Tag: Recurrent Abortion

Confirmed causes of recurrent abortion


Confirmed causes of recurrent abortion


Recurrent abortion: RPL- (recurrent pregnancy loss): – It is defined as a sequence of three or more consecutive spontaneous abortions before 20 weeks. American society for reproductive medicine (2013) defines RPL as 2 or more failed pregnancies confirmed by USG or histologically.

• Uterine causes account for 10-50 %.

• M/c cause of RPL is cervical incompetence followed by uterine malformations.

• Uterine causes lead to 2nd trimester abortions/

• Most common uterine cause is cervical incompetence >uterine malformation.

1.Uterine causes:

Congenital causes-

o Uterine malformations

o Septate uterus

Acquired causes-

o Cervical incompetence

o Fibroid

o Endometrial polyp

2.Hypothyroidism

3.Chromosomal Abnormality-Balanced translocation

4. Antiphospholipid antibody syndrome-5-15%

Recurrent Abortion

Recurrent Abortion


Recurrent Abortion

DEFINITION:

  • A sequence of three or more consecutive spontaneous abortion before 20 weeks.
  • It may be primary or secondary (having previous viable birth).
  • A woman procuring three consecutive induced abortions is not a habitual aborter.

ETIOLOGY:

FIRST TRIMESTER ABORTION:

Genetic factors (3–5%):

  • Most common abnormality is a balanced translocation(25%)

Endocrine and metabolic: 

  • Poorly controlled diabetic
  • Presence of thyroid autoantibodies
  • Luteal phase defect (LPD)
  • Polycystic ovary syndrome (PCOS)

Infection:

  • Bacterial vaginosis
  • Transplacental fetal infection

Inherited thrombophilia:

  • Protein C (factor resistance V Leiden mutation)
  • Other factors are—deficiencies of protein C, S and antithrombin III
  • Hyperhomocystinemia and prothrombin gene mutation

Immune factors (10–15%):

  • Autoimmunity:second trimesters
  • Antinuclear antibodies, anti-DNA,and antiphospholipid antibodies(lupus anticoagulant ,anticardiolipin antibody, Antibody that cause false positive syphilis test (BFP-ST).
  • Alloimmunity—Natural killer (NK) cells
  • Parental human leukocyte antigen (HLA)

SECOND TRIMESTER MISCARRIAGE:

Anatomic abnormalities(10–15%)

  • Mullerian fusion defects:Unicornuate, bicornuate, septate or double uterus
  • Acquired anomalies :
  • Intrauterine adhesions, uterine fibroids and endometriosis and cervical

Chronic maternal illness

  • Uncontrolled diabetes with arteriosclerosis
  • Hemoglobinopathies
  • Chronic renal disease. 
  • Rh incompatibility
  • Inflammatory bowel

SLE

  • Infection—Syphilis, toxoplasmosis and listeriosis

INVESTIGATIONS:

Careful history

  • The nature of previous abortion process
  • Histology of placenta or karyotyping of the conceptus
  • Any chronic illness

Diagnostic tests:

  • Blood-glucose (fasting and postprandial)
  •  VDRL, thyroid function test 
  • ABO and Rh grouping 
  • Toxoplasma antibodies IgG and IgM.
  • Autoimmune screening—lupus anticoagulant and anticardiolipin antibodies
  • Prolonged PTT and a normal PT-lupus anticoagulant 
  • Serum LH on D2/D3 of the cycle.
  • Ultrasonography—to detect congenital malformation of uterus, polycystic ovaries and uterine fibroid.
  • Hysterosalpingography in the secretory phase to detect—cervical incompetence, uterine synechiae and uterine malformation
  • Karyotyping
  • Endocervical swab to detect chlamydia, mycoplasma and bacterial vaginosis.

