Recurrent Pregnancy Loss: Evidence-Based Evaluation, Diagnosis and Treatment

211 Pages·2016·7.38 MB·English

by  Asher Bashiri

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Recurrent Pregnancy Loss

Asher Bashiri (cid:129) Avi Harlev
Ashok Agarwal
Editors
Recurrent Pregnancy Loss
Evidence-Based Evaluation,
Diagnosis and Treatment
Editors
Asher Bashiri Avi Harlev
Director Maternity C and Recurrent Recurrent Pregnancy Loss Clinic
Pregnancy Loss Clinic Fertility and IVF Unit
Department of Obstetrics and Department of Obstetrics and
Gynecology Gynecology
Soroka University Medical Center Soroka University Medical Center
Faculty of Health Sciences Ben Gurion University of the Negev
Ben-Gurion University of the Negev Be’er Sheva, Israel
Be’er Sheva , Israel
Ashok Agarwal
American Center for Reproductive
Medicine
Cleveland Clinic
Cleveland , OH , USA
ISBN 978-3-319-27450-8 ISBN 978-3-319-27452-2 (eBook)
DOI 10.1007/978-3-319-27452-2
Library of Congress Control Number: 2015960757
Springer Cham Heidelberg New York Dordrecht London
© Springer International Publishing Switzerland 2016
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of
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or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specifi c statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
T he publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made.
Printed on acid-free paper
Springer International Publishing AG Switzerland is part of Springer Science+Business Media
(www.springer.com)
To my father who supported me
To my mother who gave me the spirit
To my children who gave me the power
To my wife who showed me the way
To all my brothers and sisters who were there for me
And to all my mentors who helped me to treat the patients.
-Prof. Asher Bashiri
We dedicate this book to our patients for the privilege of trying
our best to learn, diagnose, and treat RPL—a complex medical
disorder.
-Asher Bashiri, MD
-Avi Harlev, MD
-Ashok Agarwal, PhD

Foreword
Recurrent pregnancy loss, depending on the defi nition, affects 2–3 % of all
women attempting to get a child, and there are indications that the incidence
may be increasing. It spite of its high incidence and the anger and grief that
are suffered by the affected couples, the research activity on the topic as mea-
sured by the number of publications and presentations at scientifi c congresses
is low compared with the activity in other areas of involuntary childlessness.
The result of this relative inactivity is that our knowledge about causes and
treatments of recurrent pregnancy loss is limited. Still approximately 1/3 of
all patients with recurrent pregnancy loss 5 years after getting the diagnosis
have not got the desired child in spite of all what can be offered to them.
It is often stated that in 50 % of couples with recurrent pregnancy loss a
cause can be found; however, more correctly I think that in 50 % of couples a
risk factor can be found, which is not the same as fi nding a cause. With all
what is known today very few cases of recurrent pregnancy loss are caused by
a single pathogenic factor; the vast majority may have a multifactorial back-
ground involving the interaction of multiple genetic and environmental risk
factors. This complexity renders the research in recurrent pregnancy loss very
diffi cult because you need very large patient and control populations to be
able to detect causal factors, the importance of which can be confi rmed in
other studies, and you need large populations of patients to test therapeutic
interventions to be able to detect any effect. Since very few dedicated recur-
rent pregnancy loss clinics exist, it is diffi cult to collect the large populations
of patients needed for good studies.
Several books about recurrent pregnancy loss have been published in the
recent years, and some would pose the question: why publish a new book?
Reading a book reviewing a particular disease area has advantages compared
with reading the original articles in the area. Because much research in recur-
rent pregnancy loss is based on small and few studies, there are large “white”
areas on the map, and where there is knowledge there is in most cases sub-
stantial controversy. A book provides an easily accessible overview on a large
research area, and the contributions from various authors can highlight the
areas of agreement and areas of controversy.
T he book by Bashiri, Harlev, and Agarwal provides an extensive overview
of all relevant aspects of recurrent pregnancy loss seen from both the health-
care giver’s and patient’s perspectives. Contributions from prominent
researches in the fi eld will focus on both well-known risk factors for recurrent
pregnancy loss such as uterine, endocrine, and chromosomal abnormalities
vii
viii Foreword
but much focus will also be on the fi elds of genetic and immunological fac-
tors associated with recurrent pregnancy loss, since in these areas diagnostic
techniques are developing rapidly and new knowledge relating to recurrent
pregnancy loss is accordingly accumulating fast. More “soft” topics that have
previously often been ignored such as the relevance of lifestyle factors in
recurrent pregnancy loss and the importance of understanding and coping
with the emotions of the couples suffering from the problem will be exten-
sively dealt with.
T he book will be an interesting read for all people meeting and taking care
of couples with recurrent pregnancy loss: scientists, physicians, nurses, and
midwifes. I hope it will stimulate more high-quality research in the area and
improve healthcare givers’ skills in managing these often deeply stressed and
depressed patients.
Copenhagen, Denmark Ole B. Christiansen, DMSc
Aalborg, Denmark
Pref ace
Most current guidelines defi ne recurrent pregnancy loss (RPL) as two or
more consecutive pregnancy losses before 20–22 weeks of gestation.
Initially, RPL was defi ned as three consecutive pregnancy losses; however,
signifi cant developments in medicine, such as the introduction of low molec-
ular weight heparin, advanced laboratory tests like antiphospholipid anti-
bodies, and advanced imaging modalities including 3D ultrasound,
contributed signifi cantly to this change. Thus, we should reconsider the rel-
evant medical developments that infl uence the defi nition of RPL, evaluation,
and treatment of this specifi c condition.
D espite the research and the above-mentioned developments, we are still
far from understanding the total picture of RPL. More than 50 % of RPL
cases are considered unexplained even after a thorough RPL etiology workup.
This means that research must be expanded and consist mainly of multicenter
trials. This approach will help overcome the methodologic weaknesses of the
current studies, which are mostly small study groups that make it diffi cult to
draw valid conclusions.
A s a consequence, patients suffering from RPL can be very frustrated, and
the inaccessible nature of professional evaluation and treatment due to the
very few specialized RPL clinics serves to increase their frustration. This
means that most patients will see their general gynecologist, who is not well
equipped with all the needs of those patients and unfortunately will not have
the chance to refer to clinics that have such knowledge and resources.
The reason for writing the book is to put RPL on the front line of OB-GYN
research. Our book consists of the most updated literature on RPL, with chap-
ters written by leading international experts in the fi eld. The primary intended
audience is OB-GYN specialists, who can get the best overview on this topic
and have all the information necessary to evaluate and treat the patients.
Other specialists who could benefi t include hematologists, rheumatologists,
endocrinologists, immunologists, radiologists, psychiatrists, psychologists,
and social workers. The fact that we still have several approaches to some
topics means that we still don't have the best answers in all situations, but this
book will help to increase awareness of RPL for all specialists in the fi eld,
even if they don’t treat these patients directly.
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