Preventive medicine in obstetrics regarding pregnancy loss

Dr. Mohammed Abdalla Domiat general hospital

Can Pregnancy complications such as Recurrent abortion, Preterm labour, Still birth, Preeclampsia. be prevented

In the past the obstetrical art focused mainly on how to deal with complications . but now by the remarkable advance in modern obstetrics ,immunology, and hematology, the goal is

how to prevent them.

Maternal risk assessment

Maternal risk assessment can be firstly identified from

Maternal risk assessment

Recurrent pregnancy loss is not just a Bad Luck and must be investigated .

Maternal risk assessment

But on other hand some conditions need no recurrence to be alarming, and to be investigated.

one unexplained fetal deaths after ten weeks of pregnancy one preeclampsia or placental insufficiencies occurring before 34 weeks One previous preterm birth one or more confirmed
episodes of venous or arterial thrombosis.

any of these must invite a big question mark

Maternal risk assessment The initial attempts to predict preterm delivery in asymptomatic patients involved the use of risk factor assessment.

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

Risk Factors for Preterm Birth

The diagnosis is usually based on a history of late miscarriage, preceded by spontaneous rupture of membranes or painless cervical dilatation.

Risk Factors for Preterm Birth

The diagnosis of Uterine Anomalies is usually found on a HSG . Differentiation between the uterine septum and the bicornuate uterus cannot be made with the HSG alone but Further evaluation of the fundal contour must be done with laparascopy, MRI, or US as therapy is very different.

Etiologic view of pregnancy loss after 10wk

pregnancy loss after 10wk

one pregnancy loss more than 10wk. Gestation or pregnancy associated with late adverse outcome

need no recurrence to be investigated.

pregnancy loss after 10wk

100.00 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00
95%

preg.loss

3%

2%

0.5%

ca l

m pr e ter

im mu no

ch ro mo so ma l

l og ica

an at om i

pregnancy loss after 10wk

How much is thrombophilia common among general population

Inherited thrombophilia %
5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

%population

MTFRD

Proth.G

PSD

ATIII

PCD

FVL

thrombophilia and fetal loss Recent case-control studies and meta analyses attempted to quantify the risks associated with different thrombophilic defects and adverse clinical events in pregnancy,

thrombophilia and fetal loss

Severe preeclampsia Antithrombin deficiency Protein S deficiency Protein C deficiency APC resistance Factor V Leiden MTHFR C677T Hyperhomocysteinemia Factor II G 20210A Antiphospholipid syndrome Combined defects
++ + ++ ++ ++ ++ ++ ++ ++ ++ ++ ++ ++

IUGR

Placental abruption
++ ++ ++ ++ ++ ++ + ++ ++ ++ ++ + ++

thrombophilia and fetal loss A meta analysis published in

LANCET 15 march 2003

included 31 studies published between 1975 and 2002 (by Medline search).

Relative risk is quantified by odd ratio

thrombophilia and fetal loss Odd ratio

3.5 3 2.5 2 1.5 1 0.5 0 FVLG mutation
16 14 12 10
early RL late non RL

Odd ratio 4
3.5 3 2.5
early RFL lare non RL

2 1.5 1 0.5 0 APCR

early R loss

2.6 2.55 2.5 2.45 2.4 2.35 2.3 2.25 2.2 2.15

8 6 4 2 0

recurrent early loss late non recurrent loss

prothromb.GM

PSD

thrombophilia and fetal loss Odd ratio

18 16 14 12 10 8 6 4 2 0 combined factor early recurrent loss late non recurrent loss

Top guidelines to prevent recurrent pregnancy loss and adverse pregnancy outcomes

Top guidelines

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 guidelines

By Transvaginal ultrasound

cervical length > 3 cm. after 24 weeks has a high negative predictive value .
to avoid unnecessary interventions. (II-2 B)

Top guidelines

Women with recurrent pregnancy loss and a uterine septum should undergo hysteroscopic evaluation and resection. (ACOG) grade C

Top guidelines

There is no clear first-line tocolytic drugs to manage preterm labor.

(ACOG) grade A

Top guidelines

Neither maintenance treatment with tocolytic drugs nor repeated acute tocolysis improve perinatal outcome but just prolong pregnancy for 2-7 days giving time for steroids.

(ACOG) grade A

Top guidelines

If a tocolytic drug is used, Atosiban or nifedipine appear preferable as they have fewer adverse effects and seem to have comparable (RCOG) A effectiveness.

Top guidelines

Screening for and treatment of bacterial vaginosis in early pregnancy among high risk women with a previous history of secondtrimester miscarriage or spontaneous preterm labour may reduce the risk of recurrent late loss and (RCOG) A preterm birth.

Top guidelines

(TORCH and herpes simplex virus)

screening is unhelpful in the investigation of recurrent miscarriage.

Top guidelines

In all couples with a history of recurrent miscarriage cytogenetic analysis of the products of conception should be performed if the next pregnancy fails.

Top guidelines

There is insufficient evidence to evaluate the effect of (hCG) in pregnancy to prevent

Top guidelines

There is insufficient evidence to evaluate the effect of progesterone supplementation in pregnancy to prevent a miscarriage.

Top guidelines

In women with a history of recurrent miscarriage and APL, the future live birth rate is markedly improved when a combination therapy of aspirin plus heparin is prescribed.

Top guidelines

Pregnancies associated with aPL treated with aspirin and heparin remain at high risk of complications

Top guidelines

Currently there is no reliable evidence to show that steroids improve the live birth rate of women with recurrent miscarriage associated with aPL. their use may provoke significant maternal and

Top guidelines

If a diagnosis of luteal phase defect is sought in a woman with recurrent pregnancy loss, it should be confirmed by endometrial biopsy.
ACOG (B)

Top guidelines

low-dose aspirin, have smallmoderate benefits when used for prevention of pre-eclampsia. Further information is required to assess which women are most likely to benefit, when treatment is best started, and at what dose.
Cochrane Review 2005

Top guidelines

Antiplatelet therapy ( low dose aspirin) reduces the risk of preeclampsia by around 15% for women at low or high risk . RCOG(B)

Top guidelines

The combination of aspirin and heparin is effective in recurrent fetal loss in APS and could be considered for women with

and history of severe preeclampsia, IUGR, abruptio placentae or fetal loss, although no controlled studies on the subject are currently available
Cochrane Review 2003

inherited thrombophilias

Assessment of maternal risk and prediction of risk factors is the gate for prevention of adverse pregnancy outcomes.