Bleeding causes in the first trimester pregnancy Threatened abortion Ectopic pregnancy Cervical polyps Hydatidiform mole Cervicitis

Abortion Threatened abortion Inevitable abortion Complete abortion Incomplete abortion Missed abortion

Bleeding and uterine cramping without cervical dilation Threatened abortion Bleeding and uterine cramping without cervical dilation

Inevitable abortion Profuse haemorrhaging, rupture of the membranes, cramping with a dilated cervical os

Incomplete abortion When some products of conception are expelled but some tissue remains in the uterine cavity.

RECURRENT PREGNANCY LOSS (RPL) The loss of tree or more spontaneous and consecutive pregnancies, occuring before the period of viabity PRIMARY RPL SECONDARY RPL

Causes of RPL Chromosomal 1,8- 4,6% Anatomic 1-28% Immunologic 6-65% Hormonal 5- 29% Infectious Unexpained 15-50%

Genetic causes Trisomy 40-50% Monosomy 15-25% Triploidy 15% tetraploidy 5%

Anatomic abnormalities Uterine congenital abnormalieties ( septate uterus, bicornuate or unicornuate uterus) Intrauterine adhaesiones Leiomyomata Cervical incompetence

Endokrinologic causes The luteal phase deficiency Thyroid disease diabetes

Infections Listeria monocytogenes Mycoplasma hominis Ureaplasma urealiticum Toxoplasmosis Cytomegalia Rubella

Enviromental factors Smoking Alkohol Ansthetic gases Toxins Radiations

Missed abortion Death of the fetus or embryo without the onset of labour or the passage of tissue

Diagnosis of abortion Clinical examination ( bleeding, abdominal pain, cramping) Ultrasonography

Medical conditions associated with pregnancy loss Collagen vascular diseases Thyroid disease Diabetes mellitus Chronic active hepatitis Infections Endometriosis Thrombo-embolic disease Chronic renal disease Chronic cardiovascular disease

Immune theories of RPL In the alloimmune theory state, the maintenance of normal pregnancy requires the immune system to recognize the implanting embryo as foreign the autoimmune theory state, in whichwomen’s immune system may produce antiphospholipid antibodies

Criteria for the antiphospholipid antiboby syndrome

Criteria for anti-phospholipid antibody syndrome Laboratory findings Persistently elevated anti-phospholipid antibodies (ACA) Lupus anticoagulant (LA) Clinical findnings Thrombosis (venous or arterial) Recurrent pregnancy loss Thrombocytopenia

The target cells for antiphospholipid antibodies Endothelial cells Throphoblastic cells Blood platelets Embyonic tissue cells Coagulation factors Proteins involved in the coagulation cascade or in antibodies bindings

Molar pregnancy (microscopic features)

Molar pregnancy (microscopic features) Complete mole Marked oedema and enlargement of the villi Dissappearance of the villous blood vassels Proliferation of lining trophoblast of the villi Absence of the fetus, cord ar amniotic membrane A normal kariotype Partial mole Marked swelling of the villi with atrophic throphoblastic cells Presence of normal villi Presence of fetus, cord and amniotic membrane An abnormal karyotype

Symptoms: Bleeding The uterus is often larger than expected Nausea and vomiting Preeclampsia Clinical hyperthyroidism Abdominal pain secondary to theca lutean cysts

Diagnosis Passage of vesicular tissue A quantitative HCG > 100 000 uIU/ml Ultrasonography ( snow storm)

Clinical classification of gestational thropfoblastic disease Molar pregnancy (hydatidiform mole) Compete mole Partial mole Gestational throphoblastic neoplasia

Persistent gestational throphoblastic neoplasia Histologically benign Persistent histologically benign Persistent histologically malignant

Benign GTD Low socioeconomic status Older women Spontaneous remission in 80-85% after dilatation and evacuation Choriocarcinoma develops in 3- 5% of moles

Malignant GTD 1 : 20 000 pregnancies A/ molar pregnancy (50%) B/ normal pregnancy (25%) C/ abortion and ectopic pregnancy (25%)

Management Suction curetage Primary hysterectomy Prophylactic chemiotherapy

Follow–up examination include HCG determinations every 1-2 weeks until they are negative twice, then montly for 1 year Contraception for 1year Physical examination every 2 weeks until remission, then every 3 months for 1 year Chest film initially and repeated if the HCG plateau or rises Chemiotherapy should be started if the HCG titer rises or is stable if metastases are detected at any time

Abortion Spontaneous Induced Early ( before 12 weeks) Late (after 12 weeks)

Abortion The termination of pregnancy before viability, (22 weeks from the first day of the last normal menstrual bleeding).