TREATMENT:

INTERCONCEPTIONAL PERIOD:

  • To alleviate anxiety and to improve the psychology
  • Hysteroscopic resection of uterine septa, synechiae and submucous myomas
  • Uterine unification operation (metroplasty) in bicornuate uterus
  • Chromosomal anomalies:PCOS
  • Karyotyping of the products of conception
  • Counseled for Preimplantation genetic diagnosis (PGD)

PCOS:

  • Treatment for insulin resistance, hyperinsulinemia and hyperandrogenemia.
  • Metformin therapy
  • Control of diabetes and thyroid disorders
  • Genital tract infections are treated(doxycycline or erythromycin)
DURING PREGNANCY:
  • Reassurance and tender loving care (TLC)
  • Ultrasound:At the earliest to detect a viable pregnancy.
  • Rest
  • Progesterone therapy:
  • Luteal phase defect and recurrent miscarriage
  • Immunomodulatory role
  • Low-dose aspirin and heparin:Antiphospholipid antibody syndrome up to 34 weeks
  • Cerclage operation for cervical incompetence
  • Chromosomal anomaly—Prenatal diagnosis
  • Inherited thrombophilias:Antithrombotic therapy(Heparin is given up to 34 weeks.)
  • Medical complications in pregnancy: 
  • Hemoglobinopathies, SLE, cyanotic heart disease
  • Advised to delay pregnancy until the disease is optimally treated

Exam Important

  • In cases of recurrent abortions, most common uterine malformation seen is Mullerian fusion defects
  • Lupus anticoagulant  is associated with recurrent abortion and isolated prolonged APTT
  • Recurrent abortion in 1st trimester is most often due to Chromosomal abnormalities
  • Recurrent spontaneous abortions are seen in Uterine pathology,SLE ,Rh incompatibility & Syphilis
  • Recurrent abortion in 1st trimester, investigation of choice is Karyotyping
  • Hysteroscopy,Parental cytogenetics, Testing Antiphospholipid antibodies & Thyroid function tests are investigation carried out in Recurrent abortion
  • Low-dose aspirin is used to treat Antiphospholipid antibody syndrome up to 34 weeks
Don’t Forget to Solve all the previous Year Question asked on Recurrent Abortion

Module Below Start Quiz
 

Recurrent Abortion

Recurrent Abortion

Q. 1

In cases of recurrent abortions, most common uterine malformation seen is?

 A Mullerian fusion defects
 B

Uterine syncytium

 C Unicornuate uterus
 D

Uterine agenesis

Q. 1

In cases of recurrent abortions, most common uterine malformation seen is?

 A Mullerian fusion defects
 B

Uterine syncytium

 C Unicornuate uterus
 D

Uterine agenesis

Ans. A

Explanation:

Mullerian fusion defects REF: William’s 22′ ed chapter 9

Abnormal Mullerian duct formation or fusion defects may develop spontaneously or may follow in utero exposure to diethylstilbestrol is the commonest cause of uterine factors leading to recurrent spontaneous abortions.


Q. 2 30 years old female presents in gynaec OPD with complaints of recurrent abortions and menorahagia. Her USG showed 2 sub-serosal fibroids of 3 x 4 cm on anterior wall of uterus and fundus, which is best line of management:-
 A TAH with BSO
 B Myolysis
 C Myomectomy
 D Uterine artery embolisation (UAE)
Q. 2 30 years old female presents in gynaec OPD with complaints of recurrent abortions and menorahagia. Her USG showed 2 sub-serosal fibroids of 3 x 4 cm on anterior wall of uterus and fundus, which is best line of management:-
 A TAH with BSO
 B Myolysis
 C Myomectomy
 D Uterine artery embolisation (UAE)
Ans. C

Explanation:

Laparoscopic myomectomy is  best treatment for  such  young infertile patients, but  it  requires subserosal pedunculated fibroids and surgical expertise.

Hysterectomy is advisable in patients who had completed their family.

Myolysis is myoma coagulation with laparoscopic lasers. (Nd- YAG) or bipolar needle & used in perimenopausal patients.

UAE is newer intervention for fibroid management in surgically unfit high risk patients, but it causes decreased fertility & carries risk of placental insufficiency and uterus rupture in subsequent pregnancy.


