RPL (Recurrent Pregancy Loss)

  34 year Pt presented with BOH 1st was preterm delivery at 30 wk abnormal baby with TOF ::2nd was missed abortion at 12 wk & 3rd was again missed at 8 wk well investigated for BOH without any neg report she wants to plan her pregnancy again . Please expert advice for management

Top of Form

 

 Honestly speaking even after many tests aiming at etiological diagnosis many a case of such recurrent pregnancy loss-sadly no aetiology can’t be ascertained(about 50%)

. However following tests may be offered to the couple.
However following tests may be offered to the couple.
In the woman:-1) Acqd Thrombophilia,(Level 1+evidence), 2) Inherited Thrombophilia(Level 2+). 3) Anatomic defects of Uterus( Level ¾) as rightly mentioned 4) Infective cause (level -3), 5) Endocrine Disorders (Level-3) .including PCOS and Low Ov reserve ; 5) Chromosomal aberration of Developing Embryo (level 4) Environmental Pollutants. 6) Psychological cause is considered one of the imp. Etiologic factor-TLC concept”-Psych-Neuro-Endocrinology “ in continuation of Preg. 7) Impaired expression of HLA antigens. 8) Hcst.(homocysteine).
• 2) Causes in the Male: - Chromosomal Defects / Deletion disorders in genes, 2) Pollutants & Drug abuse-Life style disorders-Smoking etc.
•  Cryofreeze-Selection of best embryo/ Delayed transfer  3) Combined defect in both partner: - STI-infective cause. Hysteroscopy, May suggest ART
•  Cryofreeze-Selection of best embryo/ Delayed transfer 

3) Combined defect in both partner: - STI-infective cause. Hysteroscopy, May suggest ART

 1. History:- Geneticist opinion of –both partners ,Smoking, Alcohol intake, & other Addictions , Environmental pollutants including Workplace toxins, Regular ingestion of teratogens for some systemic diseases including drugs for depression & Psychiatric diseases Diabetes mellitus, Hypothyroidism,etc.. , Abnormal sperm morphology, Food habits,

 An aberrant immune response – either auto- or alloimmune – has been postulated to underlie some cases of ‘unexplained’ infertility, in vitro fertilisation (IVF) failure and recurrent miscarriage. Despite a paucity of evidence, a variety of immune tests and treatments for reproductive failure have been introduced into clinical practice.

 Sadly, in some cases the etiology even if diagnosed are not always modifiable-!! Such unfortunate causes of preg loss are genetic, emotional, endocrinological, anatomic (partly modifiable) most importantly, immunologic causes !!

 

 

 

 Rationality of Investigation?? Benefit & loss balance sheet: What will happen if one does not investigate this particular unfortunate couple at all!!! The logic behind not investigating is that in as many cases >50% of similar cases - no etiology coul...See

 • Then what shall we do the practicing obstetrician?? What is then Standard (?) “Recurrent Preg Loss work up”:-triaging is, therefore important. ). Low cost investigations should be initiated as the first step and immunological tests and tests for coagulation to be deferred initially. Additionally, to avoid stress reduction (Yoga, exercise), control of Obesity & Hyperandrogenism if there be any. .

 • Step 2:-Most people prescribe progesterone supplement after LH surge is detected and continuing for 8-10 weeks after LH surge. LDA from preconceptionaly and after UFH after the cardiac activities are demonstrated.
• one should ideally(?) combine LDA with UFH (better than LMWH) at the dosage of 5000-10,000 better 12 hourly depending on the body weight and titre and any past H/O of VTE if there be any. Some prefer to initiate heparin as soon as UPT is +ve. Others initiate after demonstration of cardiac activity