Bleeding at the site of very placenta termed as subchorionic bleed or haematoma: Dont get worried if sonography re[ort mantions so.

–- Subchorionic hemorrhage (SCH). Is it a bad news always?

A woman who visited your chamber yesterday evening looked normal Pregancy though she conceived after 8 yrs of marriage bad had mild hypertension too high to prescribe antihypertensive (not white coat) and both arums exhibited a BP of 138/96 mm. Now exactly 24 hrs after booking visit her father in law comes running at your clinic with the report of USG stating Subchorionic bleeding

Subchorionic hemorrhage (SCH), also called subchorionic hematoma, represents a situation when there is a crescent shaped fluid collection between the chorionic membrane and the decidual. The fluid collection, felt to be blood and serum, is presumably due to a type of placental abruption where the bleeding detaches the trophoblastic tissue from the decidual of the uterine wall. The ultrasound images of acute bleeding are hyperechoic and isochoric to the surrounding rim of the GS and are heterogeneous; however, after 1-2 weeks the SCH typically appears isochoric to the chorionic fluid .The prevalence of this condition may be as low as 1.3% in a general obstetric population  or as high as 39.5% in patients who present with signs and symptoms of threatened abortion . The natural history of this problem is such that 70% of the time SCH resolves by the end of the second trimester.

The various reports in the literature over the past fifteen years are conflicting regarding the sonographic finding of SCH and its clinical significance, especially its relationship to either

To conclude : take home message: Royal College of Obstetricians and Gynecologists (RCOG). The investigation and treatment of couples with recurrent first-trimester and second-trimester miscarriage.
Royal College of Obstetricians and Gynaecologists (RCOG). The investigation and treatment of couples with recurrent first-trimester and second-trimester miscarriage. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2011 Apr. 18 p. (Green-top guideline; no. 17). [124 references]
Guideline Status
this is the current release of the guideline.
This guideline updates a previous version: Royal College of Obstetricians and Gynaecologists (RCOG). The investigation and treatment of couples with recurrent miscarriage. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2003 May. 13 p. (Guideline; no. 17).
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Recurrent miscarriage, specifically:
• Three or more first-trimester miscarriages
• One or more second-trimester miscarriages
Guideline Category
on the investigation and treatment of couples with three or more first-trimester miscarriages or one or more second-trimester miscarriages
Target Population
Evaluation
1. Screening for antiphospholipid antibodies
2. Peripheral blood karyotyping
3. Screening for inherited Thrombophilia
4. Referral to a clinical geneticist
5. Cytogenetic analysis of the products of conception
Management/Treatment
1. Aspirin plus heparin therapy for antiphospholipid antibodies
2. Cervical cerclage (not recommended routinely)
3. Supportive care for women with unexplained recurrent miscarriage
Note: The following interventions were considered but not recommended: progesterone supplementation, human chorionic gonadotrophin supplementation, prepregnancy suppression of high luteinizing hormone (LH), metformin supplementation, steroid treatment, immunotherapy, serial sonographic surveillance, preimplantation genetic screening, uterine septum resection, routine TORCH (toxoplasmosis, other [congenital syphilis and viruses], rubella, cytomegalovirus, and herpes simplex virus) screening.
Major Outcomes Considered
• Miscarriage rate
• Incidence of abnormal parental karyotype
• Healthy live birth rate following miscarriagePrevalence of fetal chromosomal abnormality
• Perinatal survival after ultrasound-indicated cervical cerclage
• Maternal and fetal morbidity and mortality from treatments
Ba
1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias
1– Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2– Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal
3 Non-analytical studies, e.g., case reports, case series
4 Expert opinion
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Rating Scheme for the Strength of the Recommendations
Grades of Recommendations
A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++, and directly applicable to the target population; or
A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results.
B - A body of evidence including studies rated as 2++ directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
following discussion in the Guidelines Committee (GC), each Green-top guideline is formally peering reviewed. At the same time, the draft guideline is published on the Royal College of Obstetricians and Gynaecologists (RCOG) Web site for further peer discussion before final publication.
All comments will be collated by the RCOG and tabulated for consideration by the guideline leads. Each comment will require discussion. Where comments are rejected then justification will need to be made. Following this review, the document will be updated and the GC will then review the revised draft and the table of comments.