Q. 3

A female with recurrent abortion and isolated prolonged APTT is most likely associated with

 A >Lupus anticoagulant
 B >DIC
 C >Von wilebrand disease
 D >Hemophilia
Q. 3

A female with recurrent abortion and isolated prolonged APTT is most likely associated with

 A >Lupus anticoagulant
 B >DIC
 C >Von wilebrand disease
 D >Hemophilia
Ans. A

Explanation:

Lupus anticoagulant [Dutta 6th/e p 169, 343, 636, Fernando Aries 2nd/e p 61]

  • They have asked about antiphospholipid antibody syndrome.
  • Antiphospholipid antibodies account for 3% to 5% of patients with repetitive pregnancy losses.
  • The frequency of fetal death and recurrent abortion in untreated patients with antiphospholipid antibodies is greater than 90%.
  • There are several antiphospholipid antibodies. The most relevant to obstetricians are:

The lupus anticoagulant (LAC),

– The anticardiolipin antibody and

The antibody that cause false positive syphilis test (BFP-ST).

  • The name lupus anticoagulant was derived from the fact that this antibody was found first in patients with systemic lupus erythematosus and acted as an anticoagulant by prolonging the partial thromboplastin time (PTT).
  • This name was a poor choice because soon it was found that lupus anticoagulant was present in many patients who did not have lupus and that in majority of patients the antibody was responsible for episodes of thrombosis, rather than anticoagulation.
  • In the laboratory, LAC is not measured directly.

– It is assessed by its effect on PTT and the kaolin clotting time.

– Typically patients with lupus anticoagulant have a prolonged PTT and a normal PT.

– Unfortunately, a normal PTT does not exclude the possibility of LAC, and if the clinical suspicion is strong

and the PIT is normal a kaolin clotting time or a dilute Russel viper venom time should be performed.

– It has also been found that some patients with LAC and recurrent abortions have elevated values of serum

1gM.

Other antiphospholipid antibodies

The anticardiolipin antibody is the antiphospholipid antibody, most commonly found in patients with repetitive early pregnancy losses.

Anlicardiolipin antibody is found in 90% of patients with L.A.C. but the majority of patients with positive anticardiolipin antibody do not have L.A.C.

– Anticardiolipin antibody is measured in the laboratory by the ELISA test.

BFP-ST

– It is the less common antiphospholipid antibody.

– Both BFP-ST and Anticardiolipin antibody, measure the antibody against cardiolipin but they are not the same.

Clinical features of antiphospholipid antibodies.

  • The presence of any or several of the three antiphospholipid antibodies is associated with

–  Recurrent early pregnancy losses.

– Episodes of venous and arterial thrombosis

– Severe preeclampsia

– Chorea gravidarum

– Pilo ischemic strokes, transient ischemic episodes, migraine headaches.

– Postpartum complications such as pulmonary infiltrates, fever, and cardiac symptoms.

Abortions in antiphospholipid antibody syndrome

– Typically these patients give a history of a live fetus documented by ultrasound or by Doppler before demise or abortion occurs.

The majority of the pregnancy losses occur between 14 and 18 weeks.

Fetal death is these patients is caused by extensive thrombosis of the placental vessels and the placenta is usually smaller than expected for the gestational age.

Quiz In Between


Q. 4

A lady has recurrent abortions in 1st trimester with history of autosomal recessive disorder in family. The true statement regarding this is:

 A

Consanguinity may be the cause

 B

Complete penetrance is common

 C

Affected members in the family

 D

All are correct

Q. 4

A lady has recurrent abortions in 1st trimester with history of autosomal recessive disorder in family. The true statement regarding this is:

 A

Consanguinity may be the cause

 B

Complete penetrance is common

 C

Affected members in the family

 D

All are correct

Ans. D

Explanation:

Ans. is d i.e. All are correct

Characteristics of autosomal recessive disorders

Autosomal recessive inheritance is the single largest category of Mendelian disorders.

