The clinical management of repeated early pregnancy wastage

A small T-shaped uterus with cavity constrictions is common in DES daughters

1983 Study Abstract

A rational systematic evaluation is essential to the management of a couple with repeated early pregnancy wastage. Psychologic support in the form of frequent discussions and sympathetic counseling are crucial to the successful evaluation and treatment of the anxious couple. A prompt and orderly evaluation will relieve anxiety. When no etiologic factor is identified, a 60% to 80% fetal salvage rate may be expected. Once a patient conceives, serial ultrasonography, beta-hCG determination, and estradiol determination may be useful in detecting the stage of the embryonic death if subsequent abortion occurs. A karyotypic analysis of the products of conception should be performed if fetal loss occurs.

PIP: This review of the current literature on the clinical management of repeated early pregnancy wastage focuses on several etiologic factors (i.e., genetic, medical, immunologic, endocrine, psychogenic, environmental, occupational, infectious, and uterine) which have been noted to result in repeated pregnancy wastage. Suggestions for further clinical study are outlined where appropriate, and a rational approach to clinical evaluation and management is provided, based on the interpretation of the state of the art. The frequency of clinically recognized spontaneous abortion in the general population has been estimated to range between 15-20%. The actual spontaneous abortion rate is difficult to determine due to the fact that some patients do not seek medical services and abort completely at home. Despite the present uncertainty concerning the actual risk of recurrent abortion, most clinicians agree that repeated early spontaneous pregnancy wastage (i.e., repeated pregnancy loss) is defined as the occurrence of 3 or more pregnancy losses prior to the 20th week of gestation. From cytogenetic studies of aborted products of conception, chromosomal abnormalities account for between 50-60% of spontaneous abortions in the 1st trimester of pregnancy. Most of the chromosomal aberrations involved in spontaneous abortions have been presumed to be due to random events that are not necessarily repetitious. Sporadic chromosomal errors account for approximately 30% of spontaneous pregnancy losses, and repeated pregnancy loss under these conditions would therefore occur as a matter of chance and would not be predictive of future pregnancy loss. Several medical diseases have been implicated in causing habitual abortion, and these include systemic lupus erythematosus, congenital cardiac disease, and renal disease. The severity of the disease correlates best with fetal wastage. An absence of blocking antibodies within the serum of women with repeated abortions was reported by Rocklin et al. A review of the literature shows that only an association exists between psychologic disturbances and habitual abortion. Intrauterine infection may result in early pregnancy wastage, and fetal death may result from an acute overwhelming infection. It has long been recognized that congenital anomalies of the uterus have been responsible in some instances for reproductive failure. The gynecologist must consider the time of initiation of an evaluation of a patient with reproductive loss. Any evaluation must include a complete history and a karyotypic analysis with fluorescent banding of both partners, a hysterogram, and a properly timed endometrial biopsy. In the authors’ experience, about 50% of patients with repeated pregnancy loss have no discernible etiologic factor. Subsequent early pregnancy should be carefully monitored in these patients. When no etiologic factor is identfied, a 60-80% fetal salvage rate may be expected.

Uterine Anomalies Associated with Diethylstilbestrol Exposure in Utero

Kaufman and associates performed hysterosalpingographic examinations of 267 women who had been exposed in utero to diethylstilbestrol (DES). One hundred
eighty-five (69%) of these women demonstrated an abnormality, and 82 women had normal findings. The pregnancy outcome among 93 women who conceived was significantly worse than that found in a control population of 87 women. Abnormalities on the hysterogram included a small T-shaped uterus with cavity constrictions.

The T-shaped uterus is the most commonly noted abnormality. Haney and Hammond recorded various uterine measurements, which revealed a reduced surface area of the endometrium of these patients, as compared with a suitable control population. Nevertheless, there was no increased incidence of pregnancy loss in patients enrolled in the National Cooperative Diethylstilbestrol Adenosis Project. Rosenfeld and Bronson noted that 3 of 25 DES-exposed women reported repeated abortion of three or more pregnancies. One of these patients conceived without therapy and carried to term. Thus, there is little evidence that the uterine defects associated with DES exposure in utero are associated with recurrent early pregnancy wastage.

Sources and more information
  • Full study (free access) PDF : The clinical management of repeated early pregnancy wastage, Fertility and Sterility Vol. 39, No.2, February 1983, Rock and Zacur, Habitual abortion, NCBI PubMed PMID: 6337066, 1987.
  • Uterus of daughter associated with maternal exposure of DES. Note the T shape with the irregular cavity and constriction featured image credit fertstert 11/18.

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