Steroids in RPL

Steroid in RPL-its role?? Should we rule out autoimmune diseases in such cases? What test we should order to rule out this condition? In obstinate cases one may possibly use omnacortil in 1st trimester in idiopathic recurrent miuse.seen good results by some colleagues. Steroids Wundt put a possible xx fetus at risk of virilization? One of our pt advised 30 mg omnacortil at Kishanganj medical College,  Bihar with good outcome but one cant attribute it to steroid only unless RCT is done in cases where no cause can’t be substantiated. AS  mentioned earlier  Some people are using immunoglobin bharglobe intramuscular injections weakly or fortnightly
Prior to conception and during first trimester

 In unexplained recurrent miscarriage, supportive care on its own can give good outcomes in up to 70 percent women. The problem with using treatment methods that are unproven is that the woman starts believing that she needs it in all future pregnancies and some of these treatments have not been studied well enough to ensure low risk of harm.

Costly tests for Recurrent early preg loss

What is seronegative aplA(anti phospholipid antibody) ?? What other costlier tests??   Tests that have to be done in view of RPL :( evidenced based in cases of RPL-(i.e. tests which are worth spending) are 1) Screening for antiphospholipid antibodies
2. Peripheral blood karyotyping
3. Screening for inherited Thrombophilia, (one should remember that APLA panel include following parameters e.g.  B2glycoprotein-drVVT, dry Vat
Lupus anticoagulant ( apt, DRW screen ) ,ACA ( Anti cardiolipin ab)  (Ig &IgM ab)-Negative means the legal is < 10 GPL units /ml But if persistently the leabel is high to 40 GPL that has a real significance.
Cardiolipin antibody,=IgM ab (ACA):- may also cause IUFD, RPLm Unexplained subfertility, )
4. Referral to a clinical geneticist
5. Cytogenetic analysis of the products of conception, Foetal/POC chromosome   & Paternal chromosome=any translocations??  6) Tests for APL, One may ask what step to be adopted if only DRVTT positive? I feel that under such circumstances one should be give LMWH and (LDA).  May proceed for tests for secondary APLA or other autoimmune probality ( ANF, anti-ds DNA antibody  ,  or inherited thrombophilia unless one  work up completely we will not know or 80 percent of times we  may get negative results . Simplest trial is preconception folic with Vit B 12 and ecosprin with UPT positive itself start heparin may b diff in such cases to reach ideal time to start heparin. There is an entity called seronegative aplA.

Class 3 tests (contd):-Not evidence based tests for RPL but people quite often in insist on such, possibly meaningless, clinically irrelevant tests? Therefore such tests are optional :- 1) serum homocysteine (normal level is 6-14 µmol/Lit, , Serum Vit D & B12 level, 2) Anti-mitochondrial ab & Anti Neutrophil cytoplasmic ab(ANCA) , Anti smooth ms ab  

3) To relentlessly search for Chr. Nonspecific infn of uterus –Chlamydial screening,  Mycoplasma culture,, Brucellosis, CMV screening, 4) Sperm-for polyspermia( per sperm less DNA share à resulting into  Post implantation disorders),

5) Class 3 tests (contd):-Not evidence based tests for RPL but people quite often in insist on such,  Tests for hypercoagulability-like less Protein C,(normal range of Pro C is 70-130 %of normal biological range- and Pro C is a cofactor for proteins, But this  range will be altered while someone is on Heparin  Ry ) ::

 Protein-S deficiency (these two proteins C & S - are natural anticoagulants) –Normal value of Protein S is 55-122%of biological value   & raised ANTITHROMBIN III,

 5) Class 3 tests (contd):-Not evidence based tests for RPL but people quite often in insist on such,  T Hysteroscopy for synechiae, anatomical defects of ut e.g. - small septum, polyp, slight duplications of ut, unicornate ut. Hysteroscopy also help us to rule out Koch's 6) Any subtle Endocrinopathy: - –autoimmune thyroiditis, PCOS women with androgen excess milieu, Poor Ov reserve (AFC, AMH), ERA tests-poor endomeruial receptivity. Etc. 

