1. ASSOCIATE PROFESSOR IOLANDA BLIDARU
SPONTANEOUS ABORTION
ASSOCIATE PROFESSOR IOLANDA BLIDARU
MD, PhD

3. Definitions
The termination of pregnancy by any means before the fetus is sufficiently developed to survive.
USA and western European cuntries → the termination of pregnancy before 20 weeks gestation based upon the date of the first day of the LMP.
Another commonly used definition: delivery of product of conception that weighs less than 500g.
In some European countries, including Romania, this definition is confined to the interruption of pregnancy before 24 weeks of gestation, less than l000g (dead) or less than 500g (alive).

4. Frequency
Approximately 15% to 20% of clinically recognized pregnancies are aborted spontaneously.

5. Abortions
45% in the weeks 5 to 9
35% in the weeks 10 to 14
15% in the weeks 15 to 18

6. Classification
unique (isolated) or recurrent (3 or more consecutive spontaneous abortions)
early abortions (before 12 weeks) or late abortions (in the 2nd trimester)
threatened, inevitable (or in evolution), incomplete, missed and complete abortion

7. Mechanisms responsible for abortion
Etiology
Mechanisms responsible for abortion
- mechanical causes
- infections
- genetic causes
- endocrine causes
- immunological causes
- maternal systemic conditions

8. I. Mechanical causes ovular (multiple pregnancy, hydramnios)
uterine defects:
1. - congenital anomalies
2. - uterine malposition (retroversion)
3. - uterine tumors (myomas)
4. - intrauterine adhesions synechiae (Asherman syndrome)
5. - incompetent cervix

9. II. Infections Microorganisms associate with spontaneous abortion:
- variola
- malaria
- CMV
- Toxoplasma
- Mycoplasma hominis
- Chlamydia trachomatis
- Salmonella typhi
- Ureaplasma urealyticum

10. III. Genetic causes
 abnormality of development of the zygote, embryo, fetus and/or the placenta
aneuploidy (abnormal no. of chromosomes )
euploidy (abnormal chromosom component)

11. ~ 50% of clinically recognized pregnancy loss
Aneuploid abortion
~ 50% of clinically recognized pregnancy loss
Autosomal trisomy → the first trimester abortions + recurrent abortions.
Monosomy X (45/X) → compatible with live-born females (Turner syndrome).
Triploidy → associated with hydropic placental degeneration

12. Euploid abortion chromosomally normal abortuses → in late pregnancy
incidence increased after maternal age of 35 years
chromosomal structural abnormalities → (translocations and inversions)
isolated mutation or polygenic factors
various maternal factors
paternal factors (chromosome translocation in sperm

13. IV. Endocrine causes
Disturbances in the secretions of reproductive hormones → abnormal trophoblastic function
Luteal phase deficiency (LPD) - inadequate progesterone effect on the endometrium - 35% of recurrent pregnancy loss
Combined deficiency of E and P → the most common cause
Other forms: isolated E insufficiency, isolated P insufficiency, hyperandrogenism

14. V. Immunological causes
Autoimmune mechanisms
antiphospholipid antibodies
anticardiolipin antibodies
against platelets and vascular endothelium
vascular damage thrombosis placental destruction
abortion

15. V. Immunological abortions
Alloimmune mechanisms
The human embryo → an allogenic transplant that is tolerated / facilitated by the mother.
Several immunological mechanisms - to prevent fetal rejection:
- histocompatibility factors CMH, HLA-G
- circulating blocking factors
- local supressor factors
- maternal or antipaternal anti-leukocytotoxic antibodies

16. VI. Maternal systemic conditions
endocrine disorders
blood group incompatibility (ABO, Rh)
toxic factors (cocaine, alcohol, cigarette smoking)
psychic or emotional causes, advanced maternal age, poor socio­economic status, protein and vitamin under-nutrition
Cardio-vascular-renal hypertensive disorders

17. Symptoms - bleedingspotting of bright blood
Clinical stages
A. Threatened abortion
Symptoms - bleedingspotting of bright blood
dark brown discharge
- cramping pain
- no changes in the cervix
Usually, bleeding begins first and cramping abdominal pain follows (hours to several days).
Differential diagnosis
- ectopic pregnancy
- dysfunctional uterine bleeding
- uterine fibro-myomas
- hydatidiform mole
- benign lesions / invasive cancer

18. Clinical stages B. Inevitable abortion Symptoms
- abdominal and back pain
- severe bleeding
- open cervix
During first 2 months, abortion - 1 stage.
During the 2-nd trim., abortion - 2 stages:
1. rupture of the membranes + fetal expulsion;
2. incomplete expulsion of the placenta

19. Clinical stages C. Incomplete abortion
In the majority of spontaneous abortions variable amounts of placental tissue may remain within the uterus (attached to the wall or lying free in the cavity).
Bleeding - during or following abortion may be life-threatening
profuse → massive (→ hypovolemia)
severe
persistent
Sepsis - in cases with criminal or self- induced abortion.

20. retention of dead conceptus in utero for several weeks
Clinical stages
D. Missed abortion
retention of dead conceptus in utero for several weeks
E. Complete abortion
the uterus empties itself completely (fetus, fetal membranes, the placenta, the decidua). This is possible only during the first 6 weeks.

21. Avortul – forme clinice

22. Treatment accurate evaluation
pelvic examination visual and digital examination of the cervix + bimanual palpation of the uterus and of the adnexa.
the degree of cervical effacement and dilation - determined by palpation.
Ultrasonic scanning (a normal-appearing sac+ normal embryo/fetus - favorable prognosis).
Serial beta-HCG

23. Treatment
Threatened abortion → treated at home / hospitalized. Medical treatment - progesterone / synthetic progestational agents, i.m. or orally.
Inevitable abortion → surgical uterine evacuation (with suction technique or surgical procedure) + reducing blood loss and pain.
Incomplete abortion → surgical uterine evacuation because of the risk of infection and/or continued and excessive bleeding.
Missed abortion → surgical uterine evacuation
Infected abortion → the operation should be delayed, unless excessive uncontrolled blood loss, and antibiotics are administered.

26. Treatment
Cervical incompetence → CERCLAGE = surgical treatment, consisting of reinforcement of the cervix by some type of purse string stitches; best performed after the first trimester (14 weeks) but before cervical dilatation of 2 to 3 cm is reached.
Bleeding, uterine contractions or ruptured membranes are contraindications to this surgery.
The Mc Donald procedure = suture of monofilament placed in the cervix to encircle the internal os (less traumatic with reduced blood loss).

27. INCOMPETENT CERVIX

28. Treatment
Asherman syndrome treatment = lysis of the adhesions via hysteroscopy and placement of an IUD to prevent recurrence of synechiae. Continuous high-dose estrogen therapy for 60 to 90 days.
Lupus erythematosus - Successful pregnancies with low-dose aspirin (inhibit thromboxane production by damaged platelets and endothelium).
Antiphospholipid syndrome – Heparin (to inhibit thrombosis) + corticosteroids (to suppress antibodies as well as to inhibit their action on target antigen).
Immunotherapy - highly controversial.