Dr Gillani"s Blog: Case History : Recurrent Abortions

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.

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.

Infectious Causes:

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.

Environmental Etiologies :

Links between sporadic and/or RPL and occupational and environmental exposures to organic solvents, medications, ionizing radiation, and toxins have been suggested.

Three particular exposures-smoking, alcohol, and caffeine-have gained particular attention, and merit special consideration given their widespread use and modifiable nature.

Although maternal alcoholism (or frequent consumption of intoxicating amounts of alcohol) is consistently associated with higher rates of spontaneous pregnancy loss,

3. How will you approach a case of recurrent abortions ?

Genetic etiology : Genetic counseling.

Balanced translocations IVF with preimplantation genetic diagnosis

Müllerian anomalies :

Hysteroscopic resection of septa, adhesions, and submucosal fibroids. Asherman syndrome :Myomectomy for those intramural and subserosal fibroids >5 cm

PCOS :Metformin

Hypothyroidism :Thyroid hormone replacement

Luteal phase defect/unexplained : Progesterone supplementation

Diabetes mellitus: Appropriate management of diabetes, insulin if indicated.

Infectious :Antibiotics for endometritis or underlying infection.

Autoimmune :Low-dose aspirin plus prophylactic LMWH in women without a history of a systemic autoimmune disease such as SLE, or a history of thrombosis.

4.Her brucella serology is found to be positive

How will you treat/ manage this patient?

According to the CDC, doxycycline (Vibramycin) and rifampin (Rifadin) are the recommended antibiotics, taken in combination, for a minimum of six to eight weeks to treat infected patients.

This long treatment time is due to the organism's ability to survive inside human cells; consequently, the CDC recommends that a firm diagnosis be established before long-term antibiotic treatment is begun.

Advise the patient to avoid getting pregnant during this treatment and also that Rifampicin can cause red discoloration of urine and tears.