RPL

1. RPL
Case scenario3
Prof. Aboubakr Elnashar
elnashar53@hotmail.com
ABOUBAKR ELNASHAR

2.  33-YEAR-OLD WOMAN
 MARRIED SINCE 7Y NO LIVING CHILDREN
 G3 P0+3
 MISCARRIAGE AT 20W, 18W, 16W
 HSG
ABOUBAKR ELNASHAR

3. ABOUBAKR ELNASHAR

4. 1- Hysteroscopy
2- Laparoscopy
3-MRI
4- 3D US
 WHAT IS THE NEXT STEP?
ABOUBAKR ELNASHAR

5. 1. Pelvic US:
To assess
uterine anatomy
congenital uterine abnormalities. S
The preferred technique
 TV 3D US
{1. high sensitivity and specificity
2. distinguish between uterus septum and
bicornuate uterus}. C
ABOUBAKR ELNASHAR

6. 3D TVS
 Noninvasive
 highly accurate
 able to provide detailed images of uterine anatomy.
Septate
Bicornuate
ABOUBAKR ELNASHAR

7.  IF 3 DUS IS NOT AVAILABLE?
2. Sonohysterography (SHG)
more accurate than HSG in diagnosing uterine
malformations. C
used to
evaluate uterine morphology when 3D US is
not available, or
when tubal patency has to be investigated
MRI
not recommended for the assessment of uterine
malformations in women with RPL. S
ABOUBAKR ELNASHAR

8. 3. Investigation of the kidneys and urinary tract
If a Müllerian uterine malformation is diagnosed. C
ABOUBAKR ELNASHAR

9.  HOW TO DD BETWEEN BICORNUATE UTERUS &
SEPTATE UTERUS?
ABOUBAKR ELNASHAR

10. DD: Troiano and McCarthy:
a line was traced joining both horns of the uterine cavity.
 If this line crossed the fundus or was ≤5 mm from it= bicornuate
(a and b)
 if it was >5 mm from the fundus=septate, regardless of whether
the fundus was dome-shaped (c), smooth or discretely notched.ABOUBAKR ELNASHAR

11. • Class U2: septate
internal indentation >50% of the uterine wall thickness
and external contour straight or with indentation
<50%,
• Class U3: Bicorporeal
external indentation >50% of the uterine wall
thickness,
• Class U3b:
width of the fundal indentation at the midline >150% of the
uterine wall thickness). ABOUBAKR ELNASHAR
ESHRE classification

12. 3DU:
septate uterus
ABOUBAKR ELNASHAR

13. 1- Hysteroscopic resection of the septum
2- No resection
 WHICH IS THE NEXT LINE OF MANAGEMENT?
ABOUBAKR ELNASHAR

14. Treatment for uterine abnormalities
Uterine septum:
Whether hysteroscopic septum resection has
beneficial effects
(improving LBR, and decreasing miscarriage rates, without
doing harm)
should be evaluated. C
Didelphic uterus
insufficient evidence in favor of metroplasty. C
Bicornuate uterus
Metroplasty is not recommended. S
Unicornuate uterus
Uterine reconstruction is not recommended. S
ABOUBAKR ELNASHAR

15. 1- Cervical cerclage
2-No Cervical cerclage
 IS CERCLAGE A WORTHWHILE IF THIS PATIENT
GOT PREGNANT ?
ABOUBAKR ELNASHAR

16. History-indicated cerclage
 Indications
 Three or more previous preterm births and/or
second-trimester losses.
 Not an indication:
 two or fewer previous preterm births and/or second-
trimester losses.
 Previous adverse event:
 painless dilatation of the cervix or
 rupture of the membranes before the onset of
contractions, or
 additional risk factors, such as cervical surgery
ABOUBAKR ELNASHAR

17. Ultrasound-indicated cerclage
 Indication:
 History of one or more spontaneous mid-
trimester losses or preterm births before 24 w.
plus
 TVS: cervix is 25 mm or less
 Not indicated
 without a history of spontaneous preterm
delivery or second-trimester loss who have an
incidentally identified short cervix of 25 mm or
less.
ABOUBAKR ELNASHAR