it all about practical approach to unexplained recurrent miscarriage

1. Unexplained Recurrent
Miscarriage (RPL):
A Practicle approach:
Dr Iftikhar Sadique…

2. Incidence
• Single Pregnancy Loss:
• Fairly commone: 15 to 25%
• Recurrent Pregnancy Loss (RPL)
• Fairly Uncommon:
• Two Miscarriages: 5%
• Three Miscarriages: 1%
The Practice Committee of the American Society for Reproductive Medicine
Fertility and Sterility® Vol. 98, No. 5, November 2012 0015-0282/$36.00
Recurrent Pregnancy Loss

3. • After 2 miscarriages: 17% to 25%
• After 3 miscarriages: 25% to 46%
• Worsens with advancing age
• Higher in subfertile groups
Risk of RPL
J Hum Reprod Sci. 2014 Jul-Sep; 7(3): 159–169.

4. • Two or More consecutive pregnancy
losses….Documented
• 29% Reported miscarriages are not
verifiable
Definition
The Practice Committee of the American Society for Reproductive Medicine
Fertility and Sterility® Vol. 98, No. 5, November 2012 0015-0282

5. • Identifiable Causes:
•50%
• Unknown Causes:
•50%
The Practice Committee of the American Society for Reproductive Medicine
Fertility and Sterility® Vol. 98, No. 5, November 2012 0015-0282/$36.00
Causes of RPL

6. • Cytogenetic Causes
• aPL (antiphospholipid syndrome)
• Inherited thrombophilia
• Anatomic
• Hormonal or Metabolic ( LH , PCO, )
• Infections
• Male factor
• Psychological
• Alloimmune
J Hum Reprod Sci. 2014 Jul-Sep; 7(3): 159–169.
Known causes :

7. • Comprehensive Hormonal Status
• Paternal and Maternal Karyotyping
• Cervical swabs for chlamydia,
ureaplasma,mycoplasma
• Evaluation of Antiphospholipid syndrome
• Evaluation of Hereditary Thrombophilia
• Hysteroscopy
Standard workup

8. • 40% to 60% are found to have
none of these pathologies
Unexplained RPL (URPL)

9. • Chances of successful pregnancy
outcome after 3 consecutive miscarriage 75%
• 78% miscarriages are between 6 – 8 weeks
• 89% miscarriage are before appearance of cardiac activity
• Incidence of miscarriage > 8 weeks 2%
• Incidence of miscarriage > 10 weeks 0.2 %
• Chances of survival after +FCA >98%
• In recurrent miscarriage group after +FCA 78%
Human Reproduction: vol 14 no 11 pp 2868- 2871, 1999
Important facts about URPL

10. • Aspirin
• Debateable..
• Few RCT suggest role.
• Helps improve uterine flow
• Steroids
• There is no robust evidence in favour.
• 90% live birth rate achieved in one trial of 277
patients in combination with Aspirin
Réznikoff-Etievant MF, Cayol V, Zou GM, Abuaf N, Robert A, Johanet C, et al. Habitual abortions in 678
healthy patients: investigation and prevention. Hum Reprod 1999;14(8):2106 –9.
Possible therapies

11. • Progesterone
• Meta analysis of 4 RCT have shown statistically significant
reduction in miscarriage.
• hCG
• No evidence in support.. Use not recommended
• LMWH
• Only recommended in Antiphospholipid syndrome
• Immunoglobulins
• No Evidence in support. Not recommended.
• Tender Loving Care
• 75% increase in survival rate
J Hum Reprod Sci. 2014 Jul-Sep; 7(3): 159–169.
Possible therapies

12. • University of Vienna, Austria
• 210 women with RPL (3 RPL before 15 weeks)
• Standard investigations performed
• 80 diagnosed as Unexplained RPL
• Combination Treatment given:
1. Prednisolone 20mg/day upto 12 weeks
2. Progesterone 20 mg / day upto 12 weeks
3. Aspirin 100 mg /day upto 38 weeks
4. Folic acid 5 mg/day through out
Matched – pair study
Clemens B. Tempfer, Christine Kurz, et al.
Fertility and Sterility Vol. 86, No. 1, July 2006 145 to 148

13. Category Control Treated
Live Birth rate 35% 77%
1st trimester miscarriage 63% 19%
2nd trimester miscarriage 2% 0%
Results

14. • 37 years old female, resident of Gojra, Punjab presented
with history of 30 consecutive miscarriages. Out of these
23 documented and 17 were followed by D and Cs.
• Labs and Karyotyping were normal
• Treatment give and 31st pregnancy was carried on to 34
weeks of gestation.
• Emergency C/Section was done at 34 weeks for sevre
PIH.
• Conceived again 32nd time but didn’t take treatment.
Pregnancy ended in Miscarriage.
• 33rd time took treatment again and reached term.
Case Study

15. Thank you