Original Article
Does the fibrinogen/albumin ratio predict the prognosis of
pregnancies with abortus insipiens?
Ceyda S. Usta, MD, Tugba K. Atik, MD, Ruhsen Ozcaglayan, MD, Cagla B. Bulbul, MD,
Figen E. Camili, MD, Ertan Adali, MD.
ABSTRACT
‫) للنساء احلوامل‬FAR( ‫األلبومني‬/‫ دراسة نسبة الفيبرينوجني‬:‫األهداف‬
‫) وقيمته التنبؤية للتنبؤ باإلجهاض‬AI( ‫املصابات باإلجهاض الوشيك‬
.‫التلقائي‬
‫ حالة مت تشخيصها‬52 ‫ ومن بينها‬،‫ حالة حمل مبكر‬102 ‫ شخصنا‬:‫املنهجية‬
‫ حالة تطابقت بالعمر ومؤشر كتلة اجلسم مع مجموعة من نساء حوامل‬50 ‫ و‬،)AI(
،‫صحيات في هذه الدراسة القائمة على اماللحظة التي أجريت في مستشفى البحث والتدريب‬
‫ تركيا خالل‬،‫ باليكسير‬،‫جامعة باليكسير‬
/‫ متت مقارنة قيم الفيبرينوجني‬.‫م‬2020 ‫م وأغسطس‬2019 ‫الفترة من سبتمبر‬
.‫ ومجموعة التحكم‬AI ‫األلبومني بني مجموعة‬
‫ كان معدل اإلجهاض التلقائي في حاالت احلمل املشخصة‬:‫النتائج‬
‫األلبومني‬/‫ بلغت مستويات نسبة الفيبرينوجني‬.‫ في مجتمع دراستنا‬26.9% ‫باإلجهاض الوشيك‬
‫ أظهر‬.)p=0.0088( ‫عالية في حاالت احلمل باإلجهاض الوشيك مقارنة مبجموعة التحكم‬
FAR ‫حتليل االنحدار أن زيادة قيمة‬
)p=0.0232 ‫؛‬40.7507 ‫ إلى‬1.3119 =‫ فترة الثقة‬95٪ ،7.3116=‫(نسبة األرجحية‬
‫كانت عالمة مستقلة للتنبؤ باإلجهاض التلقائي في حاالت‬
.‫احلمل املشخصة باإلجهاض الوشيك‬
‫ مقارنة‬FAR ‫ زادت حاالت حمل اإلجهاض الوشيك من مستويات‬:‫اخاللصة‬
‫األلبومني هي عالمة مستقلة‬/‫ نسبة الفيبرينوجني‬.‫بحاالت احلمل الصحية‬
.‫للتنبؤ باإلجهاض التلقائي‬
Objectives: To investigate the fibrinogen/albumin
ratio (FAR) of pregnant women with abortus
insipiens (AI) and its prognostic value for predicting
spontaneous abortion.
Methods: A total 102 early pregnancies, 52 had
been diagnosed with AI and 50 ages and body mass
index matched healthy control pregnant women
were included in this prospective observational study
conducted in the Research and Training Hospital,
Balikesir University, Balikesir, Turkey between
September 2019 and August 2020. Fibrinogen/
albumin values were compared between AI and
control group.
Results: The rate of spontaneous abortion in AI
pregnancies was 26.9% in our study population.
OPEN ACCESS
Fibrinogen/albumin ratio levels were higher in
AI pregnancies than in controls (p=0.0088). The
regression analysis have shown that the increased FAR
value (odds ratio [OR]: 7.3116 [95% CI: 1.3119 to
40.7507]; p=0.0232) was an independent marker for
spontaneous abortion prediction in AI pregnancies.
Conclusion: Pregnancies with AI have increased levels
of FAR compared to healthy pregnancies. Fibrinogen/
albumin ratio is an independent marker for predicting
spontaneous abortion.
Keywords: fibrinogen to albumin ratio, abortus
insipiens, inflammation, spontaneous abortion
Saudi Med J 2021; Vol. 42 (3): 255-263
doi: 10.15537/smj.2021.42.3.20200695
From the Department of Obstetrics and Gynecology (Usta, Bulbul,
Camili), from the Department of Clinical Microbiology (Atik), and
from the Department of Internal Medicine (Ozcaglayan), School of
Medicine, Balikesir University, Balikesir, Turkey.
Received 2nd November 2020. Accepted 20th January 2021.
Address correspondence and reprint request to: Dr. Ceyda S. Usta,
Department of Obstetrics and Gynecology, School of Medicine, Balikesir
University, Balikesir, Turkey. E-mail: drceydausta@gmail.com
ORCID ID: https://orcid.org/0000-0002-3223-7729
A bortus insipiens (AI) is defined as the presence
of vaginal spotting or bleeding without cervical
dilatation and/or effacement before the 20th week
of pregnancy. It frequently occurs during the first
12 weeks of pregnancy. Abortus insipiens affects
approximately 20-50% of all pregnancies1 and it
may cause abdominal cramps or pelvic pain. Recent
studies clearly demonstrated that there is an increased
risk of adverse pregnancy outcomes such as preterm
delivery, low birth weight, and perinatal death in AI
pregnancies.2 Abortus insipiens is also associated with
https://smj.org.sa Saudi Med J 2021; Vol. 42 (3) 255
 Increased FAR values in AI ... Usta et al
spontaneous abortion in subsequent gestational weeks. 3
Despite its clinical importance, the pathophysiology of
AI is still not known. Previous studies have suggested
that adequate invasion of cytotrophoblasts into the
endometrial and myometrial layer and their sufficient
transformation into the spiral arteries in the first
trimester of the gestation are main stone for healthy
embryonic development. Actually, failure of trophoblast
invasion into the endometrium and spiral arteries may
decrease placental blood flow at subsequent gestational
weeks. This condition eventually lead to placental
insufficiency and oxidative stress. 4 Placental ischemia
and oxidative stress cause inflammatory responses and
cell activation in vascular endothelium, which lead the
development of pregnancy complications including
spontaneous abortion, preeclampsia, and intrauterine
growth restriction (IUGR).3,5
Fibrinogen (factor 1) is a glycoprotein synthesized
by liver cells and is one of the 13 coagulation factors
responsible for normal blood clotting. It is also a positive
acute phase response protein produced in response
to proinflammatory cytokines.6 Circulating levels of
fibrinogen is characterized by elevation in systemic
inflammatory condition. Fibrinogen also increases
during pregnancy.7 Physiologically, procoagulant levels,
including that of fibrinogen increase and anti-coagulant
levels decrease in the blood during pregnancy; the
coagulation system is, overall, strong in pregnant
women.7 However, excessive increases in fibrinogen
levels heighten the risk of thromboembolism, which
causes placental infarction and may lead to miscarriage.
Albumin, produced by the liver, is a member of blood
transport protein family. It is also considered a negative
acute phase protein.8 Reduced albumin levels in the
presence of inflammation are likely associated with the
effects of inflammatory cytokines including interleukin-
6 (IL-6) and tumor necrosis factor-alpha. Recent studies
have clearly demonstrated that serum albumin levels
have protective properties, such as preventing apoptosis
and maintaining physiological homeostasis, antioxidant
activity, and anti-inflammatory effects.9
Previous studies have also demonstrated that
the fibrinogen/albumin ratio (FAR) is higher in
many different diseases including hypertension,
atherosclerosis, cardiovasculary diseases, myocardial
infarction, contrast induced nephropathy, ankylosing
Disclosure. Authors have no conflict of interests, and the
work was not supported or funded by any drug company.
256 Saudi Med J 2021; Vol. 42 (3) https://smj.org.sa
spondylitis, and various cancers, which is related to
inflammatory conditions in the body. 10-14 The FAR is
an inflammatory-based prognostic index which offers
information on disease severity, prognosis or patient
survival.11-14 Based on these observations, the purpose
of present study was to investigate the alteration of FAR
in pregnant women with AI and its prognostic value for
predicting spontaneous abortion.
Methods. A prospective observational study was
conducted in Research and Training Hospital, Balikesir
University, Balikesir, Turkey between September 2019
and August 2020. The investigation protocol of the
study was in accordance with the Helsinki committee
requirement. The study protocol was approved by
