Atualidades em perda gestacional de repetição: definição, diagnóstico e propedêutica / Current guidelines for recurrent pregnancy loss: definition, diagnostic tests and investigation

Classicamente, a perda gestacional de repetição (PGR) é a ocorrência de três ou mais perdas consecutivas antes de 20 semanas de gestação. Entretanto, as diretrizes para definição, propedêutica e tratamento são controversas. As causas de PGR podem ser multifatoriais e incluem alterações anatômicas do útero, distúrbios endócrinos, alterações imunológicas, infecções, alterações genéticas, obesidade materna, entre outras. Entretanto, na maioria dos casos, a causa de PGR é desconhecida. Os protocolos para o diagnóstico de PGR variam muito e são direcionados à pesquisa de possíveis fatores causais. Neste artigo foi realizada uma revisão e comparação das últimas diretrizes para diagnóstico e propedêutica das causas de PGR da Sociedade Europeia de Reprodução Humana e Embriologia (ESHRE), da Sociedade Americana de Medicina Reprodutiva (ASRM) e do Royal College of Obstetricians and Gynaecologists (RCOG).(AU)

Recurrent pregnancy loss (RPL) is traditionally defined by the occurrence of three or more consecutive losses before 20 weeks of gestation. The guidelines for definition, investigations and treatments are controversial. The causes of RPL can be multifactorial and includes structural uterine anomalies, endocrine alterations, immunological dysfunction, infections, genetic anomalies, maternal obesity, among others. However, in most cases the cause of RPL is unknown. The diagnosis protocols of RPL vary widely and causal factors are the major goal. In this article, we review and compare the latest RPL diagnosis and investigations guidelines, including the European Society for Human Reproduction and Embryology (ESHRE), American Society for Reproductive Medicine (ASRM) and the UK Royal College of Obstetricians and Gynaecologists (RCOG).(AU)

Aborto recurrente / Recurrent pregnancy loss

Aproximadamente 1-3 por ciento de parejas en edad reproductiva experimentan 3 ó más abortos espontáneos consecutivos, lo que se define como aborto recurrente. La evaluación debe incluir una detallada historia clínica y examen físico, seguida de una serie de exámenes protocolizados destinados a detectar los factores más frecuentemente involucrados en esta patología (anatómico, cromosómico, inmunológico, endocrinológico y trombofílico). El manejo debe basarse en evidencias, evitando tratamientos experimentales o sin sustento científico, e incluyendo siempre un adecuado soporte emocional, tan necesario en estas parejas. A pesar de los esfuerzos por dilucidar los orígenes del aborto recurrente, sigue existiendo un 50 por ciento de casos sin causa aparente, los cuales suelen lograr tasas de embarazo exitoso de hasta 70 por ciento sin mediar tratamiento médico alguno.

Approximately 1-3 percent of reproductive age couples experience3 or more consecutive pregnancy losses, which is known as recurrent pregnancy loss. The evaluation must include a detailed clinical history and physical examination, followed by a diagnostic screening protocol in order to detect the most frequent factors involved in this disorder (anatomic, chromosomic, immunologic endocrinologic and thrombophilic). Management must be evidenced based, avoiding experimental or unproven treatments, and always including an adequate emotional support, so necessary for these couples. In spite of every effort made to find out the origins of recurrent pregnancy loss, 50 percent of couples remain with unknown diagnosis, however, they may reach up to 70 percent of successful future pregnancies even without medical treatment.

Hysteroscopy - 3 Years experience at a Teaching Hospital

To evaluate the indications, effectiveness and safety of hysteroscopy in Gynaecological surgery. Design, A retrospective observational study from January 2003 to December 2005 at Fatima Memorial Hospital, Lahore. 76 patients who presented in the outpatient department of Gynae and Obstetrics at Fatima Memorial Hospital, Lahore with the following complaints including abnormal uterine bleeding, infertility, recurrent abortions and secondary amenorrhea were included in the study. They were pre-operatively investigated and admitted a day prior to the surgery and discharged usually within 24 hours postoperatively. The subsequent follow-up was done in outpatient department. All the data was recorded and then subsequently analyzed. 76 patients were inducted in the study. Out of these 36 [47%] had infertility 20 [26.3%] had abnormal uterine bleeding, 8 patients [10.5%] had recurrent abortions, 8 [10.5%] presented with secondary amenorrhea, 3 patients [3.9%] presented with lost IUCD and one patient [l.3%] had follow-up hysteroscopy after resection of intra- uterine septum. Hysteroscopic findings revealed intra-uterine adhesions in 8 [10.5%], submucous fibroids in 15 [19.7%], endometrial polyp in 10 [13.l%] uterine septa in 8 [10.5%], atrophic endometrium in 9 [11.8%] while there was no abnormal finding in 26 [34.2%] patients. Two patients [0.6%] sustained uterine perforations, which were diagnosed and managed during operation but no other complication occurred. Hysteroscopy is an excellent tool to perform intra-uterine adhesiolysis, polypectomy, submucous myomectomy and endometrial ablation. In addition to being a quicker, less invasive and low risk procedure, it has got the advantage of being cheap with a shorter hospital stay and diminished recovery time. Hysteroscopy, both diagnostic and operative should be an integral part of gynaecological surgery in the teaching units

Recurrent pregnancy loss.

