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7/27/2019 Pregnancy Loss Prevention
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Preventive medicine inobstetrics regarding
pregnancy loss
Dr. Mohammed Abdalla
Domiat general hospital
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Can Pregnancy
complications such as Recurrent abortion,
Preterm labour,
Still birth,
Preeclampsia.
be prevented
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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.
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Maternal risk assessment
Maternal risk
assessment can befirstly identified from
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Recurrentpregnancy
loss is not just a BadLuck and must be
investigated .
Maternal risk assessment
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But on other hand
some conditions needno recurrence to be
alarming, and to beinvestigated.
Maternal risk assessment
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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
?
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The initial attempts to predict
preterm delivery in
asymptomatic patients
involved the use of
risk factor assessment.
Maternal risk assessment
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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
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The diagnosis is usually
based on a history oflate miscarriage,
preceded byspontaneous rupture ofmembranes or painless
cervical dilatation.
Risk Factors for Preterm
Birth
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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
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Etiologic view
of pregnancy
lossafter 10wk
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pregnancy loss after 10wk
one pregnancy loss more than
10wk. Gestation or pregnancy
associated with late adverseoutcome
need no recurrenceto be investigated.
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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%
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How much is thrombophilia
common among generalpopulation
pregnancy loss after 10wk
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Inherited thrombophilia
00.5
1
1.5
2
2.53
3.5
4
4.5
5
FVL
MTFRD
Proth.G
PCD
PSD
ATIII
%population
%
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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
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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
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A meta analysis published in
LANCET 15 march 2003included 31 studies
published between 1975 and
2002 (by Medline search).
thrombophilia and fetal loss
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Relative risk is quantified by odd ratio
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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
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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
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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
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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
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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
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Women with recurrent
pregnancy loss and a
uterine septum should
undergo hysteroscopic
evaluation and resection.
(ACOG) grade C
Top guidelinesTop guidelines
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There is no clearfirst-line tocolytic
drugs to managepreterm labor.
(ACOG) grade A
Top guidelinesTop guidelines
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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
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If a tocolytic drug isused, Atosiban ornifedipine appear
preferable as theyhave fewer adverse
effects and seem tohave comparable
effectiveness.
(RCOG) A
Top guidelinesTop guidelines
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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
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(TORCH and herpes simplex
virus)
screening isunhelpful in the
investigation ofrecurrent
miscarriage
Top guidelinesTop guidelines
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In all couples with a
history of recurrentmiscarriage
cytogenetic analysisof the products of
conception should beperformed if the next
pregnancy fails.
Top guidelinesTop guidelines
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There isinsufficient
evidence toevaluate the
effect of(hCG) inpregnancy to
prevent
Top guidelinesTop guidelines
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There is insufficientevidence to evaluate
the effect of
progesteronesupplementation in
pregnancy toprevent a
miscarriage.
Top guidelinesTop guidelines
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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
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Pregnanciesassociated with
aPL treated withaspirin and
heparin remain athigh risk of
complications
Top guidelinesTop guidelines
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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
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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
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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
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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
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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
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Assessment of maternal
risk and prediction ofrisk factors is the gate
for prevention of
adverse pregnancyoutcomes.
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