Balikesir University Institutional Ethical Committee
(Date: 28/08/2019, No: 2019/111). Pregnant women
who have vaginal bleeding and the ages and body mass
indexes (BMIs) matched controls were participated
in the study population. All subjects gave written
informed consent. A total of 102 pregnant women,
52 of AI, 50 of age and BMI matched healthy control
were included in the study population during the first
antenatal visit. The loss of pregnancy before the 20
weeks of gestation was defined as spontaneous abortion.
All pregnancies without spontaneous abortion followed
until 20th week of gestation. The demographic
characteristic, ultrasonography measurements, and
laboratory parameters were obtained prospectively from
all participants and their electronic records. Pregnant
women who had fetal anomaly, recurrent pregnancy
loss, intrauterine infections, serious systemic diseases,
multiple pregnancies, and in vitro fertilization were
excluded. All participants were non smokers, in the
same socioeconomic status and non-obese (<30 kg/m2).
In addition, all participants did not use vitamin and
mineral supplementation other than folic acid.
Obstetric and physical examinations of all
participants were performed in our antenatal outpatient
clinics. The demographic characteristics such as maternal
age, BMI, and previous obstetric and medical histories
were recorded in the first prenatal visit. The gestational
weeks were determined according to biometric
measurement (croved-rumb-length) which performed
with an ultrasound machine (GE, Voluson 730 expert,
CA, USA) equipped with a transvaginal probe.
A 5 ml antecubital venous blood samples were
obtained at the time of diagnosis in the AI group and
routine antenatal visit in the control group. Blood
samples were divided into the 2 and approximately
half of them put into light blue tube buffered sodium
 Increased FAR values in AI ... Usta et al
citrate 0.109M (3.2%) for the fibrinogen (mg/dL)
measurement and remaining half of the put into
gold tube including clot activator and gel for serum
separation for the measurement albumin levels (g/dL).
All collected sample were centrifugate at 4000 rpm for
10 minutes and were storage in deep freeze at -80ºC
until analysis.
Abortus insipiens was defined as presence of any
degree of vaginal bleeding confirmed with vaginal
speculum examination and close internal and external
cervical ostium confirmed with transvaginal ultrasound.
During the followed period, there was no detected
maternal comorbities, fetal anomaly, and coagulation
abnormality in all of AI and control pregnancies.
Pregnant women with AI were prescribe with 200 mg
natural micronized progesterone orally or intravaginally
twice a day to eliminate the risk of progesterone
insufficiency following collection of blood samples.
Biochemical evaluation. Blood levels of fibrinogen
were measured using the fibrinogen clotting time
on Clauss method as described elsewhere.15 In this
method, plasma samples was dilued 1/10 and thrombin
solution was added, the clotting time of samples was
recorded and plasma fibrinogen concentrations of all
samples were calculated using standard charts. Plasma
fibrinogen levels was considered normal ranges at
200-400 mg/dL.7 Serum levels of albumin were measured
via a bromocresol green dye-binding analyzer (Roche
Modular DP, Roche Diagnostics, Basel, Switzerland).
Serum albumin level was considered normal range
at 3.2-5.5 g/dL. FAR was calculated by dividing the
plasma fibrinogen concentration by the serum albumin
concentration. To avoid assay variability, all collected
blood samples were analyzed together. Complete blood
counts of participants were measured via a blood count
analyser (Sysmex XE-2100, Kobe, Japan).
A power analysis was performed by using the data of
previous studies that provide information of fibrinogen
levels in pregnancy16 and necessary sample size in AI and
control group were found as 46 of AI and 46 controls
in ratio of 1:1 when the desired significance level was
set at 0.05 (alpha) and power was set at 0.8 (1-Beta).
Therefore, it was calculated that 46 control patients
were required for at least 46 patients in the AI group in
order to test whether there was a significant difference
in the FAR levels between AI and the control group.
Statistical analysis. All statistical analysis was made
using MedCalc Statistical Software version 19.2.1
(MedCalc Software Ltd, Ostend, Belgium; https://
www.medcalc.org; 2020). The Kolmogrov-Smirnov test
was used for the evaluation the distribution of variables
in the groups. Levene test or F test was used for the
evaluation of the variances between the groups. All
variables was evaluate by describing the mean ± standard
deviation (SD) or median (min-max), where applicable.
The student’s t-test and Mann-Whitney test were
applied for comparisons for independent measurements
of mean or median values. The Chi-square test was used
to evaluate he differences between categorical data.
The univariate logistic regression was used to evaluate
associated factors that effect FAR value. For the purpose
determining the cut-off value of FAR, the receiver
operating characteristic (ROC) analysis was used. Data
were evaluated in the 95% confidence interval (CI).
One-way analysis of variance (ANOVA) test was used
to compare the independent groups more than 2. A
p-value less than 0.05 were considered statistically
significant.
Results. A total of 102 pregnant women, 52 with
AI and 50 healthy controls, participated in the study
population. The mean age of pregnant women was 30.1
± 5.8 in the AI group and 29.6±6.1 in the control group.
The mean BMI of pregnant women was 23.2±2.5 in
the AI group, and 23.6±2.9 in the control group. There
was no statistically significant difference in terms of age
and BMI between the groups (p=0.6743 and p=0.4667,
respectively). Demographic variables of participants
were summarized in Table 1.
The spontaneous abortion rate was 14/52 (26.9%)
in AI group and 0/50 (0%) in control group. Compared
the control pregnancies, the rate of spontaneous
abortion rate was significantly higher in AI group
(p=0.0001). Also in the AI group, 15/52 (28.8%)
experienced pelvic pain and 21/52 (40.4%) experienced
abdominal cramps and there was a statistical significant
differences between in pregnancies with AI (p<0.0001)
and controls (p<0.0001).
Regarding the alteration of inflammatory parameters
in pregnancies with and without AI, plasma fibrinogen
concentration were significantly higher, and serum
albumin concentration significantly lower, in AI
pregnancies compared to the controls (p=0.0374 and
p=0.0150, respectively). As expected, calculated FAR
values were significantly higher in AI pregnancies than
in the control group (p=0.0088) (Table 2). Our subgroup
analysis demonstrated that plasma fibrinogen (Figure 2),
and FAR levels (Figure 4) were significantly higher and
serum albumin levels (Figure 3) was significantly lower
in AI pregnancies with spontaneous abortion than in
AI pregnancies without spontaneous abortion and
control pregnancies (p=0.001, p=0.002, and p<0.001,
respectively).
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 Increased FAR values in AI ... Usta et al

