Author: Kajal mangukiya

Recurrent pregnancy loss 

Definition of Recurrent Pregnancy Loss:
➡️Spontaneous & recurrent abortion occurring consecutively 3 or more occasions
➡️Maybe primary or secondary, if it occurs after the birth of viable babies 

What Causes Recurrent Pregnancy Loss?
➡️Most pregnancy losses result from chromosomal, or genetic, abnormalities, and are random events. The abnormality may come from the egg, the sperm, or the early embryo. Approximately 12-15% of all clinically recognized pregnancies end in miscarriage; however, it is estimated that at least 30-60% of all conceptions will end within the first 12 weeks of gestation. Up to 50% of the time, the woman doesn’t even realize that she was ever pregnant. The risk of miscarriage increases with the number of previous pregnancy losses, but is typically less than 50%.

(A.) Maternal 

    •    Systemic disorders like syphilis infection, diabetes mellitus, chronic nephritis, essential hypertension and Rh- incompatibility 

    •    Hormonal 
    ⁃    Luteal phase defect (progesterone deficiency)
    ⁃    Polycystic ovarian disease (hypersecretion of luteinising hormone)
    ⁃    Presence of thyroid auto antibodies 

    •    Cervical incompetence (occurs after 14th week of gestation)

    •    Development abnormalities of the uterus 
    ⁃    septate uterus 
    ⁃    Bicornuate uterus

    •    Immunologic causes:
    ⁃    Autoimmunity 
    ⁃    Antibodies responsible are antinuclear antibodies, anti DNA antibodies, anti phospholipid antibodies.
    ⁃    Allo immunity (failure of maternal recognition of trophoblast lymphocyte cross-reactive antigen) TLX. Consequently lack of production of blocking antibodies by the mother. Due to sharing of HLA between the partners.

    •    Infection in the genital tract 

(B.) Foetal ➡️ chromosomal defects

(C.) Idiopathic (Unexplained Recurrent Pregnancy Loss)
➡️Over one-half of patients with recurrent pregnancy loss will have unexplained recurrent pregnancy loss, which means that no specific cause could be identified in the work-up.

(D.) Paternal causes of infertility 
➡️Husband’s genetic defects in the sperm can also lead to Bad Obstetric history. There are various factors that can lead to RPL such as increased consumption of alcohol, chronic smokers or drug users, extreme work environment, injuries to private parts, infection in childhood or chronic health problems (eg: diabetes, obesity, hypertension)

What Tests are Done for Couples with Recurrent Pregnancy Loss?

➡️First, a physician will take a detailed medical, surgical, family, and genetic history and perform a physical examination. Testing that may be done include karyotype analysis of both partners. The karyotype is the chromosomal, or genetic, make-up of a person. The purpose is to find abnormalities in the parents that could be passed on to the offspring, resulting in miscarriage. Because karyotype abnormalities are relatively rare, a doctor may choose to not perform this test unless other, more common, abnormalities are ruled out.

➡️Preconception stage 
    ⁃    Blood group & RH typing of both (male & female)
    ⁃    Haemoglobin estimation, complete blood count
    ⁃    Karyotyping of both (male & female)
    ⁃    Urine routine examination, microscopy and culture 
    ⁃    Glucose tolerance test
    ⁃    Liver, renal & thyroid function test
    ⁃    TORCH titre estimation 
    ⁃    Anti phospholipid antibodies 
    ⁃    Hysterosalpingogram
    ⁃    Cervical swab culture: Listeria & chlamydia known to cause recurrent abortions. 
    ⁃    Sperm aneuploidy test for males

Treatment of Recurrent Pregnancy Loss
    1.    Surgery
    2.    Blood-thinning medicines 
    3.    Correcting other medical problems
Treating medical conditions such as diabetes, thyroid dysfunction, or high prolactin levels can improve the chances of having a healthy, full-term pregnancy.

