Early pregnancy complication - Recurrent miscarriage & Gestational Trophoblastic Disease

Question 1

What is the definition of recurrent miscarriage?

Answer 1

3+ 1st timester miscarriage

Question 2

How common is recurrent miscarriage?

Answer 2

1% women

Question 3

What is the greatest RF for recurrent miscarriage?

And other RF?

Answer 3

Maternal Age

Paternal age, N previous misc , black ethic BG, smoking, excision ETOH or caffeine, BMI <19 >25, antiphospholpoid, anatomical, endocrine (DM, thyroid, PCOS)

Question 4

Rates of miscarriage
12-19
20-24
25-29
30-34
35-39
40-44
45+

Answer 4

12–19 years = 13%;
20–24 years = 11%;
25–29 years = 12%;
30–34 years = 15%;
35–39 years = 25%;
40–44 years = 51%;
45 + = 93%.

Question 5

Rates of miscarriage
1 previous
2 previous
3 previous
4 previous
5 previous
6 previous

Answer 5

1 previous 11%
2 previous 17%
3 previous 28%
4 previous 40%
5 previous 47%
6 previous 64%

Question 6

What % of women with recurrent miscarriage have antiphospholipid syndrome?

Answer 6

15%

Question 7

Which antiphopholispid antibodies are tested?

Answer 7

Lupus anticaogulant
Anticardiolipin antibodies
Anti B2 glycoprotein 1 antibody

2+ve test 12 weeks apart

Question 8

What other features should be present other than the antibodies to Dx aPL syndrome?

Answer 8

Adverse pregnancy outcomes
- 3+ miscarriage <10/40
- 1+ morphologically normal loss >10/40
- 1+ preterm birth <34/40 due to placental disease

or

vascular thrombosis

Question 9

What other Ix should be completed for recurrent misc?

Answer 9

• aPL antibodies
• Cytogenetics on POC
  If POC shows unbalanced structural chromosomal abnormlairt → parental peripheral blood karyotype both parents
• Pelvis USS, if suspect uterine abnormality consider hsyteroscopy/Lap

Question 10

If 2nd trimester miscarriage, what else should be tested for?

Answer 10

If 2nd trimInherited thrombophilias, factor V leiden, prothrombin gene mutation or protein S deficiency

Question 11

What is the most common cause of sporadic and recurrent miscarriage?

Answer 11

Chromosomal abnormality
For sporadic 50% CA, most common trisomy 52%

Question 12

In recurrent miscarriage which is the most common type of chromosomal abnormality?

Answer 12

Aneuploidy 40%

Question 13

After 3 recurrent miscarriages, what % of 1 or both couples have a balanced translocation?

Answer 13

3-5%

Question 14

What the chances of parents with a balanced translocation having a health child?

Answer 14

83%

Lower if reciprocal translocation (54%), robertsonain (34%)

Question 15

If antiphospholipid syndrome, what is the Tx?

Answer 15

Aspirin and LMWH

Question 16

What can be offered to women who have had a 2nd trimester miscarriage and suspected cervical weakness?

Answer 16

Cervical USS, if <25mm can offer cerlclage

Question 17

Women with unexplained recurrent miscarriage have excellent prognosis for future pregnancy outcomes. What % successful pregnancy

Answer 17

75%

Question 18

Which gestational trophoblastic disease are pre-malignant?

Answer 18

Complete and partial molar pregnancy

Question 19

Which gestational trophoblastic disease are malignant?

Answer 19

Invasive mole
Choriocarcinoma
Placental site trophoblastic tumour (PSTT)
Epithelioid trophoblastic tumour (ETT)

Question 20

What is the definition of complete molar?

Answer 20

46XX
Diploid
- 75-80% - No nucleus - single sperm duplicates
- 20-25% No nuclear - 2 sperm fertilise

Question 21

What is the definition of partial molar?

Answer 21

69XXY
Triploid
2 sperm + nucleated egg

Question 22

Incidence of GTD in UK?

Answer 22

1 in 714 live births

Question 23

Incidence of GTD if <15yrs

Answer 23

1 in 500

Question 24

Incidence GTD if >50yrs

Answer 24

1 in 8

Question 25

Incidence of GTN (neoplasia)

Answer 25

1 in 50,000

Question 26

Cure rate of GTD

Answer 26

98-100%

Question 27

What % need chemotherapy for partial molar and complete?

Answer 27

Partial: 0.5-1%
Complete 13-16%

Question 28

Reurrance of molar pregnancy?
After 1 and after 2

Answer 28

1 in 80
1 in 6.5 after 2

Question 29

Where does choriocarcinoma spread to?

Answer 29

Haematogenous spread to lungs, brain and liver (cannon ball mets)

Question 30

Common presentation of GTD?

Answer 30

Irregular vaginal bleeding
Positive pregnancy test
Supporting ultrasonographic evidence
Less common presentations include hyperemesis, excessive uterine enlargement, hyperthyroidism, early‐onset pre‐eclampsia and abdominal distension due to theca lutein cysts
Very rarely women can present with haemoptysis or seizures due to metastatic disease affecting the lungs or brain.

Question 31

What is the definitive Dx of GTD?

Answer 31

Histological

Question 32

Management of molar pregnancy

Answer 32

Surgical Mgmt with suction for complete and partial (unless if fetal size deters this and medical can be used)
Anti D
Avoid use of oxytocin infusion
→ Repeat SMM/Balloon/UAE

Question 33

When should histological assessment of miscarriage be recommenced?

Answer 33

If no fetal parts are identified

Question 34

After miscarriage/aboriton, how to rule out GTD

Answer 34

UPT after 3 weeks

Question 35

Which women should be Ix for GTN after non molar pregnancy?

Answer 35

• If persistently raised HCG after an ectopic pregnancy has been excluded, or 2 x Tx with MTX
• Persistent bleeding after pregnancy event > 8 weeks after pregnancy event

Question 36

When should prenatal invasive testing for karyotype be considered?

Answer 36

• Unclear if the pregnancy is complete mole + normal town or singleton partial molar
• Abnormal placenta such as mesenchymal hyperplasia

Referred to GTD centre

Question 37

For how long should a complete molar pregnancy be followed up?

Answer 37

If normal bHCG within 56 days, 6 month FU from uterine removal

If not reverted to normal within 56days, 6 months from normalisation of bHCG

Question 38

How long should a partial molar be followed up?

Answer 38

On bHCG has returned to normal on 2 samples, 4 weeks apart

Question 39

When can women attempt conception again after GTD?

Without chemo
Following chemo

Answer 39

without: Once completed follow up
with: 1 year after chemo

Question 40

If a women has GTN, they can be treated with chemotherapy what score is used to determine if the need single or multi-agent chemo?

Answer 40

FIGO scoring
<6 single agent IM MTX with folinic acid
> 7 Muliagent check

Question 41

Draw table of FIGO

Answer 41

Question 42

What % of women have successful future pregnancies with chemotherapy Tx GTN?

Answer 42

80%