Table 1 - Demographic characteristic of abortus insipiens (AI) and control patients.

Characteristics AI group (n=52) Control group (n=50) P-value

Age (year), mean±SD (min-max) 30.1±5.8 (20-41) 29.6±6.1 (21-41) 0.6743*
BMI (kg/m2 ), mean±SD (min-max) 23.2±2.5 (19.2-28.9) 23.6±2.9 (18.5-29.3) 0.4667*
Gestational Age (weeks), mean±SD 9.1±1.5 8.3±1.5 0.1404*
Gravidity (n), mean±SD 2.2±1.1 2.3±1.1 0.7554*
Parity (n), mean±SD 0.6 ±0.9 0.7±0.8 0.7038*
Systolic blood pressure (mmHg), mean±SD 109.4±13.6 107.6±10.9 0.4585*
Diastolic blood pressure (mmHg), mean±SD 71.9±7.7 70.6±7.5 0.3821*
Plasma glucose levels (mg/dL), mean±SD 79.1±7.2 77.9±8.4 0.4562*
Type of vaginal bleeding (n)
Spotting 19
Pink 8
Red 17 - -
Like a menstruation 8
Presence of pelvic pain (n)
Yes 15 0
< 0.0001†
No 37 50
Presence of abdominal cramp (n)
Yes 21 0
< 0.0001†
No 31 50
Spontanous abortion (n)
0
Yes 14 0.0001†
No 38 50
*Student t-test, † Chi-squared test, BMI: body mass index

Table 2 - Inflammatory parameters of patients with and without abortus insipiens (AI).

Parameters AI group (n = 52) Control group (n = 50) P-value*

White blood cell count 9217.3 ± 1955.9 9040.0 ± 1607.5 0.6188
Neutrophil count 6284.6 ± 1963.9 6214.1 ± 2089.6 0.8609
Lymphocytes count 2155.8 ± 573.1 2126.1 ± 421.3 0.7664
Fibrinogen level 369.1 ± 72.2 339.8 ± 67.7 0.0374
Albumin level 3.73 ± 0.36 3.92 ± 0.42 0.0150
Fibrinogen to albumin ratio 100.5 ± 24.6 88.1 ± 22.1 0.0088
Values are presented as mean ± standard diviation. *Student t-test, SD: standard deviation

Figure 1 - The receiver operating characteristic analysis was performed to
investigate the effect of FAR value in predicting spontaneous
abortion in pregnancies with abortus insipiens; FAR:
Fibrinogen to albumin ratio. The area under the ROC curve
of FAR was 0.803 (p<0.001).
Figure 2 - Plasma levels of fibrinogen in the groups (data show a
mean±SD). Subgroup analysis demonstrated that plasma
fibrinogen concentration was significantly higher in abortus
insipiens (AI) with spontaneous abortion (SA) than AI
without SA and controls (p=0.001, ANOVA test).

258 Saudi Med J 2021; Vol. 42 (3) https://smj.org.sa

 Increased FAR values in AI ... Usta et al
A univariate logistic regression analysis demonstrated
that only BMI was a possible confounding factor
affecting FAR values (odds ratio [OR]: 2.9615
[95% CI: 1.2633 to 6.9425]; p=0.0111) (Table 3).
Identification of independent risk factors for the
development of spontaneous abortion in the AI group,
both a univariate and multivariate logistic regression
model were performed (Table 4). A univariate logistic
regression analysis have shown that the BMI (odds
ratio [OR]: 4.4286 [95% CI: 1.1706 to 16.7536];
p=0.0274), type of vaginal bleeding (OR: 6.4815 [95%
CI: 1.2982 to 32.3588]; p=0.0201) and the FAR values
(OR: 9.2000 [95% CI: 1.7986 to 47.0589]; p=0.0020)
were associated risk factors for the development of
spontaneous abortion. In the multivariate logistic
regression model, only the FAR values (OR: 7.3116
Figure 3 - Plasma levels of fibrinogen in the groups (data show a
mean±SD). Subgroup analysis demonstrated that plasma
fibrinogen concentration was significantly higher in abortus
insipiens (AI) with spontaneous abortion (SA) than AI
without SA and controls (p=0.001, ANOVA test).
Figure 4 - Fibrinogen/albumin ratio (FAR) in the groups (Data show a
mean±SD). Subgroup analysis demonstrated that FAR levels
were significantly higher in abortus insipiens (AI) with
spontaneous abortion (SA) than AI without SA and controls
(p<0.001, ANOVA test)
[95% CI: 1.3119 to 40.7507]; p=0.0232) was found
to be an independent marker for the prediction of
spontaneous abortion in AI.
The ROC analysis have shown that the area under the
ROC curve for FAR was 0.803 (95% CI: 0.669-0.900;
p<0.0001). Youden’s index established cut-off values of
>97.18 for FAR (sensitivity=85.7%; specificity=60.5%).
Discussion. In this study, we evaluate the alteration
of FAR in AI pregnancies and its prognostic value in
predicting spontaneous abortion. According to our
present results, pregnant women with AI demonstrated
significantly higher levels of FAR in blood samples
as compared to women without AI. Moreover, a
univariate and multivariate logistic regression analyses
clearly demonstrated that increased levels of FAR was
an independent risk factor for the development of
spontaneous abortion in this pregnancy group.
Vaginal spotting or bleeding in early pregnancy is a
common complication, and it may be associated with
the development of spontaneous abortion. In the extant
literature on the subject, the spontaneous abortion rate
has been reported as 14-50% in AI pregnancies:17,18
in the present study population, the rate was 26.9%.
Several maternal and fetal etiopathogenetic factors are
associated with the development of spontaneous abortion
in AI pregnancies, such as genetic disorders, increased
maternal age and BMI, previous spontaneous abortion
history, abnormal placental development, infectious
diseases, and immunolosgical factors.19 However,
regardless of underlying etiological factors, vaginal
bleeding is an early indicator of placental dysfunction
and progression to abortion in some AI cases. 3 In these
instances, placental dysfunction and altered perfusion
may eventually lead to placental ischemia and oxidative
stress. A recent study conducted by Jauniaux et al20 have
shown that the blood flow alteration in intervillous
vessels usually occurs much earlier in the abortion group
than in normal pregnancies. The authors concluded
that in miscarriage group, there was a close relationship
between altered placental blood flow and oxidative
damage in placental tissue. Under these conditions,
oxidative stress activates vascular endothelial cells and
systemic inflammatory responses, which is the main
cause for the development of pregnancy complications,
including spontaneous abortion. 3,5 Comparable to these
results, previous studies have clearly demonstrated that
there was a close relationship between higher levels of
inflammatory makers and development of threatened
abortion and early pregnancy loss.21,22
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 Increased FAR values in AI ... Usta et al

Table 3 - Possible confounding factors associated with fibrinogen/albumin ratio values.

