Bad obstetric history an evaluation

Usha . M . G Amrita School of Medicine

Not all conceptions result in live born infant 50-70% of conceptions are lost by the 12wks

Most of them during the first month

Frequency of loss

About 2/3 rd of pregnancies that miscarry are lost before clinical recognition

- Wilcox NEJM ;1988

Total loss rate 16% Mean gestational age 4 - 5 wks

- Mills and colleagues National institute of child health and human development study

Maternal age at 40yrs double the risk at 20 yrs Prior loss - 6% for nulliparous - 25-30% after 3 miscarriages

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Timing of conception
Optimal interval Loss rate 7% on the day of ovulation or one day prior Loss rate 23% for conception on other days
- Grey & Simpson; AJOG 1995

Timing of loss
Fetal demise occurs before the clinical signs Almost all losses are missed abortions Loss after 8wks after 16wks after 20 wks : 2 - 3% : 1% : <1%

Clinical loss
Chromosomal abnormalities : 50%

Comparative genome hybridisation (microarray technique) detects anomalies not evident at karyotype

Detects anomaly 70 - 90%

Advanced pregnancy loss

Second trimester - Autosomal trisomies 13 ,18 , 21 - Monosomy X
Third trimester (5%)

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Etiology of preclinical loss

Study on preimplantation embryo shows high incidence of aneuploidy or polyploidy Morphologically normal embryos 25% show chromosomal abnormalities with FISH

- American journal of human genetics ;1994

Placental abnormalities

2/3rd of early pregnancy loss shows evidence of defective placentation

Premature onset of maternal circulation of placenta

CASE SCENARIOS

CASE 1

28yr old ; married 4 yrs with 3 first trimester losses

- Identify whether it is embryonic or anembryonic loss

Anembryonic loss
Family h/o recurrent loss or abnormal babies
Chromosomal evaluation of couple

Embryonic loss
Screen for bacterial vaginosis Congenital thrombophilia , APLA screen Collagen screen with ANA study TSH & antithyroid antibodies USG : structural lesion like split cavity sub mucous fibroid; PCOS

Case 2
26yr old lady ; presents with h/o 2 II trimester losses at 16 and 18 wks. - Proper history of the event. - Rapid painless en mass expulsion of live infant.

L/E for torn,damaged or short cx Look for uterine anomalies and cervical insufficiency in USG Plan elective circlage in next pregnancy

Case 3 ..
30 yr, G2P1L0 , term stillbirth - Detailed history of previous loss

- Antenatal records, fresh or macerated,whether labour spontaneous or induced - Baby wt , sex, infantogram or autopsy details

CASE 4
24 yr old G2P1L1 ,previous CS , now presenting with anterior type 2 placenta praevia - May need evaluation for a morbidly adherent placenta this time , by MRI

CASE 5
G2P1L0 ,with H/O Severe PET , IUGR , IUD

Evaluate by APLA screen

Uterine artery doppler for placentation Serial USG for growth, doppler for fetal perfusion Intense surveillance with NST,BPP Timed delivery before fetal affection

Case 6......
G2P1L0 with H/O complex congenital heart disease. - Anomaly scan at11-14 wks for NT - Fetal echo by 18wks

Case 7.
26yrs ; G4P1A2L0 with h/o isoimmunisation and fetal loss last time.
- Serial ICT to study sensitisation - Amniocentesis & PCR for fetal blood group and affection - Usg for fetal affection - Amniotic bilirubin optical density - Pulsatility index for fetal anemia

Case 8..
G3P2L0 , previous 2 neonatal deaths
- Detail about intrapartum & postnatal events - R/O metabolic abnormalities & storage disorders

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Case 9
32 yr , G3P2L0 , post lap myomectomy , h/o rupture uterus in previous 2 pregnancies

- Evaluation of placental invasion

- Elective CS at 34wks

To conclude.
Management of BOH starts with the understanding of initial loss , followed by interval evaluation. Pregnancy is planned and carefully followed up , intensely monitored for a successful outcome.

THANK YOU