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SPONTANEOUS ABORTION

SPONTANEOUS ABORTION. ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD. Definitions. The termination of pregnancy by any means before the fetus is sufficiently developed to survive.

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SPONTANEOUS ABORTION

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  1. SPONTANEOUS ABORTION ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD

  2. 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).

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

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

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

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

  7. 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

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

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

  10. 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

  11. 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 polygenicfactors • various maternal factors • paternal factors (chromosome translocation insperm

  12. 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

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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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.

  19. 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.

  20. Avortul – forme clinice

  21. 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

  22. 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.

  23. 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 ofmonofilament placed in the cervix to encircle the internal os (less traumatic with reduced blood loss).

  24. INCOMPETENT CERVIX

  25. 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.

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