Univariate logistic regression analysis

Variables
n OR 95% CI P-value
Age (year)
<30 49 1.0 1.0 (references)
0.5183
≥30 53 1.2946 0.5908 to 2.8369
Body mass index (kg/m 2)
<25 68 1.0 1.0 (references)
0.0111
≥25 34 2.9615 1.2633 to 6.9425
Gestational ages (weeks)
<9 58 1.0 1.0 (references)
≥9 44 1.2935 0.5874 to 2.8481 0.5226
Gravidity (n)
<2 37 1.0 1.0 (references)
0.3336
≥2 65 1.4979 0.6573 to 3.4133
Parity (n)
<1 60 1.0 1.0 (references)
0.7067
≥1 42 1.1311 0.5941 to 2.1534
Systolic blood pressure
<110 44 1.0 1.0 (references)
0.8301
≥110 58 1.0909 0.4926 to 2.4160
Diastolic blood pressure
<80 62 1.0 1.0 (references)
0.7915
≥80 40 0.8975 0.4025 to 2.0014
Type of vaginal bleeding
Spotting, pink or red 44 1.0 1.0 (references)
0.1466
Like a menstruation 8 3.2857 0.5966 to 18.0972
Presence of pelvic pain (n)
No 37 1.0 1.0 (references)
0.1720
Yes 15 2.3529 0.6720 to 8.2390
Presence of abdominal cramp (n)
No 31 1.0 1.0 (references)
0.0777
Yes 21 2.7692 0.8732 to 8.7824
OR: odd ration, CI: confidence interval

In the literature, a number of studies have shown
that plasma levels of FAR are significantly higher in
many diseases such as hypertension, atherosclerosis,
cardiovasculary diseases, myocardial infarction,
ankylosing spondylitis and various cancer, which is
related to inflammatory conditions in the body. 10-14
Karahan et al13 clearly demonstrated that FAR may
predict the severity of coronary artery atherosclerosis in
patients with myocardial infarction. Similarly, Ozdemir
et al10 have demonstrated that plasma FAR levels were
higher in patients with hypertension than in controls.
Comparable to these results, the FAR has been
shown to be a good prognostic indicator for patients
with breast cancer.14 In a recent research conducted by
Tan et al11 indicated that increased plasma FAR value
was an independent risk factor for poor prognosis,
early recurrence and short cancer-free survival times
in patients with esophageal squamous cell carcinoma.
Lui et al12 have also shown that plasma FAR values
were higher in ankylosing spondylitis than in controls;
therefore, they concluded that the FAR may be a novel
inflammatory parameter for monitoring activity of
the diseases in patients with ankylosing spondylitis.
Thus, it may be argued that the FAR can serve as an
inflammatory based prognostic indicator in many
diseases that cause systemic inflammation.11,12,14
Regarding the role of fibrinogen or albumine
levels in the normal and abnormal pathophysiological
conditions in human pregnancies, there were a small
number of studies that investigated and results were
vary. Manten et al 23 indicated that compared to normal
pregnancies, circulating levels of total fibrinogen
and particularly high molecular weight fibrinogen
concentration were slightly increased in pre-eclampsia.

260 Saudi Med J 2021; Vol. 42 (3) https://smj.org.sa

 Increased FAR values in AI ... Usta et al

Table 4 - A univariate and multivariate logistic regression analysis showing the predictors for the development of spontaneous abortion in
pregnancies with abortus insipiens.

Univariate logistic regression analysis Multivariate logistic regression analysis

Variables
n OR 95% CI P-value OR 95% CI P-value
Age (year)
<30 5/24 1.0 1.0 (references)
≥30 9/28 1.8000 0.5082 to 6.3758 0.3563
Body mass index (kg/m 2)
<25 7/38 1.0 1.0 (references)
≥25 7/14 4.4286 1.1706 to 16.7536 0.0274 2.8925 0.6471 to 12.9296 0.1644
Gestational ages (weeks)
<9 7/25 1.0 1.0 (references)
≥9 7/27 0.9000 0.2641 to 3.0668 0.8662
Gravida (n)
<2 4/18 1.0 1.0 (references)
≥2 10/34 1.4583 0.3842 to 5.5350 0.5743
Parite (n)
<1 9/32 1.0 1.0 (references)
≥1 5/20 0.8519 0.2387 to 3.0398 0.8042
Fibrinogen/albumin ratio
<97.2 2/25 1.0 1.0 (references)
≥97.2 12/27 9.2000 1.7986 to 47.0589 0.0020 7.3116 1.3119 to 40.7507 0.0232
Type of vaginal bleeding
Spotting, pink or red 9/44 1.0 1.0 (references)
Like a menstruation 5/8 6.4815 1.2982 to 32.3588 0.0201 4.4784 0.7440 to 26.9560 0.1016
Presence of abdominal cramp (n)
No 6/31 1.0 1.0 (references)
Yes 8/21 2.5641 0.7325 to 8.9752 0.1374
Presence of pelvic pain (n)
No 9/38 1.0 1.0 (references)
Yes 6/14 2.4167 0.6612 to 8.8326 0.1852

Therefore, the authors concluded that increased levels
of total fibrinogen concentration and alteration of high
molecular weight fibrinogen may play a role in vasculary
endothelial activation, and exaggerated inflammatory
response which are believed to be underlying molecular
mechanisms in pre-eclampsia.23 Similarly, Davitson et
al24 demonstrated that pregnacies with hypertension
have higher fibrinogen concentrations in blood samples
compared to controls. Tetik et al25 also showed that
circulating fibrinogen concentration were significantly
higher in IUGR than control pregnancies. However,
Chen et al26 asserted that compared to non-pregnant
women and healthy pregnancies, women with
preeclampsia have lower fibrinogen levels in the third
trimester. These conflicting results may be associated
with differences in sample sizes, demographic
characteristics of participants or fibrinogen to fibrin
transformation on the third trimester. It is known that
circulating levels of fibrinogen immediately decrease in
parallel with the amount of acute hemorrhage during
the abortion and postpartum hemorrhage.
According to the extant literature, serum albumin
levels, unlike fibrinogen, decreases in the presence
of pregnancy related hypertension, and it is a useful
predictor for timing of delivery, presence of severe
proteinuria, and poor prognosis of pregnancy.27
Ozdemir et al28 indicated that serum albumin levels
in first trimester were significantly lower in women
with histories of recurrent pregnancy loss than in
controls. Comparably, we found that serum albumin
concentration was significantly decreased in the AI
group than in the controls.
The present study also determined that vaginal
bleeding in early pregnancy was associated with