They have following features :

  • The trait does not usually affect the parents but siblings may show the disease (Option “c” is correct).
  • Siblings have one chance in four of being affected (i.e. recurrence risk is 25% for each birth).
  • Cor,Inguineoo. ,;c1r.rojc: may :./c:                 tjaue• (option a is correct).
  • The expression of the defect tends to be more uniform than in autosomal dominant disorders.
  • Complete nPnotranre is rnnimon (Option “b is correct).
  • Onset is frequently early in life.

In the question the lady has recurrent abortions and H/o autosomal recessive disorder in the family, therefore all features of autosomal recessive disorders .1pply to her


Q. 5

Recurrent abortion in 1st trimester is most often due to.

 A

Chromosomal abnormalities

 B

Uterine anomaly

 C

Hormonal disturbance

 D

Infection

Q. 5

Recurrent abortion in 1st trimester is most often due to.

 A

Chromosomal abnormalities

 B

Uterine anomaly

 C

Hormonal disturbance

 D

Infection

Ans. A

Explanation:

Ans. is a i.e. Chromosomal abnormalities

Historically. recurrent pregnancy loss or “habitual abortion” was defined as 3 or more consecutive spontaneous miscarriages.

Today, recurrent pregnancy is usually defined as 3 or more pregnancy losses (not necessarily cnnc,ecr_itive).

Most obstetricians also consider clinical investigation and treatment should be considered in couples with ,„,ntaneo— miscarriages, especially when any of the following are present :

  • Embryonic heart activity observed before any earlier pregnancy loss.
  • Normal karyotype of products on conception from an earlier loss.
  • Female partner age over 35 years.
  • Infertility.

cause rf recurrent abortions

1st trimester • Genetic factor / defective germplasm.

  • Most common type of chromosomal abnormality is balanced translocation.

2nd trimester • Cervical incompetence


Q. 6

ecurrent spontaneous abortions are seen in all expect:

 A

TORCH infection

 B

Uterine pathology

 C

Herpes infection

 D

a and c

Q. 6

ecurrent spontaneous abortions are seen in all expect:

 A

TORCH infection

 B

Uterine pathology

 C

Herpes infection

 D

a and c

Ans. D

Explanation:

Ans. is a and c i.e. TORCH infection; and Herpes infection

Remember all causes of abortions given earlier in the chapter for spontaenous abortions hold good for recurrent abortions also except for infections be it — TORCH infections or any other infection.

According to Williams Gynae lie, p 149

Few infections are firmly associated with early pregnancy loss. Moreover, if any of those infections are associ­ated with miscarriage, they are even less likely to cause recurrent miscarriage because maternal antibodies usually develop with primary infection.

Leon Speroff says :

“Overall, data , L9arding the possibility that cervicovaginal infections might be a cause of early preg­nancy loss are relatively scarce. Despite periodic reports that have implicated specific infectious agents as risk factors for miscarriages, there remains no compelling evidence that bacterial or viral infections are a cause of recurrent pregnancy loss.”

It further says on Gage 1091

“Routine serological tests, cervical cultures and endometrial biopsy to detect genital infections in women with recurrent pregnancy loss can not be justified. Evaluation should be limited to women with clinical cervicitis, chronic or recurrent bacterial vaginosis or other symptoms of pelvic infection.”

Quiz In Between


Q. 7

All of the folowing are known causes of recurren abortion except.

 A

TORCH infections

 B

SLE

 C

Rh incompatibility

 D

Syphilis

Q. 7

All of the folowing are known causes of recurren abortion except.

 A

TORCH infections

 B

SLE

 C

Rh incompatibility

 D

Syphilis

Ans. A

Explanation:

Ans. is a i.e TORCH infection

As discussed in previous question TORCH infection do not lead to recurrent abortion.

SLE is an established cause for recurrent abortion

SLE is associated with antiphospholipid syndrome (anti-cardiolipin antibodies) and is known to cause recurrent abortions.

