rest are structural or mosaicism 2/3 of the remaining 25% with normal karyotype exhibit gross structural abnormalities 2/3 of the remaining 25% with normal karyotype exhibit gross structural abnormalities

8 Etiology Uterine Defect (~30%) Uterine Defect (~30%) Congenital Congenital Acquired Acquired Thrombophilia Thrombophilia Congenital Congenital Immunologic (~3-5%) Immunologic (~3-5%) Genetic Genetic Meiotic Nondisjunction Meiotic Nondisjunction Balanced Translocation (5%) Balanced Translocation (5%) General Endocrine General Endocrine

9 Uterine Defect Congenital Congenital Septum Septum Bicornuate / Unicornuate Bicornuate / Unicornuate T-Shaped Uterus T-Shaped Uterus Acquired Acquired Submucosal Leiomyoma Submucosal Leiomyoma Endometrial Polyp Endometrial Polyp Synechia Synechia Adenomyosis Adenomyosis

10 Uterine Evaluation Ultrasound Ultrasound Sonohysterogram (saline ultrasound) Sonohysterogram (saline ultrasound) Hysterosalpingogram Hysterosalpingogram MRI MRI Hysteroscopy Hysteroscopy

11 Bicornuate or Septate

12 Endometrial Polyp

13 Thrombophilias Congenital Congenital Factor V Leiden Mutation Factor V Leiden Mutation Protein C / Protein S Deficiency Protein C / Protein S Deficiency Prothrombin Gene Mutation Prothrombin Gene Mutation Methylenetetrahydrofolate Reductase (MTHFR) – homocysteine Methylenetetrahydrofolate Reductase (MTHFR) – homocysteine Antithrombin III Antithrombin III Immunologic - Antiphospholipid Syndrome Immunologic - Antiphospholipid Syndrome Anticardiolipin Antibodies Anticardiolipin Antibodies Lupus Anticoagulant Lupus Anticoagulant

14 Virchows Triad Stasis (Decrease flow in placental vessels) Stasis (Decrease flow in placental vessels) Damaged Vasculature Damaged Vasculature Hypercoagulable State Hypercoagulable State Cancer Cancer Pregnancy (Elevated Estradiol leads to increased hepatic production of clotting factors) Pregnancy (Elevated Estradiol leads to increased hepatic production of clotting factors) Congenital Congenital Immunologic Immunologic

15 Genetic Meiotic Nondisjunction Meiotic Nondisjunction Risk of miscarriage increases with advancing reproductive age Risk of miscarriage increases with advancing reproductive age Balanced Translocation (5% of couples) Balanced Translocation (5% of couples) Robertsonian Robertsonian Reciprocal Reciprocal Others Others Mosaicism Mosaicism Inversion Inversion Chromosomally abnormal sperm do not play a role in RPL Chromosomally abnormal sperm do not play a role in RPL

16 Meiotic Nondisjunction

17 Age and Miscarriage Risk

18 Risk of Chromosomal Abnormality in Newborns by Maternal Age Maternal Fetal Medicine: Practice and Principles. Creasey and Resnick 1994

19 Preimplantation Genetic Diagnosis

20

21

22 Robertsonian Translocation

23 Reciprocal Translocation

24 General Endocrine Diabetes (Fasting Glucose) Diabetes (Fasting Glucose) Thyroid Disease (TSH) Thyroid Disease (TSH) Hyperprolactinemia (Prolactin) Hyperprolactinemia (Prolactin) Polycystic Ovary Syndrome Polycystic Ovary Syndrome Luteal Phase Deficiency (Supplement Everyone) Luteal Phase Deficiency (Supplement Everyone)

25 Treatment Provide Emotional Support Provide Emotional Support Uterus Uterus Resect lesion Resect lesion Hypercoagulable State Hypercoagulable State Heparin Heparin Aspirin Aspirin Folate Folate Genetic Genetic PGD PGD General Endocrine General Endocrine Correct hormonal imbalance Correct hormonal imbalance

26 What Does Not Work Alloimmune Disorders Alloimmune Disorders Testing Testing HLA testing HLA testing Mixed lymphocyte culture Mixed lymphocyte culture Natural killer cell assay Natural killer cell assay Treatment Treatment Paternal leukocyte immunization Paternal leukocyte immunization Intravenous immunoglobulins (IVIG) Intravenous immunoglobulins (IVIG) Genetic PGD Hypercoagulable State Glucocorticoids Uterus Metroplasty

27 Conclusion The 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. The 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.


Download ppt "The Diagnostic Evaluation and Treatment of Recurrent Pregnancy Loss Ashim Kumar, M.D. Reproductive Endocrinology and Infertility Clinical Assistant Professor,"

Similar presentations


Ads by Google