https://smj.org.sa Saudi Med J 2021; Vol. 42 (3) 261

 Increased FAR values in AI ... Usta et al
increased fibrinogen levels and decreased albumin
levels in blood samples. Also, the FAR was significantly
higher in pregnant women with AI than in controls
and increased FAR values in women with AI was an
independent risk factor for subsequent spontaneous
abortion.
In normal pregnancy, there is a mild systemic
inflammatory response which is promote with the
progression of pregnancy and peaks during the
third trimester. This physiological inflammatory
response is characterized by slightly increase in the
circulating concentration of cytokines, as well as the
activation of white blood cells such as neutrophils,
lymphocytes, monocytes, and granulocytes. 29 However,
in pregnancies with miscarriage or threatened
abortion, the intensity of the systemic inflammatory
response is stronger than normal pregnancies due
to the increase of proinflammatory cytokines in the
maternal circulation.30 In the present study, contrary
to FAR leves, there were no differences in white blood
cell, neutrophil and lymphocytes counts between in
pregnancies with and without AI. These results may be
associated with small number of study population, mild
systemic inflammation among the participants, and
the participants’ early gestational age. However, it may
also be that the FAR is a more sensitive inflammatory
marker than other indicators.
On the other hand, in the literature there was a
few studies have evaluated the relation between the
presence of abdominal cramp, pelvic pain and type
of vaginal bleeding with the development of the
spontaneous abortion.21,22 Those authors have found
a close relationship between increased inflammatory
status and uterine contractions with progressive cervical
effacement and dilatation, which can initiate and
maintain labor at any gestational age. 21,22 The present
study determined that pelvic pains or abdominal
cramps were significantly higher in AI pregnancies than
in control pregnancies. However, we did not find any
association between presence of pelvic pain, abdominal
cramp or type of vaginal bleeding with progression to
spontaneous abortion.
Study limitations. There was no any information
on patients’ physical examinations and laboratory
parameters was available. There was a progesterone
exposure in the AI group (but not in the control group).
There was no information on the genetic consequences
of abortion materials in pregnancies with spontaneous
abortion. The authors also had no information on
maternal and perinatal pregnancy complications after
20 weeks of gestation or their association with the FAR.
262 Saudi Med J 2021; Vol. 42 (3) https://smj.org.sa
In conclusion, the present results have shown that
AI pregnancies exhibit increased FAR values compared
to healthy pregnancies. FAR levels were associated with
progression to spontaneous abortion. These higher FAR
levels and their association with spontaneous abortion
may be related to the underlying molecular mechanism
of AI.
Acknowledgment. We would like to thank all staff of the
Department of Obstetrics and Gynecology, School of Medicine, Balikesir
University for their assistance in data collection step. We also would like
to thank Scribendi (www.scribendi.com) for English language editing.
References
1. Simpson JL, Mills JL, Holmes LB, Ober CL, Aarons J, Jovanovic
L, et al. Low fetal loss rates after ultrasound-proved viability in
early pregnancy. JAMA 1987; 258: 2555-2557.
2. Weiss JL, Malone FD, Vidaver J, Ball RH, Nyberg DA,
Comstock CH, et al. Threatened abortion: a risk factor for poor
pregnancy outcome, a population-based screening study. Am J
Obstet Gynecol 2004; 190: 745-750.
3. Katar-Yildirim C, Tokmak A, Yildirim C, Erel O, Caglar AT.
Investigation of serum thiol/disulphide homeostasis in patients
with abortus insipiens. J Matern Fetal Neonatal Med 2018
Sep 17; 31: 2457-2462.
4. Kaufmann P, Black S, Huppertz B. Endovascular Trophoblast
Invasion: Implications for the Pathogenesis of Intrauterine
Growth Retardation and Preeclampsia. Biol Reprod 2003; 69:
1-7.
5. Gupta S, Agarwal A, Banerjee J, Alvarez JG. The role of oxidative
stress in spontaneous abortion and recurrent pregnancy loss: a
systematic review. Obstet Gynecol Surv 2007; 62: 335-347.
6. Ghanim B, Hoda MA, Klikovits T, Winter M-P, Alimohammadi
A, Grusch M, et al. Circulating fibrinogen is a prognostic and
predictive biomarker in malignant pleural mesothelioma. Br J
Cancer 2014; 110: 984-990.
7. Sadeghi M, Akhlaghi L, Rahimi-Esboei B, Tabatabaie F.
Evaluation of the Plasma Level of Fibrinogen in the First
Trimester in Mothers with Toxoplasmosis. J Arch Mil Med
2018; 6: e67012.
8. Haefliger DN, Moskaitis JE, Schoenberg DR, Wahli W.
Amphibian albumins as members of the albumin, alpha-
fetoprotein, vitamin D-binding protein multigene family. J Mol
Evol 1989; 29: 344-354.
9. Seo MH, Choa M, You JS, Lee HS, Hong JH, Park YS, et
al. Hypoalbuminemia, low base excess values, and tachypnea
predict 28-day mortality in severe sepsis and septic shock
patients in the emergency department. Yonsei Med J 2016; 57:
1361-1369.
10. Özdemir M, Yurtdaş M, Asoğlu R, Yildirim T, Aladağ N, Asoğlu
E. Fibrinogen to albumin ratio as a powerful predictor of the
exaggerated morning blood pressure surge in newly diagnosed
treatment-naive hypertensive patients. Clin Exp Hypertens
2020; 42: 692-699.
11. Tan Z, Zhang M, Han Q, Wen J, Luo K, Lin P, et al. A novel
blood tool of cancer prognosis in esophageal squamous cell
carcinoma: the Fibrinogen/Albumin ratio. J Cancer 2017; 8:
1025-1029.
 Increased FAR values in AI ... Usta et al
12. Liu M, Huang Y, Huang Z, Zhong Z, Deng W, Huang Z,
et al. The role of fibrinogen to albumin ratio in ankylosing
spondylitis: Correlation with disease activity. Clin Chim Acta
2020; 505: 136-140.
13. Karahan O, Acet H, Ertaş F, Tezcan O, Çalişkan A, Demir M,
et al. The relationship between fibrinogen to albumin ratio and
severity of coronary artery disease in patients with STEMI. Am
J Emerg Med 2016; 34:1037-1042.
14. Hwang K-T, Chung JK, Roh EY, Kim J, Oh S, Kim YA, et
al. Prognostic influence of preoperative fibrinogen to albumin
ratio for breast cancer. J Breast Cancer 2017; 20: 254-63.
15. Besselaar AMHP van den, Rijn CJJ van, Cobbaert CM,
Reijnierse GLA, Hollestelle MJ, Niessen RWLM, et al.
Fibrinogen determination according to Clauss: commutability
assessment of International and commercial standards and
quality control samples. Clin Chem Lab Med CCLM 2017; 55:
1761-1769.
16. van Rijn BB, Veerbeek JH, Scholtens LC, Uiterweer EDP,
Koster MP, Peeters LL, et al. C-reactive protein and fibrinogen
levels as determinants of recurrent preeclampsia: a prospective
cohort study. J Hypertens 2014; 32: 408-414.
17. Hasan R, Baird DD, Herring AH, Olshan AF, Jonsson Funk
ML, Hartmann KE. Association between first-trimester vaginal
bleeding and miscarriage. Obstet Gynecol 2009; 114: 860-867.
18. Basama FMS, Crosfill F. The outcome of pregnancies in 182
women with threatened miscarriage. Arch Gynecol Obstet 2004;
270: 86-90.
19. du Fossé NA, van der Hoorn M-LP, van Lith JMM, le Cessie
S, Lashley EELO. Advanced paternal age is associated with an
increased risk of spontaneous miscarriage: a systematic review
and meta-analysis. Hum Reprod Update 2020; 26: 650-669.
20. Jauniaux E, Gulbis B, Burton GJ. The human first trimester
gestational sac limits rather than facilitates oxygen transfer to
the foetus–a review. Placenta 2003; 24: S86-S93.
21.
Ata N, Kulhan M, Kulhan NG, Turkler C. Can neutrophil-
lymphocyte and platelet-lymphocyte ratios predict threatened
abortion and early pregnancy loss? Ginekol Pol 2020; 91:
210-215.
22. Bas FY, Tola EN, Sak S, Cankaya BA. The role of complete
blood inflammation markers in the prediction of spontaneous
abortion. Pak J Med Sci 201834: 1381.
23. Manten GTR, Sikkema JM, Franx A, Hameeteman TM, Visser
GHA, de Groot PG, et al. Increased high molecular weight
fibrinogen in pre-eclampsia. Thromb Res 2003; 111: 143-147.
24. Davidson EC, Phillips LL. Coagulation studies in the
hypertensive toxemias of pregnancy. Am J Obstet Gynecol 1972;
113: 905-910.
25. Tetik K, Seçkin KD, Karslı FM, Sarıaslan S, Çakmak B,
Danışman N. Can we use as a marker the maternal serum
levels of D-dimer and fibrinogen to predict intra uterin growth
restriction? Turk J Obstet Gynecol 2014; 11: 228.
26. Chen Y, Lin L. Potential value of coagulation parameters for
suggesting preeclampsia during the third trimester of pregnancy.
Am J Med Sci 2017; 354: 39-43.
27. Seong WJ, Chong GO, Hong DG, Lee TH, Lee YS, Cho
YL, et al. Clinical significance of serum albumin level in
pregnancy-related hypertension. J Obstet Gynaecol Res 2010;
36: 1165-173.
28. Özdemir S, Kıyıcı A, Balci O, Göktepe H, Çiçekler H, Çelik Ç.
Assessment of ischemia-modified albumin level in patients with
recurrent pregnancy loss during the first trimester. Eur J Obstet
Gynecol Reprod Biol 2011; 155: 209-212.
29. MacLean MA, Wilson R, Thomson JA, Krishnamurthy S,
Walker JJ. Changes in immunologic parameters in normal
pregnancy and spontaneous abortion. Am J Obstet Gynecol
1991; 165: 890-895.
30. Paradisi R, Porcu E, Venturoli S, Maldini‐Casadei M, Boni P.
Maternal serum levels of pro- inflammatory cytokines in missed
and threatened abortion. Am J Reprod Immunol 2003; 50:
302-308
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Original Investigation 239