RH incompatibility is a known cause for spontaneous abortion and may lead to recurrent abortions if it remains unrecognized.

Syphillis also does not lead to recurrent abortions but if you have to choose between TORCH infection and syphillis go for TORCH infection.


Q. 8

A woman with Hio recurrent abortions presents with isolated increase in APTT is:

 A

Lupus anticoagulant

 B

Factor VII

 C

Von willebrand’s disease

 D

Hemophilia A

Q. 8

A woman with Hio recurrent abortions presents with isolated increase in APTT is:

 A

Lupus anticoagulant

 B

Factor VII

 C

Von willebrand’s disease

 D

Hemophilia A

Ans. A

Explanation:

Ans. is a i.e. Lupus anticoagulant

Anti Russel Viper Venom Antibody is the diagnostic test for antiphospholipid antibody syndrome, which is an important cause of recurrent abortion.

Friends, Antiphospholipid antibody syndrome (APS) is an important and emerging topic for PGME exams. It is one of the least touched topic at undergraduate level. Therefore, I am explaining it in detail. Do go through it :

Antiphospholipid antibody syndrome :

  • It is a treatable, autoimune disorder associated with recurrent second trimester pregnancy loss.°
  • Antiphospholipid antibodies are acquired antibodies targeted against a phospholipid. They can be IgM, IgG or IgA isotopes.
  • Most important antiphospholipid antibodies are :

Lupus anticoagulant (LAC)

—   It was named so because it was first found in patients with SLE & prolonged partial thrombo­plastin time

—   But the name is a misomer as though it increases PTT (i.e., similar to anticoagulant) but functions as a procoagulant & causes thrombosis

Anticardiolipin antibody

–      It is most commonly seen in patients with repetitive early pregnancy loss

BFP – ST

i.e. antibody which causes biologically false positive syphilis test

— Less common antiphospho­lipid antibody

–    Both anticardio lipin & BFP­ST antibodies measure the antibody against cardiotipin but they are not same.

Diagnosis For diagnosis of antiphospholipid antibody syndrome there should be two positive tests 6 weeks apart for lupus anticoagulant or anticardiolipin antibody.

Mqrpclerrient 7 Treatment as proposed by ACOG is a combination of low dose aspirin (81 mg) daily and low molecular weight heparin (LMWH) in prophylactic doses (e.g. dalteparin 5000 units S/C twice daily), started as soon as pregnancy is confirmed. Aspirin can be initiated preconceptionaly and is usually discontinued at 36 weeks. LMWH is continued up to term and for 5 days postpartum.

Women with previous history of thrombosis will usually already be on maintenance therapy with warfarin. In such cases as soon as pregnancy is confirmed, warfarin is changed to LMWH and aspirin.

Although this treatment improves overall pregnancy success, these women remain at high risk for preterm labor, PROM. IUGR. preeclampsia and placental abruption.

In question 10 Patient is presenting with recurrent abortions with isolated increase in APTT which leaves no doubt that lupus anticoagulant is the cause.


Q. 9

lecurrent abortion in 1st trimester, investigation of choice :

 A

Karyotyping

 B

SLE Ab

 C

HIV

 D

TORCH infection

Q. 9

lecurrent abortion in 1st trimester, investigation of choice :

 A

Karyotyping

 B

SLE Ab

 C

HIV

 D

TORCH infection

Ans. A

Explanation:

Ans. is a i.e. Karyotyping

Quiz In Between


Q. 10

In a case of recurrent spontaneous abortion, fol­lowing investigation is unwanted :

 A

Hysteroscopy

 B

Testing Antiphospholipid antibodies

 C

Testing for TORCH infections

 D

Thyroid function tests

Q. 10

In a case of recurrent spontaneous abortion, fol­lowing investigation is unwanted :

 A

Hysteroscopy

 B

Testing Antiphospholipid antibodies

 C

Testing for TORCH infections

 D

Thyroid function tests

Ans. C

Explanation:

Ans. is c i.e. Testing for TORCH infections.