    4.    Genetic screening
    5.    Lifestyle Choices
In general, whatever is healthy for a woman improves the chance of a healthy pregnancy. Both the partners should Stop cigarette smoking and illicit drug use (such as cocaine) will lower the risk for miscarriage. Limiting alcohol and caffeine intake may also help. Being overweight has been linked with increased risk of miscarriage, so healthy weight loss might also help pregnancy outcomes. There is no proof that stress, anxiety, or mild depression causes RPL. However, these are important problems that go along with RPL. Psychological support and counseling can help couples cope with the emotional pain of miscarriage and create a healthy environment for a pregnancy.

Cervical cancer is a type of cancer that occurs in the cells of the cervix — the lower part of the uterus that connects to the vagina.
Various strains of the human papillomavirus (HPV), a sexually transmitted infection, play a role in causing most cervical cancer.

When exposed to HPV, the body’s immune system typically prevents the virus from doing harm. In a small percentage of people, however, the virus survives for years, contributing to the process that causes some cervical cells to become cancer cells.
You can reduce your risk of developing cervical cancer by having screening tests and receiving a vaccine that protects against HPV infection.

Symptoms

Early-stage cervical cancer generally produces no signs or symptoms.
Signs and symptoms of more-advanced cervical cancer include:
    •    Vaginal bleeding after intercourse, between periods or after menopause
    •    Watery, bloody vaginal discharge that may be heavy and have a foul odor
    •    Pelvic pain or pain during intercourse
 

Causes

Cervical cancer begins when healthy cells in the cervix develop changes (mutations) in their DNA. A cell’s DNA contains the instructions that tell a cell what to do.

Healthy cells grow and multiply at a set rate, eventually dying at a set time. The mutations tell the cells to grow and multiply out of control, and they don’t die. The accumulating abnormal cells form a mass (tumor). Cancer cells invade nearby tissues and can break off from a tumor to spread (metastasize) elsewhere in the body.
It isn’t clear what causes cervical cancer, but it’s certain that HPV plays a role. HPV is very common, and most people with the virus never develop cancer. This means other factors — such as your environment or your lifestyle choices — also determine whether you’ll develop cervical cancer.

Types of cervical cancer
The type of cervical cancer that you have helps determine your prognosis and treatment. The main types of cervical cancer are:
    •    Squamous cell carcinoma. This type of cervical cancer begins in the thin, flat cells (squamous cells) lining the outer part of the cervix, which projects into the vagina. Most cervical cancers are squamous cell carcinomas.
    •    Adenocarcinoma. This type of cervical cancer begins in the column-shaped glandular cells that line the cervical canal.
Sometimes, both types of cells are involved in cervical cancer. Very rarely, cancer occurs in other cells in the cervix.
 

Risk factors:
Risk factors for cervical cancer include:
    •    Many sexual partners. The greater your number of sexual partners — and the greater your partner’s number of sexual partners — the greater your chance of acquiring HPV.
    •    Early sexual activity. Having sex at an early age increases your risk of HPV.
    •    Other sexually transmitted infections (STIs). Having other STIs — such as chlamydia, gonorrhea, syphilis and HIV/AIDS — increases your risk of HPV.
    •    A weakened immune system. You may be more likely to develop cervical cancer if your immune system is weakened by another health condition and you have HPV.
    •    Smoking. Smoking is associated with squamous cell cervical cancer.
    •    Exposure to miscarriage prevention drug. If your mother took a drug called diethylstilbestrol (DES) while pregnant in the 1950s, you may have an increased risk of a certain type of cervical cancer called clear cell adenocarcinoma.
 

Prevention:
To reduce your risk of cervical cancer:
    •    Ask your doctor about the HPV vaccine. Receiving a vaccination to prevent HPV infection may reduce your risk of cervical cancer and other HPV-related cancers. Ask your doctor whether an HPV vaccine is appropriate for you.
    •    Have routine Pap tests. Pap tests can detect precancerous conditions of the cervix, so they can be monitored or treated in order to prevent cervical cancer. Most medical organizations suggest beginning routine Pap tests at age 21 and repeating them every few years.
    •    Practice safe sex. Reduce your risk of cervical cancer by taking measures to prevent sexually transmitted infections, such as using a condom every time you have sex and limiting the number of sexual partners you have.
    •    Don’t smoke. If you don’t smoke, don’t start. If you do smoke, talk to your doctor about strategies to help you quit.