The effects of subchorionic hematoma on pregnancy

outcome in patients with threatened abortion
Yavuz Emre Şükür1, Göksu Göç1, Osman Köse2, Gökhan Açmaz3, Batuhan Özmen1,
Cem Somer Atabekoğlu1, Acar Koç1, Feride Söylemez1
1
Department of Obstetrics and Gynaecology, Ankara University Faculty of Medicine, Ankara, Turkey
2
Department of Obstetrics and Gynaecology, Yenimahalle State Hospital, Ankara, Turkey
3
Department of Obstetrics and Gynaecology, Kayseri Education and Research Hospital, Kayseri, Turkey

Abstract
Objective: To assess the effects of ultrasonographically detected subchorionic hematomas on pregnancy outcomes in patients with vaginal
bleeding within the first half of pregnancy.
Material and Methods: Patients diagnosed with threatened abortion due to painless vaginal bleeding and who were followed up in an in-
patient service during the first vaginal bleeding between January 2009 and December 2010 were included in this retrospective cohort study.
Patients were divided into two groups according to the presence of subchorionic hematoma. Miscarriage rates and pregnancy outcomes of
ongoing pregnancies were compared between the groups.
Results: There were no statistically significant differences between the groups regarding demographic parameters, including age, parity, previ-
ous miscarriage history, and gestational age at first vaginal bleeding. While 13 of 44 pregnancies (29.5%) with subchorionic hematoma resulted
in miscarriage, 25 of 198 pregnancies (12.6%) without subchorionic hematoma resulted in miscarriage (p=.010). The gestational age at miscar-
riage and the duration between first vaginal bleeding and miscarriage were similar between the groups. The outcome measures of ongoing
pregnancies, such as gestational week at delivery, birth weight, and delivery route, were also similar between the groups.
Conclusion: Ultrasonographically detected subchorionic hematoma increases the risk of miscarriage in patients with vaginal bleeding and
threatened abortion during the first 20 weeks of gestation. However, it does not affect the pregnancy outcome measures of ongoing pregnan-
cies. (J Turk Ger Gynecol Assoc 2014; 15: 239-42)
Key words: Abortion, threatened, miscarriage, spontaneous, pregnancy outcome
Received: 02 September, 2014 Accepted: 09 October, 2014

Introduction mation of the decidua might also be the underlying cause of

Vaginal bleeding is a frequent complication of pregnancy
during the first trimester, with an incidence of 16%-25%
(1). Intrauterine bleeding without cervical dilatation and
tenderness during the early pregnancy period is defined as
threatened abortion. Generally, it is not associated with pain
and excessive bleeding. These bleedings result in maternal
anxiety and may be associated with fetal/maternal adverse
outcomes (2-4). One of the suggested mechanisms for threa-
tened abortion is placental dysfunction, which can also cause
several late complications, such as preeclampsia, preterm
labor, preterm birth, placental abruption, placenta previa,
intrauterine growth restriction, and perinatal mortality (2, 3).
Similarly, insufficient angiogenesis is associated with early
pregnancy losses, and maternal serum AFP and β-hCG are
suggested to be used as markers of angiogenesis in the first
trimester (5). Together with these markers, chronic inflam-
early pregnancy bleedings.
Intrauterine hemorrhages are commonly observed features
on ultrasound examinations, especially among patients with
clinically evident bleeding in early pregnancy, and the inci-
dence has been reported to be 4%-22% (6). Subchorionic
hematomas (SCHs) usually appear as hypoechoic or anec-
hoic crescent-shaped areas on ultrasonography. Although the
exact etiology is uncertain, they are believed to result from
partial detachment of the chorionic membranes from the
uterine wall (7). Uterine malformations, history of recurrent
pregnancy loss, and infections are the possible predisposing
factors (8-10). The clinical significance of SCH remains cont-
roversial (11-14). It is also not certain if these hemorrhages
result in abortion. However, according to the results of a
recent meta-analysis, the presence of SCH increases the risk
of early or late pregnancy loss by 2-fold (15). It is suggested
that the presence of SCH increases the risk of an adverse obs-

