+ All Categories
Home > Documents > Pregnancy Loss Prevention

Pregnancy Loss Prevention

Date post: 14-Apr-2018
Category:
Upload: cosmina-alina-moscu
View: 230 times
Download: 1 times
Share this document with a friend

of 44

Transcript
  • 7/27/2019 Pregnancy Loss Prevention

    1/44

    Preventive medicine inobstetrics regarding

    pregnancy loss

    Dr. Mohammed Abdalla

    Domiat general hospital

  • 7/27/2019 Pregnancy Loss Prevention

    2/44

    Can Pregnancy

    complications such as Recurrent abortion,

    Preterm labour,

    Still birth,

    Preeclampsia.

    be prevented

  • 7/27/2019 Pregnancy Loss Prevention

    3/44

    In the past the obstetrical art

    focused mainly on how todeal with complications .

    but now by the remarkableadvance in modern

    obstetrics ,immunology, and

    hematology, the goal is

    how to prevent them.

  • 7/27/2019 Pregnancy Loss Prevention

    4/44

    Maternal risk assessment

    Maternal risk

    assessment can befirstly identified from

  • 7/27/2019 Pregnancy Loss Prevention

    5/44

    Recurrentpregnancy

    loss is not just a BadLuck and must be

    investigated .

    Maternal risk assessment

  • 7/27/2019 Pregnancy Loss Prevention

    6/44

    But on other hand

    some conditions needno recurrence to be

    alarming, and to beinvestigated.

    Maternal risk assessment

  • 7/27/2019 Pregnancy Loss Prevention

    7/44

    oneunexplained fetal

    deaths after ten weeksof pregnancy

    onepreeclampsia or

    placental insufficiencies

    occurring before 34weeks

    One previous preterm

    birth

    one or more confirmedepisodes of venous or

    arterial thrombosis.

    any of these must invite

    a big question mark

    ?

  • 7/27/2019 Pregnancy Loss Prevention

    8/44

    The initial attempts to predict

    preterm delivery in

    asymptomatic patients

    involved the use of

    risk factor assessment.

    Maternal risk assessment

  • 7/27/2019 Pregnancy Loss Prevention

    9/44

    Risk Factors for Preterm

    Birth -Prior cone biopsy or (LEEP)

    -Greater than or equal to 3 first trimester losses

    -Any second trimester loss-Prior preterm delivery (PTD)

    -Prior myomectomy

    -Cervical cerclage

    -Uterine Anomalies

  • 7/27/2019 Pregnancy Loss Prevention

    10/44

    The diagnosis is usually

    based on a history oflate miscarriage,

    preceded byspontaneous rupture ofmembranes or painless

    cervical dilatation.

    Risk Factors for Preterm

    Birth

  • 7/27/2019 Pregnancy Loss Prevention

    11/44

    The diagnosis ofUterine Anomalies is

    usually found on a HSG . Differentiation

    between the uterine septum and thebicornuate uterus cannot be made with

    the HSG alone but Further evaluation of

    the fundal contour must be done withlaparascopy, MRI, or US as therapy is

    very different.

    Risk Factors for Preterm

    Birth

  • 7/27/2019 Pregnancy Loss Prevention

    12/44

    Etiologic view

    of pregnancy

    lossafter 10wk

  • 7/27/2019 Pregnancy Loss Prevention

    13/44

    pregnancy loss after 10wk

    one pregnancy loss more than

    10wk. Gestation or pregnancy

    associated with late adverseoutcome

    need no recurrenceto be investigated.

  • 7/27/2019 Pregnancy Loss Prevention

    14/44

    0.00

    10.0020.0030.0040.0050.0060.00

    70.0080.0090.00

    100.00

    immun

    ologic

    al

    anatom

    ical

    preterm

    chr

    omosom

    al

    preg.loss

    pregnancy loss after 10wk

    95%

    3% 2% 0.5%

  • 7/27/2019 Pregnancy Loss Prevention

    15/44

    How much is thrombophilia

    common among generalpopulation

    pregnancy loss after 10wk

  • 7/27/2019 Pregnancy Loss Prevention

    16/44

    Inherited thrombophilia

    00.5

    1

    1.5

    2

    2.53

    3.5

    4

    4.5

    5

    FVL

    MTFRD

    Proth.G

    PCD

    PSD

    ATIII

    %population

    %

  • 7/27/2019 Pregnancy Loss Prevention

    17/44

    Recent case-control studies and

    meta analyses attempted toquantify the risks associated with

    different thrombophilic defects

    and adverse clinical events in

    pregnancy,

    thrombophilia and fetal loss

  • 7/27/2019 Pregnancy Loss Prevention

    18/44

    Severepreeclampsia

    IUGR Placentalabruption

    Antithrombin deficiency ++ ++ +

    Protein S deficiency ++ ++ ++

    Protein C deficiency ++ ++

    APC resistance ++ ++ ++

    Factor V Leiden ++ ++

    MTHFR C677T +

    Hyperhomocysteinemia ++ ++ ++

    Factor II G 20210A + ++ ++

    Antiphospholipid syndrome ++ ++ ++

    Combined defects ++ ++ ++

    thrombophilia and fetal loss

  • 7/27/2019 Pregnancy Loss Prevention

    19/44

    A meta analysis published in

    LANCET 15 march 2003included 31 studies

    published between 1975 and

    2002 (by Medline search).

