I. Classification and typing
1. Non-immune RSA
Chromosomal abnormalities, anatomical abnormalities, infections and endocrine disorders
2.Immune RSA
1) Autoimmune RSA
Laboratory criteria are specifically: positive blood anticardiolipin antibody or anti-β2 glycoprotein-1 antibody (anti-β2-GP-1) or positive lupus anticoagulation factor (LAC) found on two or more occasions (six weeks or more apart).
2) Alloimmune RSA
Patients have a history of 3 or more spontaneous abortions, no history of live births, stillbirths, or stillbirths; negative autoantibody test by etiological screening to exclude chromosomal, anatomical and endocrine abnormalities and infections, and discharge of autoimmune diseases; negative microlymphocytotoxic antibodies
II. Systematic outpatient screening programs for etiology
1, general examination.
Including history taking gynecological examination, B ultrasound and other physical diagnostic techniques
2. Special examinations.
1) Chromosomal examination: karyotype analysis of couple’s karyotype, nuclear analysis of chorionic villus culture cells;
2) Anatomical examination: ultrasound examination and, if necessary, hysterosalpingography or hysteroscopy;
3) Endocrine examination: including sex hormone, thyroid and islet function measurement, etc.
4) Cytomegalovirus, toxoplasma infection, herpes simplex virus, etc;
5) Blood coagulation status: platelet aggregation test (PagT), D-dimer, platelet membrane granule protein (GMP-140) and partial clotting time (APTT)
6) Autoantibody tests: including IFANA (fluorescent antinuclear antibody), ACL (anticardiolipin antibody), anti-β2 glycoprotein-1 antibody (anti-β2-GP-1 antibody) LAC (lupus anticoagulation factor), etc;
3. Notes on etiological screening for recurrent miscarriage
Etiological screening is the key to clinical classification and typing as well as guiding clinical treatment, for which the following aspects should be noted.
1, karyotype analysis: not only the couple should be included, but also attention should be paid to the karyotype analysis of each pregnancy discharge specimen.
2. Uterine anatomical abnormalities: first of all, non-invasive examination methods, mainly ultrasound, should be used. In cases where ultrasound cannot be determined, hysteroscopy and hysterosalpingography (HSG) can be considered.
3, cervical function examination: ultrasound examination was performed at 12 and 20 weeks of gestation, and 200 ml of water bladder was placed in the vagina to observe the morphological changes of the cervical canal. If the length of the cervix is less than 2.6 cm and the inner diameter of the cervical canal is ≥0.5 cm, cervical insufficiency can be diagnosed and cervical cerclage can be performed.
4. Endocrine abnormality examination: attention should be paid to exclude luteal insufficiency, PCOS, hyperlactatemia, thyroid dysfunction and diabetes mellitus.
III. Treatment of autoimmune RSA
Individualized – small dose – short course of immunosuppressive or anticoagulant therapy, specific methods are as follows
1. Establish observation indexes
1) Blood coagulation index APTT, D-dimer
2) Platelet agglutination indicators: PagT, GMP-140
3) Antiphospholipid antibodies: anti-cardiolipin antibody (ACA), β2-GP-1
2. Observation time
1) Pre-pregnancy: once / 3-6 weeks
2).Post-pregnancy: divided into early, middle and late observation
3. individualized, small doses; anti-immune anti-platelet agglutination and anticoagulation drugs if indicated
4. treatment start time
1), prophylactic: low-dose aspirin (25mg/day) before pregnancy and low-dose adrenocorticosteroid prednisone 5mg/day
2), Therapeutic: start the medication once pregnancy until 3 days before delivery.
5. Detection index and treatment plan selection
Observation indexes
PaGT and GMP-140
D-dimer
Autoantibodies
Elevated
Normal
Elevated
Normal
Persistent positive ACL/LAC, high titer
SLE patients
Medication use
Low-dose aspirin (25mg/d)
Low-molecular heparin (5000u/d)
Low-dose adrenocorticotropic hormone prednisone 5mg/day)
Adrenal hormone dose adjusted according to disease and SLE treatment plan