WRITE UPS - PERI-CONCEPTION - Issues In Peri-Conception Care


Issues In Peri-Conception Care


Peri-conception care is rapidly becoming a specialized area in obstetrics. It has got many new developments and thanks to a high failure rate of nidation and sustenance of pregnancy in ART, this subject has become all the more important.


A blastocyst is a friendly being. It loves to make friends with many a mucosa. As soon as it arrives into existence, it knows it has to nidate – it has to make a home. It simultaneously starts talking with different mucosae. All mucosae of the genital tract are by and large sensitive to its talks. This friendliness can cause ectopic pregnancies. It has got a great enticing capacity. Usually all mucosae other than uterine pay limited heed to its signals. But sometimes they too respond and respond quickly. If such a response occurs from fallopian tube – tubal ectopic pregnancy results.


It lures the mucosa to allow it not only to stick to the mucosa but also burrow through. It is not an encroacher however. It is a nice being that knows its limitations and stops burrowing at a particular point. If it does not stop: an adherent placenta is the result. Also, all this has to be finely tuned and coordinated.
  HCG has a vital role in this! As the conductor of the orchestra, HCG generates a series of immunologicaly active substances that act like messengers and ambassadors of the blastocyst going to the endometrium (now the decidua) queering the pitch for a successful and lasting nidation. Clinical result is a successful pregnancy outcome. This could be one of the bases of the use of HCG in clinical practice for cases of pregnancy loss.


This HCG is released by the blastocyst in very early days of its development. So, not only should the blastocyst release HCG in high amounts, but also at a great speed. Thus in a very short time it has to respond very quickly. If it fails, there will be a deficient or an uncoordinated cross talk and the conceptus doesn’t nidate well. If this occurs it results in: Menstrual Abortions and Spontaneous Early First Trimester Abortion.

  Thus this cross talk opens up new vistas in explaining:-

bEctopic pregnancies
bMorbid adhesions of placenta
bPlacenta previa
bInfertility and abortions in endometriosis
bDifference in fertilization: conception rates with ovulogens
bIncreasing uterine receptivity
bInterception in contraception.


HCG in periconception care: There is another aspect of HCG as well. In late 1996 there were reports that indicated that HCG helps in preventing pregnancy loss because it is contaminated by growth factors. It is now well known that HCG has a strong immunological face. Infact late 1997 and early 1998 strongly hinted at a similarity in structure between GF and HCG. Only within six months of this research it was proved that HCG itself is the growth factor. It is therefore understandable why HCG administration is much more successful than progesterone in recurrent pregnancy loss and even prevention of immunological growth retardation.


This is a clinical break through. So when one administers HCG in recurrent pregnancy loss you are not administering a hormone but an immunological substance.


This is not a case for indiscriminate use of HCG in maintaining pregnancies. That will not help. In carefully selected cases where there are reasons to believe that an immunological cause is working –HCG helps. It was again too simplistic to practice periconception care by assessing circulating levels of HCG. If HCG levels were low supplement it with HCG and maintain. This is not rational at all. There is no arithmetic additions in maintaining pregnancy.


Threatened abortion: On its way out! With every bleeding in periconception period now being explainable, in the realms of periconception care the term “threatened abortion” is fast becoming obsolete.


Immunology of Recurrent Pregnancy Loss: 40% of losses in RSA could be due to immunology. There are two basic causes : allo-immune and auto-immune.

Allo-immune: - A conceptus of 3000grms is tolerated, protected and nourished by the mother for 280 days. After birth even 30 grams of say renal tissue of that conceptus is not tolerated and immune rejection occurs why? Husbands renal tissue transplanted in the mother during pregnancy is not accepted: How his conceptus is accepted: How come?

At feto-maternal interface when the mature immune system senses that a different immune system has arrived it mounts a protective response

This is through the syncitio-trophoblasts. Functioning of the trophoblasts is such that it will sense only on immunologicaly distinct entity. Infact if it is immunologicaly similar, the syncitiotrophoblast will not sense and the mother’s immune system will destroy it. This can occur repeatedly and results in RSA.

This can be applied in renal transplants or any other transplants. If transplant scientists can create an artificial trophoblast like shield around the donated organ, once again the recipient will protect it and there will be no rejection. Infact, then after tissue typing HLA testing and all will become obsolete because you will require the donor and the recipient to be different and not similar as in the case of the conceptus. If they are similar then there will be a problem of total rejection now.

For alloimmune causes treatment modalities like paternal leukocyte transfusion and alike or so-called immune potentiation, have been found to be irrational, unethical and even dangerous. In current literature they have no validity and be therefore discontinued.

If at all anything helps: 1) HCG: immunological face and                 2) Immunoglobulins (empirically)

Auto immune: many syndrome antibodies are implicated. But most influential and consistent have been antiphospholipid antibodies. These
generate a vasculopathy by preventing the second wave of migration of trophoblasts. Sludging of platelets in these vacant spaces and covering of trophoblasts by fibrin and like material serving as a barrier


Negative  ® <10 GPL units
Low positive  ®10-20 GPL units
Mod. Positive         ® 20-100 GPL units
Strong positive ® > 100 GPL units


Once the diagnosis is well established, treatment plans are instituted.


Nearly 18 different protocols have been tried over the period of years for the treatment of APA syndrome. But the main stay is Heparin, Low dose Aspirin and corticosteroids.

 We use the following protocol:

In interval period :
® For low and moderate positive: Aspirin in a dose of 1.2 mg/kg./day till conception – Allow a conception – Restart aspirin in the same dose from 12 to 36 weeks.

®For High positive: Prednisolone in a dose of 10 mgms./day till conception in the interval period. Allow conception- start aspirin from 12 weeks upto 36 weeks.

In Pregnancy:

® For these cases we give only the post-conception protocol of aspirin as specified
This is where aspirin helps. Recent literature has also shown an upcoming role of nitric oxide donors with aspirin. This will treat the cause as well as the effects.

 Carry home messages:

Peri conception care is a separate speciality
Blastocyst talks with the endometrium to achieve a successful outcome. If this fails a bizarre array of clinical effects can result
HCG is not only an endocrinal molecule. It has a more important immunological face
Supplementing HCG has a rationale in pregnancy loss at blastocyst endometrium cross talk level and at the level of immune supplementation.
Threatened abortion is on its way out
APA has an important role in R.S.A.
Aspirin corticosteroids and heparin are used successfully to treat these cases



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