Address for Correspondence: Yavuz Emre Şükür, Department of Obstetrics and Gynaecology, Ankara University Faculty of Medicine, Ankara, Turkey.
Phone: +90 312 595 64 05 e.mail: yesukur@yahoo.com
©Copyright 2014 by the Turkish-German Gynecological Education and Research Foundation - Available online at www.jtgga.org
DOI:10.5152/jtgga.2014.14170
 Şükür et al.
Subchorionic hematoma in threatened abortion
240
tetric outcome, and fetal outcome is associated with the size
of the hematoma, maternal age, and gestational age (16, 17).
The aim of the present retrospective cohort study was to assess
the effects of ultrasonographically detected SCH on pregnancy
outcomes in patients with vaginal bleeding within the first half
of pregnancy.
Material and Methods
In this retrospective cohort study, patients with threatened
abortion (n=242) who were followed at a university-based
perinatology clinic between January 2009 and December 2010
were recruited. The study was approved by the institutional
review board of Ankara University School of Medicine. The inc-
lusion criteria were hospitalization due to threatened abortion,
singleton pregnancy, gestational age <20 weeks, and being
followed up at our clinic until the end of the pregnancy. The
exclusion criteria were a diagnosis of incipient abortion, no fetal
cardiac activity, gestational age ≥20 weeks, multiple pregnancy,
and recurrent pregnancy loss. The study group consisted of
44 patients with SCHs observed on ultrasonography, and the
control group consisted of 198 patients without SCHs. All inc-
luded patients were hospitalized for at least 3 days following
the first vaginal bleeding episode. All patients were adminis-
tered prophylactic progesterone treatment in oral (Progestan
capsule; Koçak Farma, İstanbul, Turkey), vaginal (Crinone 8%
gel; Serono, İstanbul, Turkey), or intramuscular (Proluton depot
ampule; Schering Alman, İstanbul, Turkey) forms. Subsequent
to discharge from the hospital, patients went on routine ante-
natal follow-up programs. The pregnancy outcomes were
compared between the study and control groups. In patients
whose pregnancies resulted in miscarriage, the gestational
age at miscarriage and the duration between the first bleeding
and miscarriage were compared. In patients whose pregnan-
cies resulted in delivery, gestational age at labor, birth weight,
preterm delivery, and cesarean section rates were compared
between the groups.
Statistical analysis
Statistical Package for the Social Sciences (SPSS) 15.0 for
Windows (Chicago, IL, USA) was used for all statistical analyses.
Shapiro-Wilk test was used to test the distribution of normality.
According to the results, non-parametric tests were preferred.
Continuous variables were compared with Kruskal-Wallis test.
Categorical variables were compared with chi-square test or
Fisher’s exact test where appropriate. A p value of <.05 was
considered statistically significant.
Results
The incidence of SCH among patients with threatened abortion
was 18.2% (44/242) for this population. The demographic vari-
ables of the study and control groups are presented in Table
1. The mean ages of the patients with and without SCH were
29.5±6.2 and 29.0±5.5 years, respectively (p=.624). The groups
were comparable regarding previous parity and miscarriage
histories (Table 1). Similarly, the groups were comparable
J Turk Ger Gynecol Assoc 2014; 15: 239-42
regarding gestational age at the first vaginal bleeding (9.3±2.8
vs. 10.2±3.3 weeks, respectively; p=.085).
Table 2 summarizes the parameters of both groups regarding
miscarriage; 13 of 44 pregnancies with SCH resulted in miscar-
riage (29.5%), while 25 of 198 pregnancies with SCH resulted
in miscarriage (12.6%) (p=.010). The gestational age at mis-
carriage was similar between the study and control groups
(10.8±3.6 vs. 10.9±4.8 weeks, respectively; p=.581). Similarly,
there was no statistically significant difference between the
study and control groups regarding duration between the first
vaginal bleeding and miscarriage (16.4±23.8 vs. 9.0±7.5 days,
respectively; p=.436).
Table 3 summarizes the pregnancy outcomes of 204 patients
whose pregnancy resulted in delivery. The mean gestational
ages at delivery were 37.4±4.1 weeks in 31 patients with SCH
Table 1. Demographic parameters of the study and control
groups
SCH (+) SCH (-)
n=44 n=198 p
Age (years) 29.5±6.2 29.0±5.5 .624
Parity (n) .5±.8 .6±.8 .581
Previous miscarriage (n) .5±.7 .4±.8 .657
Gestational age at first
vaginal bleeding (weeks) 9.3±2.8 10.2±3.3 .085
SCH: subchorionic hematoma
Table 2. Comparison of miscarriage and related param-
eters between study and control groups
SCH (+) SCH (-)
n=44 n=198 p
Miscarriage, n (%) 13 (29.5) 25 (12.6) .010
Within pregnancies
resulting in miscarriage n=13 n=25
Gestational age at
miscarriage (weeks) 10.8±3.6 10.9±4.8 .581
Duration between first
bleeding and miscarriage 16.4±23.8 9.0±7.5 .436
(days)
SCH: subchorionic hematoma
Table 3. Comparison of pregnancy outcomes in patients
whose pregnancy resulted in delivery
SCH (+) SCH (-)
n=44 n=198 p
Gestational age at delivery
(weeks) 37.4±4.1 37.4±3.6 .962
Preterm delivery, n (%) 5 (16.1) 44 (25.4) .362
Birth weight (kg) 2958±810 3004±763 .792
Cesarean section, n (%) 13 (41.9) 80 (45.9) .701
SCH: subchorionic hematoma

