EBCOG P1 – 3 Month – Reproductive medicine – Recurrent pregnancy loss- Day 1 EMQ

A. Asherman’s syndrome
B. Autoimmune dysfunction
C. Anti-thrombin III deficiency
D. Antiphospholipid syndrome (APS)
E. Bacterial vaginosis
F. Hypoplastic uterus
G. Hyperhomocysteinaemia
H. Cervical weakness
I. Protein C deficiency
J. Protein S deficiency
K. Lupus anticoagulant
L. Protein Z deficiency
M. Hypothyroidism
N. Unexplained (idiopathic)
O. Polycystic ovary syndrome
P. Uterine fibroids
Instructions: For each of the following case scenarios, choose from the option list above the single most likely cause of the recurrent miscarriage. Each option may be selected once, more than once or not at all.
1) A 38-year-old P1+3 presents after her third miscarriage for investigations. The miscarriages were at 10, 9 and 8 weeks, respectively. Her periods are regular but very heavy. Her hormone profile was as follows:
Prolactin = 578 mIU/L (normal up to 400 mIU/L),
LH = 6.4 IU/L,
FSH = 6.4 IU/L,
TSH = 3.4 mIU/L and free T4 = 12 pmol/L.
An ultrasound of the pelvic organs revealed a normal left ovary and a right ovary with suspicions of PCOS: the uterus was described as enlarged and containing a 4 X 6 cm submucous fibroid located in the upper part of the uterus.

2) A 32 year old presented to the recurrent miscarriage clinic after her third miscarriage. The miscarriages were all at around 8–10 weeks. On each occasion, she had an ultrasound scan at 6 weeks which showed a viable intrauterine pregnancy. However, on each occasion she bled and a further ultrasound scan at 8 weeks revealed an absent fetal heart. A thrombophilia screen has so far been negative. Her hormone profile is normal but the rest of the investigations are awaited.

Miscarriages occurring after the eighth week of gestation, and after fetal viability has been confirmed on ultrasound scan, will point to the APS even though the thrombophilia screen was negative. Autoimmune dysfunction is a recognized cause, but it is not as common as APS.
EMQ
A. Repeat test after 12 week
B. Aspirin in pregnancy
C. Aspirin +LMWH in pregnancy
D. Repeat test immediately
E. Start Aspirin + LMWH immediately
F. Laparoscopic interval cervical cerclage
G. Serial cervical length measurements from 14-16 weeks
H. Abdominal cerclage during pregnancy at 10-11 weeks
I. Mc Donald’s cerclage
J. Shirodkar cerclage
K. Cervical length measurements offered from 14-16 weeks and cerclage considered if Cervical length ≤25mm
L. Aspirin
M. Heparin and aspirin
N. Heparin only
O. Reassurance


3. A 32 yrs old women with history of recurrent miscarriages. Het Anticardiolipin antibodies in her initial visit were high. what will be your advice?

4.A 28 yrs old woman who had previous 3 miscarriage with all miscarriages happening between 18-20 weeks. The most appropriate management option would be?

5.Patient presented with a history of previous 3 miscarriages of 1st trimesters. On investigations value of antiphospholid antibody was 20g/l (<40g/l) thrombophilia screening was also normal, factor 5 Leiden was within normal limits. When pregnant what is the best treatment option for her.