C)  What are the treatment modalities which are not agreed upon by most Int authorities?? Such Treatments which, as I mentioned are   less evidence based though, admittedly many advocate such procedures (not talking if tests):- cervical cerclage may be associated with a high risk of minor morbidity but no serious morbidity.
• Heparin can be associated with maternal complications including bleeding, hypersensitivity reactions, and heparin-induced thrombocytopenia and, when used long term, osteopenia and vertebral fractures. Two prospective studies have shown that the loss of bone mineral density at the lumbar spine associated with low-dose long-term heparin therapy is similar to that which occurs physiologically during normal.

How best to treat a case of Recurrent eraly abortion??

What other investigations?? ATA, .Homocysteine...AMA, ANA consider hysteroscopy workup can be done.  Uterine septum is one of the main causes of RPL. karyotypic of conceptus is debatable.  Due to that septum, there is no vascular supply n due to that embryo grows only up to 6-8 wk n then abortedà .so go for hysteroscopy also!!!

 Uterine septum is one of the main cause of RPL. Due to that septum ,there is no vascular supply n due to that embryo grows only upto 6-8 wk n then aborted. so go for hysteroscopy also!!! Many prefer starting prophylactic LMW heparin in these  patients, Some use Inj Bharglob as well (causes production of immunoglobulin in body)/  LMW heparin LMW Heparin to start after confirmation of intrauterine pregnancy by USG

. Empirical heparin with good progesterone support.One can rarely try DHEA 75 mg for 3 month n then plan for conceive

 1 mg /kg body weight of Enoxaparin, till 38 weeks of gestation

If  Apla is normal LMW heparin may not work but can be tried, Put her on L-methyl folate instead of Folic acid at least a month prior to planning conception and on confirmation of pregnancy try immunoglobulin- Bharglob 16,5% 1 ml. 2 inj at 21 days interval.

. Any environmental/ food ./ domestic pollutant-passive smoking , &  professional pollutant affecting may affect spermatozonesis/oogenesis.

Investigations of Recurrent Early Pregnancy loss -How best to minimize cost of investigations??

  History: - What about her nutrition, any F/H/O of Koch’s? Explore family tree for genetic diseases, Life style disease /habit of either partner.

 Low cost initial tests if not done elsewhere:-Caution: Not to Rpt Lab tests except possibly ICT, APL, and gene disorders.  Koch’s:-Common Tests”- In addition suggestions made by some forum members, may carry out Complete haemogram, Thalassaemia screening, Viral screening, Metabolic screen (HBA1C & PPBS)  & endocrine screen( TSH, PRL, Total testosterone) Thrombophilias Screening, AMH-an indirect way of assessing quality of oocyte, both partner Karyotyping, APLA, Tests for SLE ,Urine RE C/S, H semen analysis & Bacteriological screening of semen  Pap.

Uncommon Tests: - AMA, ANA. Hystero-Laparoscopy-Minimal endometriosis & septal diseases of uterus.

Psycho-immunology in the treatment of RSA is an emerging subject. Support of the family members & relatives/ friends .But in the days of consumers many doctors are hesitant to assure the couple “All is well, Next time such unfortunate event will not occur. I am with you. God is going to bless you this time.”

Summary:-Above all, uterine malformations, endocrine disorders and advanced age of any one partner are the usual causes of  may read RCOG green top guideline no. 17 (issued on April, 2011). In about 50% cases the etiology remains unexplored. But in such situation, I do prescribe, albeit imperially a course of antibiotics for pelvic . Infection like doxycycline & Azithromycin.

How to proceed to establish a cause for recurrent early pregnancy losses??

Tips to young PGs only:-How to precede in a case of recurrent Early Pregnancy losses: Tips -Suppose a couple has come to you who had faced three or even two consecutive early Pregnancy loss. That is your first day of private practice and U have duly qualified MD , DNB in firs attempt. Convocation is due . How you will proceed with a such case of RPL .You are full, move knowledge  but possibly not wisdom particularly about the financial commitment and grief counseling. Knowledge is more than absorbing facts, Information’s àKnowledge-> Wisdom it is acquiring understanding.