Recurrent Pregnancy Loss Mala Arora, Justin C Konje
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1RECURRENT PREGNANCY LOSS
(Second Edition)
Editor Mala Arora FRCOG(UK) FICOG FICMCH DA (UK) Chairperson FOGSI Quiz Committee President Faridabad Obstetrics and Gynaecology Society Director Noble Hospital India Co-editor Justin C Konje MD MRCOG Professor Reproductive Sciences Section Department of Cancer Studies and Molecular Medicine University Hospital of Leicester Leicester Royal Infirmary UK
2Published by
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Jaypee Brothers Medical Publishers (P) Ltd
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Recurrent Pregnancy Loss
© 2007, Author/Publisher
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editor and the publisher.
This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editor will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 2003
Second Edition: 2007
9788184480061
Typeset at JPBMP Typesetting Unit
Printed at Paras
3
This book is dedicated with reverence to my Guru Sri Sri Paramhansa Yogananda, who has been the invisible inspiration for writing and updating this book.
To my parents and teachers who have sculpted my intellect.
To my husband and my children (Shruti and Rishi) who have contributed to my learning in an imperceptible way.
To my patients who have been my greatest teachers.
1 Author of the book Autobiography of a Yogi
Founder of Self Realisation Fellowship, Mount Washington California, USA, and Yogoda Satsanga Society of India, Ranchi (India)
4Contributors 7Foreword
Recurrent abortions are frustrating and disheartening to the couple as well as the treating clinician. It is believed that 15–20% of all pregnancies end up as early pregnancy losses. These figures however, are for clinically recognized pregnancies i.e. those pregnancies which are confirmed around 4 to 5 weeks after conception. There is now evidence that the pregnancy loss rate before this period i.e. during the 2 to 3 weeks following conception, may be as high as 50%. The occurrence of recurrent miscarriage in the general population is believed to be around 0.8–1%. This is an adverse life event and a frustrating and heart wrenching experience for both patient and physician. Despite continued research the management of RPL seems to be as elusive as ever. It appears imperative that an interim progress report be called upon. This compilation by Dr. Mala Arora attempts to meet just such a goal.
This second edition, an in depth exploration of recurrent pregnancy loss, considers both scientific and research based work. The authors for each chapter have specially been selected based on their expertise and experience. The contents of most of the chapters have been modified and new contributions included while attempting to retain the originality of the book. This revised and updated text presented in a concise and lucid format has made this edition more reader friendly and will be an essential resource for all clinicians dealing with this elusive subject. Dr. Mala Arora needs to be commended for this well planned and executed treatise which could be a springboard for many clinicians in rising to great heights in the treatment of recurrent pregnancy loss.
In the final analysis the causes and management options of recurrent pregnancy loss are multifarious and varied. Even after a thorough and systematic evaluation, more than half of all women with recurrent pregnancy loss have no identified predisposing factors. Frequent communication, cautious optimism and emotional support during the first trimester of a subsequent pregnancy has its own distinct therapeutic value. Tender loving care with regular antenatal check ups may go a great way in achieving a term live pregnancy.
Kamini A Rao
President, Indian Society for Assisted Reproduction
8Preface to the Second Edition
Homo sapiens are characterised by a high rate of pregnancy wastage both preclinical and clinical. This may be a process of natural selection which allows for survival of the fittest embryo and evolution of species.
Nevertheless Recurrent Pregnancy Loss is a distressing experience for the patient. It also continues to be a Gynaecologists dilemma. Recurrent preclinical losses present as unexplained infertility. Current research is slowly unfolding the mysteries of embryo implantation. We are now able to categorise patients of recurrent pregnancy loss in one of the sections as described in the book. Only then are we able to treat it appropriately in certain circumstances.
Three fields that are showing rapid advancement in knowledge are the genetic, immunological and haematological causes of recurrent pregnancy loss. The role of abnormal cytogenetic studies on preimplantation embryos as studied by PGS and FISH is well documented but whether it is the prima facie cause of foetal demise or is the final common pathway of foetal demise resulting from a hostile intrauterine environment is yet to be elucidated. The role of cytokines and integrins is under close scrutiny, but the treatment modalities are yet to be developed. Haematological abnormalities leading to poor circulation in the developing gestational sac may be a major contributory factor resulting in foetal demise. The diagnostic modality of thromboelastography in deciding the institution of anticoagulant therapy are new developments in the field.
The research in this field is progressing at a phenomenal pace, so as to make the previous edition outdated in just 3 years. It is hoped that future editions will continue to update the reader in this field regularly till we are able to offer hope to all the couples that present to us with recurrent spontaneous pregnancy losses.
Faridabad
Mala Arora
December, 2006
9Preface to the First Edition
Recurrent pregnancy loss has been a gynaecologist's dilemma. The causes are poorly understood and the treatment is mostly empirical. However, current research is slowly unfolding the mysteries of recurrent pregnancy loss and we are now able to categorise it and treat it appropriately in certain circumstances.
The data presented was collected over a period of six and half years and over this period the management protocol was changed according to latest research. The cases illustrated were managed personally.
Two fields that are showing rapid advancement and knowledge are the genetic and immunological causes of recurrent pregnancy loss. It is hoped that this would take a major chunk of the as yet idiopathic causes of RPL.
It is hoped that this book will need updated editions frequently to keep the readers abreast with current research.
Mala Arora
10Acknowledgements
Prof David Price Evans for his valuable comments on the first edition of this book and encouragement to bring out a second edition.
Ms Jayashree, Ms Ruchi, Ms Ritu and Ms Subikha for help in typing the manuscript.
Mr Tarun Duneja General Manager (Publishing), Mrs Bano (Personnel Assistant) and Ms Anju Saxena (Proof reader) at Jaypee Brothers for their help in preparing this work.