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Recurrent Spontaneous Abortions

 
INTRODUCTION

Approximately 10% of all human pregnancies end in spontaneous abortions. In the majority of such cases the etiology remains unknown, but anticardiolipin antibodies are gaining recognition as potential causes of recurrent miscarriage. Repeated pregnancy loss and being childless is not only a gynecological problem but also a social stigma, in the Indian scenario. The price of motherhood is high and helpless couples seek to tide over this major crisis in their homes and society. Multiple studies have demonstrated the high incidence of psychological problems like low self-esteem; security and self-confidence among the childless couples. Women in particular suffer the deleterious consequences due to the common misconception that it is always the shortcoming of the female. This takes huge toll on the woman in terms of loss of self-esteem, grief, and feelings of failure. Recurrent abortion is a heterogeneous condition which is extremely traumatic emotionally as well as physically.

 
Definition

Recurrent pregnancy losses can be divided as follows:

  • Recurrent spontaneous abortions (RSA) (before viability)
    1st trimester and 2nd trimester
  • Recurrent bad obstetric outcomes (after viability)
  • Late 2nd trimester and third trimester.

The definition remains controversial. When do we start investigating a woman who has presented with recurrent spontaneous abortions (RSA). The conventional definition is three or more Consecutive Repeated Pregnancy losses. Then, do we deny the woman who comes to us with 2 losses, the chance to save the third loss? Or do we investigate and begin management?1,2

Most of us in clinical practice would start basic investi­gation after two losses and aggressive management after 3 losses. This is also due to the fact that, spontaneous chance of the 3rd pregnancy succeeding after two losses is not unknown but risk of a third abortion is nearly 38%.1,2 Research in RSA is associated with numerous problems
 

Problems of research in RSA

  • The cause of individual abortion may be different
  • More than one factor may exist
  • Thorough investigation often fails to reveal a cause
 

Etiology of RSA1

Doubtful causes of RSA

  • Endocrine and metabolic disease
       Untreated adrenal hyperplasia
       Diabetes mellitus
  • Exogenous causes
       Environmental factors, alcohol, street drugs, anesthesia, gases, etc
  • TORCH infections

Possible causes of RSA

  • Fetal abnormalities of genetic origin
       Parental chromosomal rearrangement, aneuploidy, previous abnormality, chance, molecular mutations
  • Uterine anatomical defects.
       Body- fibroids, septum, bicornuate uterus etc, Cervix - incompetent internal os
  • Immunological
       SLE, antiphospholipid antibodies, allo-immune factors, NK Cells
  • Maternal age
  • Hormonal
    Corpus luteum deficiency (LPD), PCOS, Hypo/hyper-thyroidism
  • General Disease
       Wilson's disease, renal dysfunction, Chronic essential HT, etc
 

Causes of RSA

Explainable—50-60%

  • Genetic
  • Infections
  • Endocrine
  • Autoimmune -SLE. anticardiolipin antibodies Unexplainable-40-50%
 
Maternal age and risk of abortions
Maternal age/years Risk of loss %
15-19 9.9
20-24 9.5
25-29 10.0
30-34 11.7
35-39 17.7
40-44 33.8
44 and older 53.2
 
CONCLUSION

Recurrent abortion is a heterogeneous condition which is extremely traumatic emotionally as well as physically. Despite thorough investigation according to various clinical protocols, the underlying etiology remains obscure in the majority of patients, and obstetricians are facing a challenge to determine the cause of these unexplained abortions.

Progesterone supplementation is the recommended therapy for luteal insufficiency. Metformin may have a role in PCOS induced recurrent pregnancy loss. Majority of research now is directed towards immunological causes and a lot of questions still remain unanswered. Since initial reports of an association between ACL and thrombosis and fetal death, much of the research has focused on the pathogenesis and clinical features of APS. The results of these studies indicate that patients with antiphospholipid antibodies and venous thrombosis should be treated with long-term (potentially indefinite) anticoagulation administered to achieve an INR of 2.0 to 3.0, when not pregnant. But, during pregnancy the treatment of choice is low dose aspirin and low molecular weight heparin.
 
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