RES Ch 31

  1. what is the definition of recurrent PG loss (RPL)
    3+ spontaneous miscarriages prior to 20 wks gestation
  2. what is the incidence of RPL
    1% of PG women have had at least 2 prior spontaneous abortions
  3. What is the liklihood of a live birth after 3+ spontaneous abortions
    • 70% w. dx of RPL
    • 55% if previous live birth has occured
    • statistics apply only in young women
  4. What are the common causes of RPL (7)
    • III AGEE
    • idiopathic loss
    • infectous causes
    • immuniologic causes
    • anatomic causes
    • genetic factors
    • environmental factors
    • endocrine factors
  5. What is the liklihood of a parental chromosomal problem in RPL
    • 3-8%
    • MC balanced translocation
    • others- sex chromo mosaicism, chromo inversions, ring chromo
  6. What is the contribution of fetal chromo abnormalities to RPL
    70% of spontaneous miscarrages are associated w. fetal chromo abnormality
  7. what is the MC fetal chromo abnormality in 1st trimester miscarrages
    • MC (50% as a group) in order trisomy 16, 22, 21, 15, 14, 18
    • Single MC abnormality is turners 45X (25%)
  8. what specific environmental factors have been linked to RPL
    • tetrachloroethylene (drycleaning)
    • ROH
    • tobacco abuse
    • no longer assoc w. RPL: caffeine, anesthetic gases
  9. what endocrinopathies are associated w. RPL
    • uncontrolled DM
    • thyroid dz
    • PCOS
  10. Explain the concept of luteal phase defect (LPD)
    • inadequate secretin on progesterone from corpus leutum during secretory phase retards the dev of the endmetrial lining
    • the underdev lining is then unable to support a PG and spontaneous abortion results
  11. How is luteal phase defect (LPD) DX
    • endometrial BX near upcoming menses (day 26-27 in a 28 day cycle)- pt notifies Dr. post BX the 1st day of menses (menses = day 28 of cycle)
    • or BX during urine LH surge (day 9-10 POST LH surge)
    • histologically exam- if there is a lag of 2+ days then LPD may be present
    • DX based on two samples from two different cycles
    • alternate quick less invasive DX- measure serial mid-luteal progesterone levels- any level less than 10ng/ml may indicate a luteal insuffiency
  12. How do we TX LPD
    • due to poor folliculogenesis any RX that improves follicular development can help
    • clomphene citrate
    • gonadotropin
    • progesterone in luteal phase PO, vaginal or IM (check mid-luteal levels)
  13. How is RPL related to anatomy
    • Type V anomalies (septate)
    • congenital mullerian anomalies related to DES exposure
    • Asherman syndrome
    • Other intrauterine filling defects (submucous myoma)
  14. Utererine anatomical abnormalities
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  15. What anatomical abnormalities are not related to RPL
    • anomalities involving incomplete mullerian fusin resulting in
    • type II unicornuate
    • Type III didelphys
    • type IV bicornate
  16. How can anatomical defects be detected
    • Gold standard HSG
    • US
    • saline infusion sonography
    • MRI to diff between uterine septum or bicornate
    • hysteroscopy- more invasive
    • laproscopic and hysteroscopy
  17. What is the appropriate course of action to distinguish between a uterine septum and a bicornate uterus
    • If suspected MRI should be performed prior to surgical correction
    • if MRI inconclusive -->laproscopic + operative hysteroscopy
    • A pt should NEVER be scheduled for hysteroscopic septum removal based on HSG findings due to risk of uterus perforation
  18. Describe the surgical procedure for correction of a septate uterus
    • Procedure of choice: hysteroscopic resection w. 1.5% glycine soln as distention medium
    • use continous flow pump during surgery to keep track of fluid balance
    • scissors can be used to cut septum in middle, which will usually retract thus no tissue is removed
    • alternative approach: use cautery to remove the septum from the bases--may risk scarring of the underlying myometrium
  19. What is the post op. management of septate removal
    • small septum: no post op hormone tx
    • otherwise post op estrogen (conjugated estrogen 1.25mg/day x 30 days followed by 10 days overlap w. medroxyprogesterone at the end of the regimen
    • post op untrauterine foley placement is rarely indicated
  20. Why do we have to be very cautious when glycine is used as distention fluid in operative hysteroscopy
    • during operative hysteroscopy glycine may gain access to uterine vasculature when vessels are opened during procedure (submucosal resection of myoma)
    • because distention medium is under pressure glycine readily passes into vasculature which may lead to hyponatremia, hypo-osmolality and HYPERvolemia --> pul. edema, water intoxication and cerebral edema
    • to minimize risks maintain low intrauterine pressure and monitor fluid deficit (total fluid = fluid in + fluid out) by continous flow pump
    • any deficit greater than 500 ml = monitor fluids post op
    • TX glycine overload- diuresis w. furosemide and monitring of vital signs and electrolytes
  21. What microorganisms have been implicated in RPL
    • Suspected orgs
    • Ureaplasma urealyticum
    • listeria monocytogenes
    • Toxoplasma gondii
    • viruses: rubella, herpes, measles, CMV, coxsackie
  22. Do antibx play a role n TX of RPL
    • no routine antibiotics
    • if ureaplasma urealyticum grow tx both partners w. doxycycline 100 mg PO x 14days
  23. What immunologic etiologies have been linked to RPL
    • proven: antiphospholipid antibodies
    • implicated: anticardiolipin ab, lupus anticoagulant, antithyroid, ANA, phosphadityl serine
  24. do thrombophilias affect risk for RPL
    antiphospholipid antimbodies: only truely established link, more likely to have a thrombolytic event.
  25. What lab blood tests can be used to r/o thrombophilic etiologies for RPL
    • consult a hemotlogist
    • order first: aPTT, anticardiolpin ab, ANA, lupus anticoagulant,
    • if neg then oreder; antithrombin III, protein C and S, activated protein C resistence ration, fibrinogen, prothrombin G mutation, thrombin time, factor V leiden mutation, homocysteine level, CBC
  26. TX thrombolic problems associated w. RPL
    • ASA 81 mg and prophylactic doses of heparin (5,000 units BID SQ)
    • give this TX during entire PG-managed by MFM
    • if IVF is to be used- stop ASA and heparin prior to oocyte retrieval
  27. what should be recommended if pts w. RPL cannot naturally acheive PG
    • superovulation agents + IVF or IUI
    • use of donor eggs or sperm
    • adoption
    • serrogate gestational carrier
  28. If suspect RPL what test should be ordered
    • parental and fetal karyotypes
    • cervical cultures for mycoplasma and ureaplasma
    • HSG or saline sonogram
    • TSH, prolactin
    • Mid-luteal progesterone levels
    • endometrial BX
    • autoimmune eval: antiphospholipid ant, ANA, aPTT
Card Set
RES Ch 31
Ch 31 recurrent PG loss