KEHILANGAN KEHAMILAN BERULANG (RECURRENT PREGNANCY LOSS) : Etiologi, Diagnosis, & Terapi

(CSS) Oleh : Ricky Pebriansyah, S. Ked. (0818011091)

Preceptor :

dr. H. Taufiqurrahman R., Sp. OG(K)

SMF OBSTETRI DAN GINEKOLOGI RSUD DR. H. ABDUL MOELOEK BANDAR LAMPUNG 2 OKTOBER 2012

Introduction
15% of all clinically recognised pregnancies end in a pregnancy failure. Only 30% of all conceptions result in a live birth. Epidemiologic studies have revealed that 1% to 2% of women experience recurrent pregnancy loss. Based on the incidence of sporadic pregnancy loss, the incidence ofrecurrent pregnancy loss should be approximately 1 in 300 pregnancies.

Definition
3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period. (Recurrent miscarriage or habitual abortion)

Primer

Sekunder

Etiology of RPL

RPL

Explained

Un-explained

Genetic factors

Endocrine Anatomical factors

Infective agents

Enviromental factors

Immune factors

Inhereted Thrombophilic defect

Bacterial Vaginosis, TORCH

Body

Cervix CI APS Uterine anomalies

Genetic Etiology
Chromosomal
Fetal chromosomal abnormalities
Parental balanced chromosomal rearrangement

Single gene disorders

Thalassemia CF, Sickle cell anemia Hemofilia

Anatomical Etiologies
Septate uterus Intrauterine adhesions Bicornuate ut (unequal horns) Unicornuate uterus T shaped uterus Submucous fibroids Large endometrial polyps

Uterine Abnormalities
CONGENITAL (Mullerian Duct abnormalities)
UTERINE NEOPLASMS (Growth) IATROGENIC (Acquired)

How they affect.

Smaller Uterine Cavities Fewer suitable implantation sites Aberrations of vascularisation May be accompanied by cervical incompetence

1. CONGENITAL (Mullerian Duct abnormalities)

Septate Uterus

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Unicornuate Uterus
Agenesis or hypoplasia of one Mullerian duct

Dr.P.M.GOPINATH Director of Social Obstetrics i/c ISO & KGH Chennai 600005

Uterus Didelphys
Failure of lateral fusion of uterus &vagina

Dr.P.M.GOPINATH Director of Social Obstetrics i/c ISO & KGH Chennai 600005

Bicornuate Uterus
Incomplete fusion of Uterine horns at level of fundus

Dr.P.M.GOPINATH Director of Social Obstetrics i/c ISO & KGH Chennai 600005

Arcuate Uterus

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T shaped Uterus
Diethylstilbestrol treatment T-Shaped uterus, small uterus, constriction rings, Cervical hypoplasia, cervical incompetence,

Dr.P.M.GOPINATH Director of Social Obstetrics i/c ISO & KGH Chennai 600005

T SHAPED MALA ARORA UTERUS- INFECTION 16

2. Uterine Neoplasms
Endometrial Polyps

4/10/2013

PERIOSTEALMALA ENDOMETRIAL POLYP ARORA 18

3. Iatrogenic

Intrauterine adhesions ,Ashermans Syndrome Lead to Poor implantation, Decreased blood supply , infection

Incompetent Cervix

Endocrine Etiologies
Luteal phase defect (LPD), Polycystic ovarian syndrome (PCOS), Diabetes mellitus, Thyroid disease, and Hyperprolactinemia

Infectious Etiology
Female Viral infections
Coxasackie B Parovo-virus B

Bacterial infections
Bacterial Vaginosis Tuberculosis Chlamydia trachomatis

TORCH infections

Male factors:
Semen infections

Immunologic etiology
Secondary to autoimmune disease such as SLE, etc Primary Antiphospholipid Syndrome (PAPS) refers to the association of adverse pregnancy outcome and presence of antiphospholipid antibodies

APS is characterized by the presence of at least 1 clinical and 1 laboratory criterion : Clinical : 1 or more confirmed episodes of vascular thrombosis (venous, arterial, or small vessel) Pregnancy complications including either 3 or more consecutive pregnancy losses at less than 10 weeks of gestation, 1 or more fetal deaths at greater than 10 weeks of gestation, or at least 1 preterm birth (< 34 weeks) due to severe preeclampsia or placental insufficiency.

APS

 Laboratory (repeated at least 2 times, more than 12 weeks apart) : Positive plasma levels of the anticardiolipin antibodies (IgG or IgM) at medium to high levels Positive plasma levels of the lupus anticoagulant

Thrombotic Etiologies
The Herritable thrombophillias : Hyperhomocysteinemia resulting from MTHFR mutations, Activated protein C resistance associated with factor V Leiden mutations, Protein C and protein S deficiencies, Prothrombin promoter mutations, and antithrombin mutations.

Environmental Etiologies
Exogenous causes

organic solvents, medications, ionizing radiation, and toxins smoking, alcohol, and caffeine

Diagnosis

Therapy

Unexplained Etiologies
Progesterone has been shown to be beneficial in decreasing the miscarriage rate among women who have experienced at least 3 losses. LDA. Antenatal counseling and psychological support.

Conclusion
Diagnostic evaluation RPL should include maternal and paternal karyotypes, assessment of the uterine anatomy, and evaluation for thyroid dysfunction, APS, and selected thrombophilias. Evaluation for insulin resistance, ovarian reserve, antithyroid antibodies, and prolactin disorders. Therapy should be directed toward any treatable etiology.

References
Holly BF and Danny JS. Recurrent Pregnancy Loss : Etiology, Diagnosis, and Therapy. Rev Obstet Gynecol. 2009;2(2):76-83. Dr.P.M.GOPINATH Director of Social Obstetrics i/c ISO & KGH Chennai 600005.

THANK YOU
for your valuable time