Preventive medicine in obstetrics regarding pregnancy loss

1. Preventive medicine in obstetrics regarding pregnancy loss Dr. Mohammed Abdalla Domiat general hospital

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

3. 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.

4. Maternal risk assessment Maternal risk assessment can be firstly identified from history

5. Maternal risk assessment Recurrentpregnancy loss is not just a Bad Luck and must be investigated .

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

7. any of these must invite a big question mark oneunexplained fetal deaths after ten weeks of pregnancy onepreeclampsia or placental insufficiencies occurring before 34 weeks ? One previous preterm birth one or more confirmed episodes of venous or arterial thrombosis.

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

9. 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

10. 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.

11. 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.

12. Etiologic view of pregnancy loss after 10wk

13. pregnancy loss after 10wk one pregnancy loss more than 10wk. Gestation or pregnancy associated with late adverse outcome need no recurrence to be investigated.

14. pregnancy loss after 10wk 95% 3% 2% 0.5%

15. pregnancy loss after 10wk How much is thrombophilia common among general population ?

16. Inherited thrombophilia %

17. 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,

18. thrombophilia and fetal loss

19. thrombophilia and fetal loss A meta analysis published in LANCET 15 march 2003 included 31 studies published between 1975 and 2002 (by Medline search).

20. Relative risk is quantified by odd ratio

22. thrombophilia and fetal loss Odd ratio Odd ratio

23. thrombophilia and fetal loss Odd ratio

24. Top guidelines to prevent recurrent pregnancy loss and adverse pregnancy outcomes

25. 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)

26. 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)

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

28. Top guidelines There is no clear “first-line” tocolytic drugs to manage preterm labor. (ACOG) grade A

29. 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

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

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

32. Top guidelines (TORCH and herpes simplex virus) screening is unhelpful in the investigation of recurrent miscarriage. RCOG(C)

33. 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. RCOG(C)

34. Top guidelines There is insufficient evidence to evaluate the effect of (hCG) in pregnancy to prevent miscarriage. RCOG(C)

35. Top guidelines There is insufficient evidence to evaluate the effect of progesterone supplementation in pregnancy to prevent a miscarriage. RCOG(C)

36. 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. RCOG(A)

37. Top guidelines Pregnancies associated with aPL treated with aspirin and heparin remain at high risk of complications during all three trimesters.

38. 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 fetal morbidity. RCOG(C)

39. 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)

40. Top guidelines low-dose aspirin, have small-moderate 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

41. Top guidelines Antiplatelet therapy ( low dose aspirin) reduces the risk of pre-eclampsia by around 15% for women at low or high risk . RCOG(B)

42. Top guidelines The combination of aspirin and heparin is effective in recurrent fetal loss in APS and could be considered for women with inherited thrombophilias and history of severe preeclampsia, IUGR, abruptio placentae or fetal loss, although no controlled studies on the subject are currently available Cochrane Review 2003

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

44. THANK YOU