Case History :
A 28 year old woman comes with her husband to your OPD.
She has one daughter and they are looking forward to having more children.
She has had 2 abortions and want to have your opinion on further management with a view to find out the underlying cause of her abortions and get treatment for conceiving.
On examination she has a pale appearance.
She appears weak and also complains of dizziness on standing up and feeling tired all the time.
Her BP is 100/60 mmHg
No obvious goiter visible.
Her weight is 65 kg.
1 .Which investigations would you like to order for her?
2.What are common causes of recurrent abortions/ Recurrent pregnancy loss (RPL).
3.How will you approach a case of recurrent abortions ?
4.Her brucella serology is found to be positive
How will you treat/ manage this patient?
Answers given below in comments section.
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1. Which investigations would you like to order for her:
Full Blood Count
Infectious diseases screen
Brucella serology
Syphilis / VDRL Test
Toxoplasmosis screen
Thyroid Function tests
Sugar levels and Hba1c if applicable
Ultrasound of abdomen.
High Vaginal swab.
Hormone profile
2. What are the common causes of recurrent abortions / Early pregnancy Loss ?
There are a number of causes of recurrent abortions.
Genetic Etiologies
Approximately 2% to 4% of RPL is associated with a parental balanced structural chromosome rearrangement, most commonly balanced reciprocal or Robertsonian translocations.
Additional structural abnormalities associated with RPL include chromosomal inversions, insertions, and mosaicism. Single gene defects, such as those associated with cystic fibrosis or sickle cell anemia, are seldom associated with RPL.
Certain infections, including Listeria monocytogenes, Toxoplasma gondii, rubella, herpes simplex virus (HSV), measles, cytomegalovirus, and coxsackieviruses, are known or suspected to play a role in sporadic spontaneous pregnancy loss.
Others include Brucellosis and syphilis.
The proposed mechanisms for infectious causes of pregnancy loss include:
(1) direct infection of the uterus, fetus, or placenta,
(2) placental insufficiency,
(3) chronic endometritis or endocervicitis,
(4) amnionitis, or
(5) infected intrauterine device.
Endocrine Etiologies
Luteal phase defect (LPD), polycystic ovarian syndrome (PCOS), diabetes mellitus, thyroid disease, and hyperprolactinemia are among the endocrinologic disorders implicated in approximately 17% to 20% of RPL ( Recurrent Pregnancy Loss ).
Immunologic Etiologies
Because a fetus is not genetically identical to its mother, it is reasonable to infer that there are immunologic events that must occur to allow the mother to carry the fetus throughout gestation without rejection. In fact, there have been at least 10 such mechanisms proposed.
Thrombotic Etiologies
Both inherited and combined inherited/acquired thrombophilias are common, with more than 15% of the white population carrying an inherited thrombophilic mutation.
The most common of these are the factor V Leiden mutation, mutation in the promoter region of the prothrombin gene, and mutations in the gene encoding methylene tetrahydrofolate reductase (MTHFR).
The potential association between RPL and heritable thrombophilias is based on the theory that impaired placental development and function secondary to venous and/or arterial thrombosis could lead to miscarriage.
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