Treatment and outcome of

anatomical factors for

abortions

Dr Rajesh Gajbhiye

Consultant Gynecologist & Laparoscopic Surgeon

Anatomical Factors

15% of women evaluated for RPL

Congenital or acquired.

Infertility, preterm labor, and abnormal

presentation.

Amenable to surgical correction.

Mullerian anomalies

Septate uterus

Absent or incomplete resorption of the

intervening uterovaginal septum

following fusion of the müllerian ducts.

Most common congenital anomaly of

the uterus, comprising approximately

55% of all anomalies.

A septum is partial or complete.

Septate Uterus

Spontaneous abortion rate is high,

averaging approximately 65% .

Raga et al reported a 25.5% incidence

of early miscarriage (< 13 weeks) and

a 6.2% incidence of late miscarriage

(14 to 22 weeks) in women with

septate uterus

Transabdominal metroplasty has been

abandoned because of the higher risk

of complications, including

postoperative reduction of intrauterine

volume, formation of intrauterine and

pelvic adhesions, and tubal occlusion.

Hysteroscopic

septal incision

The technique

Hysteroscopic

septal incision can

be performed using

microscissors,

electrosurgery, or

fiberoptic laser

energy.

Reproductive outcomes are improved after hysteroscopic resection.

Fedele et al evaluated the reproductive outcome after hysteroscopic metroplasty in 31 women with infertility and 71 women with miscarriage, and reported a cumulative pregnancy rate of 89% at 36 months for patients with complete septum and 80% for those with partial septum

Homer et al showed a dramatic

decrease in the overall miscarriage

rate from 88% to approximately 15%

after surgery.

Laparoscopic guidance frequently is

used during hysteroscopic metroplasty

to reduce the risk of uterine

perforation.

IUD insertion for 3 months with

estrogenisation is only recommended

for complete or wide septa.

Bicornuate uterus

This anomaly is a result of incomplete

fusion of the uterine horns at the level

of the fundus. The distinguishing

aspect of this anomaly is the presence

of two separate but communicating

endometrial cavities and

a single cervix.

Overall, the spontaneous abortion rate

is approximately 32%,

The premature birth rate is

approximately 21%,

The fetal survival rate is approximately

60%.

Strassman metroplasty is most often

reserved for selected patients with

RPL or premature births.

Despite controversy about its

role, there is good evidence that live

birth rates following abdominal

metroplasty improved from 3.7% to

80%.

Unicornuate ut

Spontaneous abortion rates in these

women approach 31%, premature

birth rates approach 15%, and fetal

survival is estimated at 39%.

Other pregnancy complications

include malpresentation, IUGR,

uterine rupture, and ectopic

pregnancies

Current available evidence, women

with a unicornuate uterus and no

previous history of second-trimester

loss or premature birth should be

managed expectantly with frequent

assessment of cervical length and

anatomy.

Acquired Uterine anomalies

Intrauterine Adhesions

Intrauterine trauma resulting from

vigorous endometrial curettage

After multiple myomectomy,septum

resection.

Associated with RPL.

The severity of adhesions may range

from minimal to complete

The reproductive outcomes

of women with Asherman syndrome.

are generally poor. In the absence of

treatment, approximately 40% of

pregnancies in these women appear

to end in spontaneous abortion and

another 23% result in preterm

deliveries.

Blind D&C should not be employed

instead hysteroscopic adesiolysis

should be done.

ESGE Grade 3&4 require

electrosurgical adhesiolysis and

pregnancy rates are 20-40%

Post op IUD and estrogen is

adminsitered after electrosurgical

adhesiolysis.

Complication rates are also high

Hysteroscopic myomectomy has been

used to treat women with submucous

fibroids, infertility, and RPL.

Surgery should be adviced in patients

of RPL in which abortuses were

phenotypically normal with viability

upto 9 wks

Women with repetitive second TM

The pregnancy rates after -17-77%

with mean of 45%.

Cervical insufficiency

Cervical Incompetance is now

correctly termed as Cervical

Insufficiency.

It is primarily a clinical diagnosis by

recurrent painless dilatation and

spontaneous midtrimester loss.

It is a component of larger and more

complex preterm birth syndrome.

Diagnosis of Cervical

insufficiency during any

pregnancy.

Cervical insufficiency is defined by TVU cervical length <25 mm and/or advanced cervical changes on physical examination before 24 weeks of gestation in women with either:

One or morepriorpregnancy losses/births at 14 to 36 weeks, and/or

•Other significant risk factors for cervical insufficiency.

History-indicated cerclage

For women with two or more

consecutive prior second trimester

pregnancy losses or three or more

early preterm births

Who have risk factors for cervical

insufficiency and in whom other

causes of preterm birth have been

excluded.

USG indicated cerclage

For women with suspected cervical

insufficiency and prior early preterm

birth who do not meet criteria for

history-indicated cerclage,

sonographic surveillance should be

started early in pregnancy (eg, 14 to

16 weeks). cerclage for women who

develop a short cervix (<25 mm)

before 24 weeks

Physical exam-indicated

cerclage Also called “rescue cerclage” or

“emergency cerclage.

Placement of a physical exam-

indicated cerclage when a dilated

cervix and visible membranes are

detected on digital examination at <24

wks.

Small RCT have shown prolongation

of pregnancy by 4 wks

Even upto 4cm dilatation.