Recurrent abortions are hisheartening to the couple and also to the treating clinicians. Miscarriage is the loss of pregnancy weighing 500 g or less. Recurrent miscarriage or habitual abortion is defined as three or more consective abortions. Important factors involved in recurrent early pregnancy loss are genetic factors, endocrine factors, anatomic factors, immunologic factors, infectious factors and environmental factors. The factors are described in a nutshell in the text. Any severe infection that leads to bacteraemia orviraemia can cause sporadic miscarriage. Congenital uterine abnormalities have been associated most often with second-trimestar pregnancy loss. As regarding management of recurrent pregnancy loss the clinician has limited options. The use of aspiration in low dose (75 mg) and heparin is beneficial in APS positive patients. Multivitamins and folic acid assume importance in thrombophilic disorders. Tender live care with regular antenatal check-ups go a great way in achieving live term pregnancy.

Revisión: Aborto recurrente / Review: Recurrent abortion

El aborto recurrente (AR) es una patología relativamente infrecuente, pero de difícil manejo tanto desde el punto de vista técnico como de la relación medico-paciente. Suele ser muy frustrante para las parejas que lo padecen, su estudio es dificultoso y presenta diversas etiologías: genéticas, anatómicas, endocrinas, autoinmunes, aloinmunes, infecciosas y ambientales, cuyo estudio a la fecha es insuficiente. Una vez establecido el diagnóstico de AR, el manejo debe ser de especialista en el área de la reproducción humana. La presente revisión tiene como objetivo actualizar las principales teorías y causas involucradas en el AR, contrastándolas con la evidencia científica disponible hasta el momento, así como también esbozar brevemente la aproximación diagnóstica y el enfoque terapéutico.

Diagnóstico inmunológico y terapia del aborto recurrente espontáneo

Se presenta una recopilación del diagnóstico inmunológico y los resultados preliminares del tratamiento, en parejas con aborto recurrente espontáneo atendidas en el Programa de Reproducción de la Universidad de Antioquia, en el período comprendido entre febrero de 1991 y noviembre de 1995.

La aloinmunoterapia en aborto habitual. una controversia abierta

Se presenta una revisión crítica de los resultados del Meta-análisis del Estudio Colaborativo Internacional sobre Inmunoterapia en Aborto habitual y se discuten los principales puntos de controversia, a la luz del VI Congreso Internacional de Inmunología de laReproducción, en Washington, julio de 1995

Cerclaje cervical / Cervical cerclage

The author studies the result of cervical cerclage carried out by him on seven multi-pregnant women (between 10-28 weeks gestation, of whom five had not borne any children) and on one woman who is pregnant for the first time (twins, at 12 weeks gestation) because of threatened abortion which usually would occur in the second trimester of the pregnancy, due to shortening and premature opening of the cervical os which leads to the protrusion of the membranes with interruption of the pregnancy. The author describes his patients' symptoms and signs, the week of pregnancy at which the operation was performed, vaginally, the urgent conditions which prompted the operation, the frequency of abortion and the condition of the child at the end of the pregnancy

Pérdida recurrente del embarazo en pacientes con anticuerpos anticardiolipinas; AACL / Recurrent pregnancy lost in patients with anticardiolipin antibodies

Se presenta la experiencia en 7 pacientes con antecedentes de pérdida recurrente del embarazo (x=3,7 rango 2-6) con AACL(+) en las cuales se descartó otra etiología; éstas pacientes totalizaban 26 gestaciones no tratadas concluidas en 24 pérdidas fetales (constando en 9 la muerte fetal in útero) y 2 RN vivos. La duración promedio de esas gestaciones fue 17,4 semanas (rango 8-37). Fueron tratadas con prednisona 20 mg/día y ASA 100 mg/día obteniéndose 7 RN vivos y 1 mortinato. En todas las pacientes se obtuvo descenso de los AACL. La duración promedio de las gestaciones tratadas fue de 31,7 semanas (rango 26-28). Se concluye que la presencia de AACL se correlaciona con alta mortalidad y bajo peso fetal y que con el tratamiento se obtiene gestaciones significativamente más largas que en las no tratadas y mayor relación de niños vivos respecto al número de embarazos

Ultrasonographic evaluation of cervical changes in habitual abortion

This study included 40 pregnant women divided into two groups: Habitual abortion group: which included 25 pregnant women [13 in first and 12 in the second trimester], between 8-24 weeks gestation. All were diagnosed clinically and laboratory to be cases of habitual abortion due to incompetent os, and cervical cerclage was planned for their treatment. Control group: which included 15 pregnant women [8 in the first and 7 in the second trimester], they were within the same gestational age, and with normal obstetric history. Cases of both groups were submitted for ultrasonographic examination for cervical measurements. The diagnostic reliability of cervical incompetence by ultrasound is discussed