WRITE UPS - RECURRENT PREGNANCY LOSS - Ultrasonography in Recurrent Pregnancy loss

A subject with recurrent pregnancy loss comes to you in different ways and in different phases. She may come to you for evaluation after the loss or she may come to you when pregnant again. In both these phases endosongraphy has a vital role to play.

Let us see this clinical situation: Mrs.. A., 23 years female presents with H/o three consecutive pregnancy losses. How will you evaluate her case? Vital points to be asked in this case are :
a) Are these pregnancies confirmed preferably on USG
b) At what weeks did she abort.
c) Were these live abortions or dead abortions. With each answer the approach changes:

If the pregnancies were not confirmed they might not be pregnancies at all. It is then not a case of spontaneous abortion but a case of anovulation. The entire approach now changes. If these were abortions confirmed – then ask as to whether they were live or dead if they were live abortions then there is a strong possibility of anatomical cause. If anatomical cause is suspected Endosongraphy helps you to identify the cause brilliantly. It should now be remembered that I trimester losses could be immunological as well. These are easy to investigate and a request for antiphospholipid antibody is warranted. If this is negative, chromosomal evaluation of Mrs. A, and Mr. is to be taken up now.

Mrs. B, G4 P0 H/o amenorrhea 5 weeks presents with H/o immunological losses How to manage this pregnancy.

This is the time to check for the following features:

 Chorionic Clarity

- Early chorionic sac before appearance of yolk sac 3-5 mm
- Grows by 1-2 mm / day
- Abnormal chorionic sac Õ miscarriage rate Õ 11.5 %

 Yolk  Sac :
Predictor of abnormalities when:
* Size < 2mm or > 5.6 mm.
* Not appeared with MSD > 8 mm
* Solid echogenic appearance
* Asymmetry, crenation, flattening of yolk sac : present.
* Sensitivity as predictor of outcome only 15.6 % .
*  Abnormal sonographic appearance associated with fetal pathologies such as chromosomal abnormalities, partial molar pregnancy, and omphelocoele.

Yolk Sac - Significance
1) Large yolk sac ( > 5-7 mm dia )
2) Small yolk sac ( < 2 mm dia )
3) Irregular or enfolded ( Perhaps reflects sac collapse )
4) Free floating
5) Calcification or yolk sac .
The entire above are the signs of embryonic demise and often precede the fall in HCG levels.

Subchorionic Hemorrhages
* Result from abruption of placental margin or marginal sinus rupture.
* Predominant hemorrhage often remote from placenta
* Acute hemorrhage usually hyperechoic / isoechoic relative to placenta Þ becomes sonolucent in 1 to 2 weeks.
 *Identification of subchorionic hemorrhage associated with : 60-70 % continuation rate with a positive CA .

Embryonic Heart Rate
Progressively increases from 110 beats per min at 5.5. wks. (CRL 3-4 mm) to 171 - 178 beats per/ mt. at 8 wks. (CRL 15 mm). At 9 wks embryonic heart rate reaches a plateau ranging 160 - 190 beats per min. It continues in this range into the second trimester slowing then to the 120 - 160 beats per minute range.

Embryonic bradycardia is considered as a sign of impending fetal loss.
EHR < 85 beats per minute (+- 2 SD) was taken to be sign of impending fetal loss.
Sensitivity of
1) Abnormal EHR in predicting fetal loss - 65 %
2) Normal EHR predicated ( N) outcome - 98 %.
A rapid EHR:
2 possible explanations :-
1) Embryo smaller than it should be reflecting its reduced growth capacity.
2) EHR > 200 may reflect infection

A CRL - gestational sac diameter mismatch is a sign of impending fetal demise.
Slow rate of CRL growth is suggestive of impending fetal demise.

Amniotic Sac:
Failure of the amniotic sac to grow in all directions toward the chorion.

Gestational Sac:
Irregular outline of gestational sac .

Empty gestational sac.
> 16 mm diameter by TAS
> 8 mm diameter by TVS

Treatment protocol established in these cases was according to the degree of positivity. We classified <10 GPL as negative, 10-20 as weakly positive, 20 to 100 as moderately positive and more than 100 as strongly positive. For weak and moderate positive cases, we gave low dose aspirin 1.2 mg/kg./day in the interval period. Than allowed a conception. We restarted aspirin at 12 weeks and went on to give for 36 weeks. In strong positive cases we gave prednisolone in a dose of 10-20 mg/day for three months in the interval period allowed a conception and then started aspirin in the some dose from 12 weeks to 36 wks.

Colour Doppler also helps in this:

Following qualitative observations documented on colour doppler
Abnormal Pregnancy   Trophoblastic flow   Corpus luteum flow
Embryonic demise       Poor of absent           Normal
Anembryonic              Normal                      Normal
Deficient CL               Normal                       Poor or absent
Chromosomal             Normal                       Normal

Mrs. D, G4-P0 has immunological causes of these pregnancy losses. Last time she did not respond to the treatment protocol. She is now fitting into those 8-11 % cases, who are of refractory APA. Continuous aspirin therapy is now a days being recommended for this.

K Mrs. E, G4 P0, presents with anatomical cause for losses treated surgically. How to manage this pregnancy.

The optimal treatment for uterine anomalies is still a matter of debate. Open surgical correction of congenital anomalies has been reported to give successful subsequent pregnancy outcome but may be associated with significant postoperative infertility of pelvic adhesions.

Value of treatment in recurrent pregnancy loss

Majority of studies of RPL on uterine anomalies are without  control, comparing miscarriage rate  before and after treatment in the same woman. Interpretation of results - flawed. Hysteroscopic techniques are attractive, but results from randomized control studies are lacking. Cervical incompetence -?  Over diagnosed.

Thus Endovaginal sonography has completely changed our approach and management to cases of R.P.L. and will continue to do so in the decades to follow



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