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Habitual Abortion or Recurrent Pregnancy Loss

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by

Serageldin Ayman

on 9 October 2013

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Transcript of Habitual Abortion or Recurrent Pregnancy Loss

Habitual Abortion or Recurrent Pregnancy Loss

Definition
*Occurrence of more than 2 successive spontaneous abortions.

Fetal Causes
Infections
Iatrogenic
Maternal Causes
Ismithic Incompetence
Immunological
*Antiphospholipid Antibodies.
*Systemic Lupus Erythematous (SLE) 40%.

Cerclage
Incidence
2% of couples
Causes
Congenital Uterine Causes
Traumatic
Definition
-Physiological:

Chromosomal Abnormalities
Accidental Trauma
Drugs
*Chemotherapeutic agents (e.g.: Methotrexate)
*Prostaglandins (e.g.: Mesoprostol)
*Antiprogesterone (e.g.: Mifeprostone)
Indications

*Habitual Abortions or preterm labour.
*Any congenital malformations of the uterus.

McDonald's Operation
*The esthmus uteri is surrounded by a suture abdominally.
*It is done in cases with a previous high amputation of the cervix.

Repeated Abortion:
Repeated successive spontaneous abortion
Maternal Causes
Immunological
Fetal Causes
Infections
Iatrogenic

Medical Disorder
*Uncontrolled DM
*Hypertension
General
&
*Luteal Phase Defect
*Hypothyrodism
Local
*Hypoplasia of the uterus
*Septate or bicornuate uterus.

Isthmic Incompetence
*Inability of cervix to maintain pregnancy till full term due to weakness in sphectenic mechanism at internal OS and isthmus.


Congenital
Acquired
*Associated With Congenital Anomalies.
*Must do Cerculage.
Obst.
Gyn.
*Diff. Delivery of
breach or instr.
*Delivery causing cervical laceration
*Rapid Excessive dilation of cervix.

*>8 Hegar.
Miscellaneous
*RVF Position Of The Uterus
*Sub Mucous Fibroid

*The Most Common Cause.
Numerical Disorders: 60% Of 1st Trimestric Abortions.
A. Aneuploidy With Low Tendency Of Recurrence:
-Trisomies: are the most common anomalies including 13,16,18,21 and 22.
-Monosomy: Cause Turner Syndrome
B. Triploidy: Is often associated with molar pregnancies.
C. Tetraploidy: as in Vesicular mole.


Structural disorders maybe a cause 2nd trimestic abortion.
Syphilis


External Internal
Neoplastic
abdomen.
*Blow to the
*Sound or I.U.D
-Lead to slow cervical dilation.

*Excluded by
US.
Inflammatory
Endocrinal
Inbetween Preg.
During Preg.

*Hegar 8 without pain or *Herniation of bag of water
resistance.
during PV Examination.
Inbetween
During Preg.
*HSG (Luteal Phase Isthmography) showing funneling of the internal OS.
*UltraSound Showing:
widened internal OS diameter > 8 mm
Shortened cervical canal length< 2.5 cm in 2nd trimester.
Funneling of the cervical isthmus.
Bulging and protrusion of the fetal membranes through the dilated cervical canal.
*Cerclage Operation
Time of operation: About 12-14 weeks of gestation to exclude congenital malformations of the embryo.
Investigations
&
4 bites are taken to surround the cervix from outside & the suture is tied posteriorly.
* The suture should be placed as high as possible.
*The operation is simple with high success rates (75-80%).
*Mersilene Tape is inserted under the mucosa of the cervix when the ends are tied the suture surrounds the cervix.
*The suture is placed at the level of the internal OS of the cervix.
*It's more difficult and causes more bleeding.

*
Vaginal Cerclage
Shirodkar's Operation
Abdominal Cerclage
Asherman Syndrome
Asherman Syndrome
Etiology
*Due to Over curretage in presence of infections leads to distruction of the basal layer of the endometruim with subsequent development of intra uterine adhesions .

Investigations
a)Sounding : Difficult or Impossible
b)HSG: Multilple filling Defects
c)Hysteroscopy
d)Endometrial Biopsy
e)Pelvic US: Revealing absence of the normal endometrial echoes
Treatment
*Cutting of adhesions by Hysteroscopy or D&C.
*Prevent readhesions by the use of foley's catheter for 1 week or IUD insertion for 1 month.
Stimulation of endometrial regeneration using cyclic combined estrogen and gestagine.
Treatment
Signs
Causes
Antiphospholipid Syndrome
Definition
*Antibodies produced against the phospholipid of the fetus during pregnancy.
*Action of Abs:
Block prostacyclin synthesis leading to an increased level of thromboxane A2 & increased platelets agregation with vasoconstriction leading to placental thrombosis and fetal loss.
Investigations
Treatment
ACA "Anticoagulant Ab".
LAC "Lupus Anticoagulant.



Low Dose Aspirin (75 mg).
Subcutaneous Heparin.
Diagnosis & Treatment Of RPL
Diagnosis
During Inbetween Preg.
Fetal Inv.:
- Genetic counsling
-Postmortem Exam. of the fetus cord & placenta afer abortion.
Invest. for general medical disorders
Invest. for local maternal causes by US.
Invest. for infections & Immunological causes.
*Detailed history & Physical Examination.
*Special Invistigation.
Invest. for fetal causes:
-Karyotyping for both parents.
Invest. for general maternal causes.
Invest. for local maternal causes:
-Sounding, HSG, D&C, US, Laparoscopy.
Invest. for infection:
-Vaginal Smear
Treatment
*In between Preg.:
Reassurance
Medical treatment:
-Nonhormonal: Control DM & HTN.
-Ttt of Siphilis: Penicillin.
-Hormonal:
1) Progesterone in the 2nd 1/2 of the cycle in cases of LPD.
2) Cyclic Estrogen & Progesterone for Hypoplastic Uterus.
3)Thyroid Extract for hypothyroidism
Surgical treatment:
1)Septate Uterus: Hysteroscopic Resection
2)Submucous Fibroid: Vaginal Miomectomy.
Prepared by:
Serageldin Ayman ElKhouly
Mohamed Adel Mabrouk
Mina Adel Samy
Nader Makram


*During Preg.:
-Nonhormonal: Control DM, HTN & treat infections.
-Hormonal:
1) Progesterone, or HCG during the 1st trimester in cases of progesterone insuffeciency.
2) Cyclic Estrogen & Progesterone for Hypoplastic Uterus.
3)Thyroid Extract for hypothyroidism
Surgical treatment:
Isthmic Incompetence: Cervical Cerclage.

Rest: Physical, mental and sexual.
Medical:
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