  • Chromosomal abnormality is the commonest cause for  fire,t trimpstpr
  • In 3-5% of couples with recurrent miscarriage, one of the partners will have a chromosomal anomaly.
  • is a balanced translocation of the chromosomes, more likely in the mother. In such cases, the genetic information is intact and so there is no problem for the parents. But this can lead to an unbalanced translocation in the conceptus, causing an early miscarriage.

Hence karyotyping of the both partners is recommended in recurrent miscarriage. Prenatal diagnosis is usually advised in the next pregnancy.

As discussed earlier infections be it HIV / TORCH are not a cause of recurrent abortion and SLE i.e. Lupus anticoagulant causes abortion in 14-18 weeks and not in 1st trimester: Therefor Ans of Q 13 is karyotyping.

Because TORCH infections are not a cause of recurrent abortionf‑

TORCH profile should not be included in the set of investigations done to find out the cause of recurrent abortion (Ans. 14).

Investigative measures useful in the evaluation of recurrent early pregnancy loss :

  • Parental peripheral blood karyotyping with banding technique.
  • Assessment of the intrauterine cavity with either office i’.oloiusGOp or hysterosalpingography.
  • 1;:, serum prolactin levels if indicated.
  • Anticardiolipin antibody                                                                 (aPTT or Russell Viper venom testing).
  • Complete blood counts with platelet count.
  • Thrombophilia testing :

–    Factor V leiden, prothrombin ponr    PrrifPirt

–      Serum homocvsteine level.

–      In the presence of a family or personal history of venous thromboembolism. protein C and antithrom­bin activity.

The American college of obstetricians and Gynaecology recognizes only 2 types of tests as having clear value in the investigation of recurrent miscarriages :

  1. Parental cytogenetic analysis
  2. Lupus anticoagulant and anticardiolipin antibodies assay.

Q. 11

All of the following are known causes of recurrent abortion, except:

 A

TORCH infections

 B

SLE

 C

Rh incompatibility

 D

Syphilis

Q. 11

All of the following are known causes of recurrent abortion, except:

 A

TORCH infections

 B

SLE

 C

Rh incompatibility

 D

Syphilis

Ans. A

Explanation:

SLE is associated with antiphospholipid syndrome (anti cardiolipin antibodies) and is known to cause recurrent abortions.

RH incompatibility is a known cause for spontaneous abortion and may lead to recurrent abortions if it remains unrecognized.
Syphilis has also lead to recurrent abortion.
TORCH is thus the single best answer of exclusion.
 
Ref: Gynaecology for Postgraduates and Practitioners By Sengupta, Pages 187-92; Textbook of High Risk Pregnancy By Hemant Deshpande, Hemant, Pages 248-49

Q. 12

A 23 year old female presents to the clinic with history of recurrent abortions. While investigating this patient for recurrent abortions all of the following tests are to be done EXCEPT:

 A

Parental cytogenetics

 B

Thyroid profile

 C

Antiphospholipid antibodies

 D

TORCH infection screening

Q. 12

A 23 year old female presents to the clinic with history of recurrent abortions. While investigating this patient for recurrent abortions all of the following tests are to be done EXCEPT:

 A

Parental cytogenetics

 B

Thyroid profile

 C

Antiphospholipid antibodies

 D

TORCH infection screening

Ans. D

Explanation:

Recurrent miscarriage is defined as a sequence of three or more consecutive spontaneous abortion before 20 weeks.

Investigations:

1) Blood glucose (fasting and post prandial), VDRL, thyroid function test, ABO and Rh grouping (husband and wife), toxoplasma antibodies IgG&IgM

2) Autoimmune screening – lupus anticoagulant and anticardiolipin antibodies

3) Serum LH on D2/D3 of the cycle

4) Ultrasonography – to detect congenital malformations of uterus, polycystic ovaries and uterine fibroid

5) Hysterosalpingography in the secretory phase

6) Laryngoscopy

7) Karyotyping (husband and wife)

8) Endocervical swab to detect chlamydia, mycoplasma, and bacterial vaginosis

Quiz In Between


Q. 13

Which is the most common uterine malformation seen in cases of recurrent abortions?

