SPONTANEOUS ABORTION ASSOCIATE PROFESSOR IOLANDA BLIDARU MD Ph
SPONTANEOUS ABORTION ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, Ph. D
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 500 g. In some European countries, including Romania, this definition is confined to the interruption of pregnancy before 24 weeks of gestation, less than l 000 g (dead) or less than 500 g (alive).
Frequency Approximately 15% to 20% of clinically recognized pregnancies are aborted spontaneously.
Abortions 45% in the weeks 5 to 9 35% in the weeks 10 to 14 15% in the weeks 15 to 18
Classification unique (isolated) or recurrent (3 or more consecutive spontaneous abortions) early abortions (before 12 weeks) or late abortions (in the 2 nd trimester) threatened, inevitable (or in evolution), incomplete, missed and complete abortion
Etiology Mechanisms responsible for abortion I. III. IV. VI. mechanical causes infections genetic causes endocrine causes immunological causes maternal systemic conditions
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
II. Infections Microorganisms associate with spontaneous abortion: variola malaria CMV Toxoplasma Mycoplasma hominis Chlamydia trachomatis Salmonella typhi Ureaplasma urealyticum
III. Genetic causes abnormality of development of the zygote, embryo, fetus and/or the placenta q aneuploidy (abnormal no. of chromosomes ) q euploidy (abnormal chromosom component)
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
Euploid abortion 1. chromosomally normal abortuses → in late pregnancy 2. incidence increased after maternal age of 35 years 3. chromosomal structural abnormalities → (translocations and inversions) visolated mutation or polygenic factors vvarious maternal factors vpaternal factors (chromosome translocation in sperm
IV. Endocrine causes Disturbances in the secretions of reproductive hormones → abnormal trophoblastic function 1. Luteal phase deficiency (LPD) inadequate progesterone effect on the endometrium 35% of recurrent pregnancy loss 2. Combined deficiency of E and P → the most common cause 3. Other forms: isolated E insufficiency, isolated P insufficiency, hyperandrogenism
V. Immunological causes Autoimmune mechanisms antiphospholipid antibodies anticardiolipin antibodies against platelets and vascular endothelium vascular damage thrombosis abortion placental destruction
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
VI. Maternal systemic conditions 1. endocrine disorders 2. blood group incompatibility (ABO, Rh) 3. toxic factors (cocaine, alcohol, cigarette smoking) 4. psychic or emotional causes, advanced maternal age, poor socio economic status, protein and vitamin under nutrition 5. Cardio vascular renal hypertensive disorders
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
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
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.
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.
Avortul – forme clinice
Treatment accurate evaluation 1. pelvic examination visual and digital examination of the cervix + bimanual palpation of the uterus and of the adnexa. 2. the degree of cervical effacement and dilation determined by palpation. 3. Ultrasonic scanning (a normal appearing sac+ normal embryo/fetus favorable prognosis). 4. Serial beta HCG
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.
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).
INCOMPETENT CERVIX
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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