Miscarriage, Repeated Abortions and Threatened Abortion

Miscarriage is unfortunately a very common pregnancy complication, probably more frequent than thought:

threatened abortion

Ultrasound imaging: the embryo has no heart activity and an initial placental detachment is visible.

in fact very often it happens so early that is mistaken for a simple menstruation delay.

A miscarriage experience is common to many women and usually for a single episode are not required special gynecological controls.

But when abort episodes are two or more is called “Repeated Abortion” or “Recurrent Pregnancy Loss”, and an investigations aimed at clarifying a possible predisposing condition is needed.

The causes that can lead to miscarriage and to repeated abortion conditions, unfortunately, are many.

Table 1: miscarriage causes
  • anatomical flaws (congenital or acquired)
  • infectious diseases
  • endocrine and metabolic diseases
  • genetic diseases
  • immuno-hematological disease

Therefore it is better to proceed by adopting updated diagnostic protocols to do not leave anything to chance.

Abortion Causes

The start point usually is an inspection of the genital and in particular uterine anatomy. Bulky Uterus Leiomyomas (fibroids) can be a cause, but also congenital (septate, bicornuate or hypoplastic Uterus) or acquired (results of previous interventions, synechiae …) malformations are causes of frequent reproductive failures.

Then, there are hormonal causes (especially those involving Pituitary Gland, Ovary, Thyroid) and infectious disease. Among the most common hormonal causes should be sought Ovarian deficit (i.e. Occult Ovarian failure), hyper-or hypo function of the Thyroid Gland and the presence of Autoantibodies (i.e. Hashimoto’s Thyroiditis), hypersecretion of Prolactin (Hyperprolactinemia). Tests on this group of causes of abortion and threatened abortion are often done badly in my opinion.

In Repeated abortion and Recurrent Fetal Loss an endocrinological study should never overlook the presence of a possible premature ovarian insufficiency often subclinical and therefore absolutely symptoms free; as you will read in another post on this topic the ovarian insufficiency are among the most frequent causes of abortion.

Among the metabolic causes of abortion, chronic or decompensated diabetes is one of the most important because of its consequent vascular damage.

Among infectious disease: pelvic, vulvovaginal inflammation and in particular the presence of some intra-cellular bacteria such as Chlamydia should always be identified and treated.

It is sometimes necessary to advancing in genetic and immuno-hematology researches. A chromosome map of the couple is often recommended and if there is presence of hereditary genetic disease, is definitely useful to recourse to a geneticist consultation. In particular, about the immuno-hematological disorders, they have been very prominent in hypercoagulable syndromes (thrombophilic genetic risk states) in which a coagulant overcapacity leads to early trophoblastic vascular thrombosis and then to abortion. Even some auto-immune diseases have been associated with miscarriage and then in the investigation and the search for a Trombophilia genetic predisposition is very important to look for of auto-immune diseases presence (ie, based on a self-aggression antibody).

In my own experience I don’t find very useful the distinction between early and late abortions althoug after the first quarter cervical insuffciency is most frequent.

I always explain to my patients that pregnancy is a very special transplantation: the immune system has to resort to a particular tolerance; a thing like this in the male immune system (that simply separate “self” from “non-self”) would be impossible. But this particular complexity of female immune system is sometimes the cause of a particular vulnerability (auoimmune diseases are more frequent in female as in men).

After a miscarriage, especially in the repeated and recurrent fetal loss would always be good to become pregnant after you have a diagnosis and than a programmed preventive treatment (therapy).

Table 2: some therapies reported as useful for habitual abortion.
  • – Progesterone (vaginally or intramuscularly);
  • – Anticoagulants (aspirin, low molecular weight heparins).


The best preventive treatment is the one that removes or attenuates the predisposing cause. Next to experimental treatments for which validation is required, the most widely used drugs are undoubtedly Progestin, Aspirin and Low Molecular Weight Heparins. Folic acid is always prescribed, sometimes in already metabolically active forms when MTHFR (methylenetetrahydrofolate) enzyme defects are known.

Very interesting is the recent use of Intralipid (a intravenous fat emulsion for human use) in the forms of immunological infertility and miscarriage. Soybean oil in particular has proven useful in reducing the activity of Endometrium “Natural Killer” cells, thus favoring pregnancies.

The threat of abortion is a medical condition characterized by bleeding not always accompanied by pelvic pain and sometimes evolves in abortion. The treatment of first quarter bleeding and threatened abortion is actually the same as what I wrote for the abortion prevention except for doses of Progestins and sometimes antispasmodics use and Tranexamic Acid; the rest, abstaining from sexual intercourse may be useful in these conditions. The topic is still controversial and many doctors are skeptical about the real effectiveness of therapies for threatened abortion.

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Filiberto Di Prospero
Medical Doctor, Consultant in Gynecology and Obstetrics, Endocrinology and Metabolism. Director of Gynecologic Endocrinology Unit at Civitanova Marche General Hospital (Italy). Private clinics in Civitanova Marche, Rome and Milan.

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