 A

Mullerian fusion defects

 B

Uterine syncytium

 C

Unicornuate uterus

 D

Uterine agenesis

Q. 13

Which is the most common uterine malformation seen in cases of recurrent abortions?

 A

Mullerian fusion defects

 B

Uterine syncytium

 C

Unicornuate uterus

 D

Uterine agenesis

Ans. A

Explanation:

Mullerian duct anomaly is an important cause of recurrent miscarriage in early and midtrimester. Septate or arcuate uterus is the most common uterine anomaly associated with mullerian fusion defects and it is the most common defect associated with repeated pregnancy loss.


Q. 14

For evaluating a case of recurrent spontaneous abortion, which of the  following investigation is unwanted?

 A

Hysteroscopy

 B

Testing for Antiphospholipid antibodies

 C

Testing for TORCH infections

 D

Thyroid function tests.

Q. 14

For evaluating a case of recurrent spontaneous abortion, which of the  following investigation is unwanted?

 A

Hysteroscopy

 B

Testing for Antiphospholipid antibodies

 C

Testing for TORCH infections

 D

Thyroid function tests.

Ans. C

Explanation:

TORCH infections is not a cause of recurrent spontaneous abortion.  Recurrent spontaneous abortion is defined as 3 or more consecutive pregnancy losses at 20 weeks or less or with fetal weights less than 500 grams. 
 
Causes and investigations includes :
  • Chromosomal abnormalities: karyotypic evaluation of both parents
  • Genital tract anatomical abnormalities : three-dimensional sonography, hysteroscopy
  • Autoimmune Factors like SLE: antiphospholipid antibodies
  • Alloimmune Factors 
  • Inherited Thrombophilias
  • Endocrinological factors like progesterone deficiency, PCOS, diabetes mellitus, hypothyroidism 
Ref: Williams Obstetrics, 23e chapter 9.

Q. 15

Which of the following is recommended in a woman with Antiphospholipid Antibodies and history of prior abortions / still birth.

 A

Aspirin only

 B

Aspirin + Low molecular weight Heparin

 C

Aspirin + Low molecular weight Heparin + Prednisolone

 D

No Treatment

Q. 15

Which of the following is recommended in a woman with Antiphospholipid Antibodies and history of prior abortions / still birth.

 A

Aspirin only

 B

Aspirin + Low molecular weight Heparin

 C

Aspirin + Low molecular weight Heparin + Prednisolone

 D

No Treatment

Ans. B

Explanation:

Answer is B (Aspirin + Low molecular weight Heparin):

The recommended treatment for women with recurrent pregnancy loss associated with antiphospholipid syndrome includes combined Aspirin and Heparin therapy.

‘In pregnant SLE patients with Antiphospholipid antibodies and prior fetal loss, treatment with heparin (standard or low –molecular- weight) plus low dose aspirin has been shown in prospective controlled trials to increase significantly the proportion of live births’. – Harrison’s 17th/2082

‘Combined aspirin and heparin therapy has proven effectiveness and is the preferred treatment for women with recurrent pregnancy loss associated with antiphospholipid syndrome’ – Speroff 7th/1084

Antiphospholipid syndrome in pregnancy

  • The risk of pregnancy loss in women with APS and prior pregnancy loss may exceed 60%
  • History of recurrent fetal loss in a pregnant woman with Antiphospholipid antibodies is an indication of treatment during pregnancy as these are identifiable and treatable immunologic disorders
  • Treatment options include Antiplatelet agents such as Aspirin, Anticoagulants such as Heparin / LMWH, and corticosteroids

Aspirin along with Heparin / LMWH is the recommended treatment of choice.

Corticosteroids should be avoided ifpossible. If required to control maternal SLE, these should be used at the lowest effective doses for the shortest time required.

Quiz In Between



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