    thrombophilia and fetal loss

  • 7/27/2019 Pregnancy Loss Prevention

    20/44

    Relative risk is quantified by odd ratio

  • 7/27/2019 Pregnancy Loss Prevention

    21/44

  • 7/27/2019 Pregnancy Loss Prevention

    22/44

    0

    0.5

    1

    1.5

    2

    2.5

    3

    3.5

    FVLG mutation

    early RFL

    lare non RL

    Odd ratio

    thrombophilia and fetal loss

    0

    0.5

    1

    1.5

    2

    2.5

    3

    3.5

    4

    APCR

    early R loss

    2.15

    2.2

    2.25

    2.3

    2.35

    2.4

    2.45

    2.5

    2.55

    2.6

    prothromb.GM

    early RL

    late non RL

    0

    2

    4

    6

    8

    10

    12

    14

    16

    PSD

    recurrent early loss

    late non recurrent loss

    Odd ratio

  • 7/27/2019 Pregnancy Loss Prevention

    23/44

    0

    2

    4

    6

    8

    10

    12

    14

    16

    18

    combined factor

    early recurrent loss

    late non recurrent loss

    Odd ratio

    thrombophilia and fetal loss

  • 7/27/2019 Pregnancy Loss Prevention

    24/44

    Top guidelines toTop guidelines toprevent recurrentprevent recurrent

    pregnancy loss andpregnancy loss and

    adverse pregnancyadverse pregnancyoutcomesoutcomes

    Top guidelines toTop guidelines toprevent recurrentprevent recurrent

    pregnancy loss andpregnancy loss and

    adverse pregnancyadverse pregnancyoutcomesoutcomes

  • 7/27/2019 Pregnancy Loss Prevention

    25/44

    prenatal cervical length screening

    by transvaginal ultrasound is

    indicated for women identified to

    be at increased risk of preterm birth.Cervical shortening is associated

    with increased preterm birth risk

    (II-2 B)

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    26/44

    By Transvaginal ultrasound

    cervical length > 3 cm. after

    24 weeks has a high

    negative predictive value.to avoid unnecessary

    interventions.

    (II-2 B)

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    27/44

    Women with recurrent

    pregnancy loss and a

    uterine septum should

    undergo hysteroscopic

    evaluation and resection.

    (ACOG) grade C

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    28/44

    There is no clearfirst-line tocolytic

    drugs to managepreterm labor.

    (ACOG) grade A

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    29/44

    Neither maintenance treatment

    with tocolytic drugs norrepeated acute tocolysis

    improve perinatal outcome butjust prolong pregnancy for 2-7

    days giving time for steroids.

    (ACOG) grade A

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    30/44

    If a tocolytic drug isused, Atosiban ornifedipine appear

    preferable as theyhave fewer adverse

    effects and seem tohave comparable

    effectiveness.

    (RCOG) A

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    31/44

    Screening for and treatment

    ofbacterial vaginosis inearly pregnancy amonghigh risk women with a

    previous history of second-trimester miscarriage or

    spontaneous pretermlabour may reduce the riskof recurrent late loss and

    reterm birth.

    (RCOG) A

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    32/44

    (TORCH and herpes simplex

    virus)

    screening isunhelpful in the

    investigation ofrecurrent

    miscarriage

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    33/44

    In all couples with a

    history of recurrentmiscarriage

    cytogenetic analysisof the products of

    conception should beperformed if the next

    pregnancy fails.

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    34/44

    There isinsufficient

    evidence toevaluate the

    effect of(hCG) inpregnancy to

    prevent

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    35/44

    There is insufficientevidence to evaluate

    the effect of

    progesteronesupplementation in

    pregnancy toprevent a

    miscarriage.

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    36/44

    In women with a history

    of recurrentmiscarriage and APL,

    the future live birthrate is markedlyimproved when a

    combination therapy

    ofaspirin plus

    he arin is rescribed.

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    37/44

    Pregnanciesassociated with

    aPL treated withaspirin and

    heparin remain athigh risk of

    complications

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    38/44

    Currently there is noreliable evidence to

    show that steroids

    improve the live birthrate of women with

    recurrent miscarriage

    associated with aPL.

    their use may provoke

    significant maternal and

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    39/44

    If a diagnosis ofluteal

    phase defect is sought in

    a woman with recurrent

    pregnancy loss, it should

    be confirmed by

    endometrial biopsy.ACOG (B)

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    40/44

    low-dose aspirin, have small-

    moderate benefits when usedfor prevention of

    pre-eclampsia.

    Further information is requiredto assess which women aremost likely to benefit, when

    treatment is best started, andat what dose.

    Cochrane Review2005

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    41/44

    Antiplatelet therapy

    ( low dose aspirin)

    reduces the risk ofpre-

    eclampsia by around 15% for

    women at low or high risk .

    RCOG(B)

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    42/44

    The combination ofaspirin and

    heparin is effective in recurrentfetal loss in APS and could beconsidered for women with

    inherited thrombophiliasand history of severepreeclampsia, IUGR, abruptio

    placentae or fetal loss, although nocontrolled studies on the subject

    are currently available

    Cochrane Review 2003

    Top guidelinesTop guidelines

  • 7/27/2019 Pregnancy Loss Prevention

    43/44

    Assessment of maternal

    risk and prediction ofrisk factors is the gate

    for prevention of

    adverse pregnancyoutcomes.

  • 7/27/2019 Pregnancy Loss Prevention

    44/44


Recommended