Physiology-Recurrent Pregnancy Loss

Question 1

What defines recurrent pregnancy loss?

Answer 1

2+ consecutive miscarriages

Question 2

Undisputed reasons for pregnancy loss

Answer 2

Genetic (most miscarry in 1st trimester), anatomic, immunologic

Question 3

What chromosomal abnormalities most often occur that result in pregnancy loss?

Answer 3

90% are trisomy and monosomy. 10% include translocations, inversions and mosaicism.

Question 4

Which chromosomes are at higher risk for Robertsonian translocations?

Answer 4

Acrocentric chromosomes 12, 14, 15, 21 and 22.

Question 5

Products of conception

Answer 5

Karyotypic analysis of miscarried fetal tissue after D&C.

Question 6

What can be done for a genetic cause of recurrent pregnancy loss?

Answer 6

Genetic counseling, early fetal testing (chorionic villus sampling), IVF/ICSI or donor gametes can be used.

Question 7

Anatomic causes of recurrent pregnancy loss

Answer 7

Congenital (septate, unicornuate, bicornuate, didelphys uterus), fibroids and intrauterine adhesions (Asherman syndrome after D&C).

Question 8

How can you treat patients with congenital uterine malformations?

Answer 8

Hysteroscopic septum resection for septate uterus. There is no surgery benefit in didelphys, bicornuate or unicornuate uterus.

Question 9

What type of fibroids affect pregnancy the most?

Answer 9

Submucosal and intracavitary. Subserosal and intramural typically do not affect pregnancy outcomes unless > 5cm.

Question 10

Treatment for Asherman syndrome

Answer 10

Hysteroscopic adhesiolysis. Post-op live birth rate is 50-90%

Question 11

When is the fetus at highest risk for injury in a mother with lupus?

Answer 11

2nd to 3rd trimester. Other risk factors include active disease at conception, onset of SLE during pregnancy and renal disease.

Question 12

What immunologic condition has a high risk for pre-eclampsia?

Answer 12

SLE

Question 13

Sometimes found in women without SLE. What is the diagnostic criteria for this condition?

Answer 13

Antiphospholipid antibody syndrome. Must have 1 positive from each category.

Question 14

Treatment for women with antiphospholipid antibody syndrome that are trying to get pregnant.

Answer 14

Aspirin + Heparin. LMWH (lovenox). Immunosuppressants (IVIG, prednisone not used prophylactically).

Question 15

What clotting factors are increased in pregnancy?

Answer 15

V, VII, VIII, X, fibrinogen and PAI-1. Many of these are procoagulants.

Question 16

What clotting factors are decreased in pregnancy?

Answer 16

Protein S and resistance to activated Protein C is increased. These are anticoagulants.

Question 17

When should you test a patient for thrombophilia? What do you test for? How do you treat?

Answer 17

History of clots or FH of clots. Test for factor V Leiden, prothrombin, MTHFR, AT-III and proteins C/S. You can prophylactically treat with aspirin or heparin if the patient has a history or FH of clots.

Question 18

Why do we treat women with elevated TSH levels with levothyroxine?

Answer 18

Hypothyroidism has an increased risk for miscarriage and cretinism.

Question 19

Treatment for women with history of diabetes that are pregnant

Answer 19

Metformin

Question 20

Why is hyperprolactinemia a risk factor for recurrent pregnancy loss? Treatment for women with hyperprolactinemia who want to get pregnant?

Answer 20

High levels of prolactin impair folliculogenesis and oocyte maturation. It can also cause a short luteal phase. You can suppress prolactin levels with DA agonists (cabergoline or bromocriptine).

Question 21

What things do you want to check if you suspect recurrent pregnancy loss due to luteal phase defect? How do you treat?

Answer 21

TSH and prolactin levels. Treat with ovulation induction (clomid).

Question 22

When would you put a pregnant patient on antibiotics to reduce chance of miscarriage?

Answer 22

Cervicitis and bacterial vaginosis (increases miscarriage risk 5x)

Question 23

Environmental risks for miscarriage

Answer 23

Smoking, alcohol (> 2 drinks/day doubles risk) caffeine (< 300mg/day)

Question 24

50% of women have recurrent pregnancy loss due to what?

Answer 24

No identifiable cause. 70-75% will ultimately have a successful pregnancy.