One year ago, a 32 years old female, married since 10years came to orkid hospital and IVF center with 5th pregnancy and complaint of missed abortion including past history of recurrent spontaneous miscarriage. Dr. Kajal Mangukiya advised the patient to go for D&E procedure to clear the retained products of conception.
Moreover, the distressed couple also wanted to know the reason behind this problem and desperately needed a way out. Our expert consultant obstetrician Dr. Kajal Mangukiya advised the patient to go for particular tests done for her recurrent pregnancy losses to rule out the exact cause of such mishappenings. It was a shocking news that the reports indicated HbA1C of 13.9 and RBS was 450mg/dl. Thus with the years experience and knowledge of our consultant obstetrician and gynaecologist ruled out that she was a chronic type 2 diabetes mellitus which could be the reason behind previous recurrent abortion. She was then referred to specialist consultant of endocrinology, Dr. Pradeep Dalwadi and started appropriate treatment to control her chronic diabetes. After bringing the HbA1C value to less than 7, our senior consultant Dr. Kajal Mangukiya did the routine sonography and found second part of hurdle that her antral follicle count was very low which suggested poor ovarian reserve. Hence, with the knowledge and experience of 16years our infertility specialist  Dr. Kajal Mangukiya advised the patient that her best possible treatment option is to go for IVF and without any hesitations, the couple agreed as they had full faith on our consultant Dr. Kajal Mangukiya. The patient conceived in the first cycle itself at orkid hospital and IVF center. However, this wasn’t all. As she came positive in her pregnancy test, this case was categorised as high risk pregnancy with advanced age and bad obstetric history. Additionally, with constant monitoring and regular check ups, the pregnancy went by uneventful. However, she developed preterm rupture of membranes. Hence, she was taken for emergency cessarian section and delivered healthy baby girl weighing 2kgs. Even with preterm delivery, the baby showed no signs of distress and mother is also stable with controlled glucose levels.

“Once you choose hope, anything’s possible”

Girls with MRKH have normal external female genitalia with a markedly shortened vagina. In some cases, uterine remnants are present with or without endometrium. All patients with MRKH have normally functioning ovaries, although they are sometimes found in atypical locations. MRKH is not uncommon & has an incidence of approximately one in 4000-5000 female births. It is typically diagnosed during adolescence, during workup and evaluation for primary amenorrhea which is defined as absence of menses at the age of 15 regardless of secondary sexual characteristics.

There are two types of MRKH,

Type1 MRKH – Isolated Mullerian agenesis
Type2 MRKH – Mullerian agenesis with another associated congenital anomaly

Evaluation of primary amenorrhea
When menstruation has not occurred by:
• By age 15
• 3 years after thelarche
• By age 13 & lack of breast development
• By age 14 with signs of hirsutism
• By age 14 with h/o painful intercourse or examination suggesting short vagina.

History:
⁃ CNS symptoms
⁃ Pubertal development
⁃ Obstructive symptoms
⁃ Symptoms of Hyperandrogenism
⁃ Stress, diet or exercise changed
⁃ Medication

Physical examination:
⁃ Growth curves
⁃ Tanner stages
⁃ External genital exam
⁃ Skin for hirsutism, acne or/& striae
⁃ Turner stigmata

Pelvic ultrasound
Laboratory investigations:
⁃ UPT (urine pregnancy test)
⁃ FSH, E2, TSH
⁃ Serum Testosterone
⁃ Karyotyping

Genital Examination
• External inspection
• Labial traction
• Lubricated Q-tip to evaluate depth (if tolerated by the patient)
• No speculum (with suspected vaginal agenesis)

Differential Diagnosis for a patient with primary amenorrhea & a shortened vagina
1. Obstructing vaginal or uterine anomalies
2. Imperforated hymen
3. Transverse vaginal septum
4. Distal vaginal agenesis
5. Complete androgen insensitivity syndrome (i.e difference of sex development)

MRKH Evaluation:
1. Examination, Imagining, Labs
2. Renal ultrasound
3. Spinal x-ray

Q. When to refer to a pediatrician & Adolescent Gynaecologist?
• Psychosocial support and counseling
• Management of uterine remnants
• Vaginal creation
• Fertility counseling