Macdonald and Shirodkars claiming

success rate 80-90%.

It reinforces the internal os with non

absorbable tape or suture.

In proven case prophylactic cerclage

to be done at 14 wks or 2 weeks

before the prior loss as early as 10

weeks

Contraindications

Intrauterine infections

Ruptured membranes

H/O vaginal bleeding

Uterine irritability

Cervical dilatation >4cm

Complications

Cut through of ligature

Rupture of membranes

abortion?/Preterm labour

Cervical lacerations during delivery

Cervical dystocia.

Cervical insufficiency

Shirodkar cerclage

Technically difficult

Difficult to remove suture

Modified shirodkar

Csapi at el Modification

of Shirodkar

Dr Sardesai from solapur

had used this technique

in 25 cases where there

was deep cervical

lacerations, failed

Macdonald and short

cervix. and 87% pt had

full term delivery 8%

abortion

4-5 Bites as high in the

cervix

Mersiline

Tape,Silk,Prolene

Knot tied anteriorly

Removal at 37 weeks or

if goes in labour.

Abdominal cerclage

Hypoplastic cervix, H/O

large cervical conisation

or prior failed

vaginalcerclage

Done 11-13 weeks

Merselene tape is used

at level of isthumus

LSCS is done

If preterm post colpotomy

to cut the tape.

Ludmir

Can be done in non

pregnant state

Disadvantage is inability

to conceive.

Vaginally with USG

guidence

And putting suture in

criss cross fashion.

Alternative treatment include bed rest,

Pharmacological treatment and

Pessary.

Randomised studies are needed for

their evaluation.

Conclusion

Abortion occuring after USG

confirmation of a viable pregnancy at

8-9 weeks may be more attributable to

uterine fusion defects.

Women with second trimester abortion

could benefit from uterine

reconstruction but it is not advised if

losses are restricted to first trimester.

Operative hysteroscopy like septal

resection,myoma

resection,adhesiolysis

Improves the pregnancy outcome

Women with history of previous

painless and spontaneous

midtrimester losses,or previous

preterm birth who then develop short

midtrimester cervical length have a

treatable component of cervical

insufficiency and surgical intervention

in the form of cerclage to be done.

Candidates for ultrasound surveillance and possible ultrasound indicated cerclage —The majority of women with suspected cervical insufficiency do not meet the above criteria for history-indicated cerclage. For these women, we usually initiate TVU cervical length screening (table 2), administer 17-alpha-hydroxyprogesterone caproate prophylaxis, and apply a cerclage if cervical length decreases to <25 mm [27]. The rationale for this approach is:

●Women with a short cervix on transvaginal ultrasound examination are at increased risk of spontaneous preterm birth [28].

•In women with a history of spontaneous preterm birth, a systematic review of controlled studies showed that measurement of cervical length in the second trimester, especially before 24 weeks, predicted the risk of recurrent preterm birth [28]. The use of a TVU cervical length <25 mm at <24 weeks to predict preterm birth at <35 weeks yielded sensitivity of 65.4 percent, specificity of 75.5 percent, positive predictive value of 33.0 percent, and negative predictive value of 92.0 percent. The shorter the cervical length, the higher the positive likelihood ratio for spontaneous preterm birth <35 weeks.

●In randomized trials, progesterone prophylaxis with 17 alpha hydroxy-progesterone caproatestarting at 16 to 20 weeks in women with a history of spontaneous preterm birth and continuing until 36 weeks reduced the risk of recurrent preterm birth [24,25]. (See "Progesterone supplementation to reduce the risk of spontaneous preterm birth".)

●Placement of cerclage upon identification of a short cervix (“ultrasound-indicated cerclage”) is effective in reducing preterm birth [29], results in pregnancy outcomes comparable to those with history-indicated cerclage [30], and avoids cerclage in about 60 percent of patients with a suggestive history [30]. The benefit of ultrasound-indicated cerclage may derive from bolstering cervical strength [31], preventing membranes from being exposed, and retention of the mucus plug.

We usually initiate cervical length

screening at 14 weeks, but may screen as

early as 12 weeks in women with early

second trimester losses, recurrent second

trimester losses, or prior large cold knife

conization (table 2) [32]. In women with

prior preterm birth at 28 to 36 weeks, we

initiate screening at 16 weeks. Ultrasound

examination is generally repeated every

two weeks until 24 weeks as long as the

cervical length is ≥30 mm, and increased

to weekly if cervical length is 25 to 29 mm,

with the expectation that preterm cervical

changes will precede overt preterm labor

or membrane rupture symptoms by three

to six weeks [33]. Transvaginal ultrasound

screening is usually discontinued at 24

weeks of gestation, as cerclage is not

usually performed after this time.

Overall, the prevalence of major

congenital anomalies appears to be

three-fold higher in women with RPL

compared with women without a

history of recurrent miscarriage.

Reduced intraluminal volume and/or inadequate vascular supply to the developing fetus and placenta.

There are no surgical procedures to enlarge the uterus.

The higher prevalence of cervical incompetence in uterine anomalies, however, has led some authors to recommend that cervical cerclage be placed to improve obstetrical outcome.

Methods of hysteroscopic

myomectomy

Unipolar resection with loop electrode

Bipolar resectoscope technique using

NS

Vaporising electrodes

Hysteroscopic Morcellators.