J Turk Ger Gynecol Assoc 2014; 15: 239-42
and 37.4±3.6 weeks in 173 patients without SCH (p=.962).
There was no statistically significant difference between the
study and control groups regarding preterm birth rate (16.1% vs.
25.4%, respectively; p=.362). Similarly, the birth weights were
comparable between the groups (2958±810 g vs. 3004±763 g,
respectively; p=.792). The cesarean section rates were also
similar between the study and control groups (41.9% vs. 45.9%,
respectively; p=.701).
Discussion
The results obtained from the present study revealed that the
presence of SCH in patients with threatened abortion is an
important factor for the continuation of pregnancy. The presen-
ce of SCH in patients with threatened abortion increases the
risk of miscarriage. However, it does not affect the gestational
age at miscarriage or the duration between the first bleeding
and miscarriage. In patients whose pregnancies resulted in
delivery, gestational age at labor, birth weight, preterm delivery,
and cesarean section rates were not affected by the presence
of SCH. Previously, several studies have investigated the effects
of SCH on pregnancy outcomes. Ball et al. (18) evaluated 238
patients with ultrasonographically detected SCH in a retrospec-
tive casecontrol study and reported a significant association
between SCH and miscarriage and preterm delivery rates. They
also reported increasing pregnancy loss rates with increasing
SCH size. Similarly Nagy et al. (19) compared 187 patients who
had SCH with 6488 controls, and they found increased miscar-
riage, intrauterine growth restriction, and preterm delivery rates
in the presence of SCH. However, they failed to show an asso-
ciation between the size and location of the SCH and ongoing
pregnancy outcome measures. In a retrospective cohort study,
Norman et al. (20) evaluated 63,966 patients who had an ult-
rasonographic evaluation before 22 weeks of gestation and
reported that the incidence of SCH was 1.7%. They found that
the detection of an SCH during routine second-trimester ultra-
sonography was associated with more than a 2-fold increased
risk of placental abruption, regardless of whether the woman
reported bleeding in the early half of pregnancy. They also iden-
tified that women with SCH were at increased risk of preterm
delivery. However, in the aforementioned studies, SCHs were
defined during the routine first- or second-trimester ultrasonog-
raphy, and not all patients with an SCH had threatened abortion.
Vaginal bleeding occurs in 25% of pregnancies in the first 20
weeks, and half of these result in miscarriage (16). Hence, it
is important to identify the risk factors of threatened abortion
and the factors that can affect the outcome. In a retrospective
cohort trial, Ben-Haroush et al. (21) assessed 2556 pregnant
patients who were admitted with vaginal bleeding during the
first 20 gestational weeks. The incidence of SCH was 9%. They
reported that gestational age at diagnosis, size of SCH, and
duration of bleeding did not affect the pregnancy outcome.
They also reported significantly decreased miscarriage rates
with bed rest. However, Bennett et al. (17) reported that increa-
sing SCH size increases the risk of miscarriage. In a prospective
cohort study, Pedersen and Mantoni followed up 342 pregnanci-
es with vaginal bleeding between 9 to 20 gestational weeks, in
Şükür et al.
Subchorionic hematoma in threatened abortion
241
which 18% had SCH (12). They found no association between
the presence of SCH and miscarriage or preterm delivery risks.
In another retrospective case-control study, Johns et al. (22)
reported that first-trimester vaginal bleedings were associated
with adverse pregnancy outcomes, but the presence of SCH
had no effect on the prognosis. According to the results of a
recent meta-analysis evaluating 1735 patients with SCH from
7 studies, the presence of SCH increases the risks of early and
late pregnancy loss, miscarriage, and preterm premature rup-
ture of membranes (15).
In a prospective study from Turkey, the size of the SCH was sug-
gested to be the primary risk factor for miscarriage in patients
with first-trimester vaginal bleeding (23). Uluğ et al. (24) repor-
ted that first-trimester bleedings were associated with preterm
delivery and low birth weight. However, they found no relati-
onship between the prognosis and presence or size of the SCH.
In another Turkish case-control study, Özkaya et al. (25) repor-
ted the outcomes of 43 patients with SCH, and they found that
the presence of SCH increases the risks of miscarriage and
intrauterine growth restriction but not preterm delivery. The
results of our study were partially concordant with the literatu-
re, as we could only show that the presence of SCH increased
the risk of miscarriage. However, we failed to show any signi-
ficant relationship between the presence of SCH and ongoing
pregnancy outcome measures.
The underlying mechanism of how SCH causes adverse preg-
nancy outcomes is still controversial. One of the possible mec-
hanisms is the premature perfusion of the intervillous space, as
occurs with subchorionic hemorrhage, before the development
of placental adaptations to cope with oxidative stress (26).
Another possible mechanism might be the underlying cause of
the subchorionic bleeding and secondary mechanical effects
of the hematoma. Shallow trophoblast invasion and impaired
angiogenesis with resultant friable blood vessels may predispo-
se one to subchorionic hemorrhage, as well as adverse outco-
mes (15). The presence of a hematoma, especially in a retropla-
cental location, may create an area of weakness, where further
separation of the placenta from the uterine wall may occur,
resulting in placental abruption (15). Our results support the
estimated mechanical effect of SCH that can cause miscarria-
ge. The presence of an SCH and detachment of the gestational
sac from the endometrium may result in miscarriage. However,
if the gestational sac survives, reattachment to the endometrial
wall might be enough for further progression of the pregnancy
without any other adverse effects.
In conclusion, SCH in patients with threatened abortion during
the first half of the pregnancy increases the risk of miscarriage.
However, it is not absolute if the presence of an SCH increases
the adverse pregnancy outcome risk in ongoing pregnancies
or not, because almost all of the previously reported studies
were retrospective. Large prospective randomized studies are
required to determine the true role of SCH in the prognosis of
ongoing pregnancies.
Ethics Committee Approval: N/A.
Informed Consent: N/A.
Peer-review: Externally peer-reviewed.
 Şükür et al.
Subchorionic hematoma in threatened abortion
242
Author contributions: Concept – Y.E.Ş., G.G., O.K.; Design - Y.E.Ş., O.K.,
G.A.; Supervision - B.Ö., A.K., F.S.; Resource - Y.E.Ş., G.G.; Materials -
Y.E.Ş., G.G.; Data Collection&/or Processing - Y.E.Ş., G.G.; Analysis&/or
Interpretation - Y.E.Ş., G.A.; Literature Search - Y.E.Ş.; Writing - Y.E.Ş.;
Critical Reviews - B.Ö., A.K., F.S.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study has received
no financial support.
References
1. Farrell T, Owen P. The significance of extrachorionic membrane
separation in threatened miscarriage. Br J Obstet Gynaecol 1996;
103: 926-8. [CrossRef]
2. Saraswat L, Bhattacharya S, Maheshwari A, Bhattacharya S.
Maternal and perinatal outcome in women with threatened mis-
carriage in the first trimester: A systematic review. BJOG 2010; 117:
245-57. [CrossRef]
3. Weiss JL, Malone FD, Vidaver J, Ball RH, Nyberg DA, Comstock CH,
et al. Threatened abortion: a risk factor for poor pregnancy out-
come, a population-based screening study. Am J Obstet Gynecol
2004; 190: 745-50. [CrossRef]
4. Wijesiriwardana A, Bhattacharya S, Shetty A, Smith N, Bhattacharya
S. Obstetric outcome in women with threatened miscarriage in the
first trimester. Obstet Gynecol 2006; 107: 557-62. [CrossRef]
5. Kutluer G, Çiçek NM, Moraloğlu Ö, Ertargın P, Sarıkaya E, Artar İ,
Erdem Ö. Low VEGF expression in conceptus material and mater-
nal serum AFP and β-hCG levels as indicators of defective angioge-
nesis in first-trimester miscarriages. J Turk Ger Gynecol Assoc 2012;
13: 111-7. [CrossRef]
6. Pearlstone M, Baxi L. Subchorionic hematoma: A review. Obstet
Gynecol Surv 1993; 48: 65-8. [CrossRef]
7. Maso G, D’Ottavio G, De Seta F, Sartore A, Piccoli M, Mandruzzato
G. First-trimester intrauterine hematoma and outcome of preg-
nancy. Obstet Gynecol 2005; 105: 339-44. [CrossRef]
8. Mandruzzato GP, D’Ottavio G, Rustico MA, Fontana A, Bogatti P.
The intrauterine hematoma: diagnostic and clinical aspects. J Clin
Ultrasound 1989; 17: 503-10. [CrossRef]
9. Kaufman AJ, Fleischer AC, Thiema GA, Shah DM, James AE Jr.
Separated chorioamnion and elevated chorion: sonographic featu-
res and clinical significance. J Ultrasound Med 1985; 4: 119-25.
10. Queck M, Berle P. Spontaneous abortion after vaginal hemorrha-
ge in intact early pregnancy: An etiologic analysis. Geburtshilfe
Frauenheilkd 1992; 52: 553-6. [CrossRef]
11. Mantoni M, Pederson JF. Intrauterine hematoma: An ultrasonic
study of threatened abortion. BJOG 1981; 88: 47-51. [CrossRef]
J Turk Ger Gynecol Assoc 2014; 15: 239-42
12. Pedersen JF, Mantoni M. Large intrauterine haematomata in thre-
atened miscarriage: frequency and clinical consequences. BJOG
1990; 97: 75-7. [CrossRef]
13. Bloch C, Altchek A, Levy-Ravetch M. Sonography in early preg-
nancy: the significance of subchorionic hemorrhage. Mt Sinai J
Med 1989; 56: 290-2.
14. Borlum KG, Thomsen A, Clausen I, Eriksen G. Long term prognosis
of pregnancies with intrauterine hematomas. Obstet Gynecol 1989;
74: 231-3.
15. Tuuli MG, Norman SM, Odibo AO, Macones GA, Cahill AG.
Perinatal outcomes in women with subchorionic hematoma.
Obstet Gynecol 2011; 117: 1205-12. [CrossRef]
16. Abu-Yousef MM, Bleider JJ, Williamson RA, Weiner CP. Subchorionic
hemorrhage: Sonographic diagnosis and clinical significance. Am J
Roentgenol 1987; 149: 737-40. [CrossRef]
17. Bennett GL, Bromley B, Lieberman E, Benacerraf BR. Subchorionic
hemorrhage in first-trimester pregnancies: prediction of pregnancy
outcome with sonography. Radiology 1996; 200: 803-6. [CrossRef]
18 Ball RH, Ade CM, Schoenborn JA, Crane JP. The clinical significan-
ce of ultrasonographically detected subchorionic hemorrhages.
Am J Obstet Gynecol 1996; 174: 996-1002. [CrossRef]
19. Nagy S, Bush M, Stone J, Lapinski RH, Gardo S. Clinical significan-
ce of subchorionic and retroplacental hematomas detected in
the first trimester of pregnancy. Obstet Gynecol 2003; 102: 94-100.
[CrossRef]
20. Norman SM, Odibo AO, Macones GA, Dicke JM, Crane JP, Cahill AG.
Ultrasound-detected subchorionic hemorrhage and the obstetric
implications. Obstet Gynecol 2010; 116(2Pt1): 311-5. [CrossRef]
21. Ben-Haroush A, Yogev Y, Mashiach R, Meizner I. Pregnancy outco-
me of threatened abortion with subchorionic hematoma: possible
benefit of bed-rest? IMAJ 2003; 5: 422-4.
22. Johns J, Hyett J, Jauniaux E. Obstetric outcome after threatened
miscarriage with and without a hematoma on ultrasound. Obstet
Gynecol 2003; 102: 483-7. [CrossRef]
23. Möröy P, Kaymak O, Okyay E, Çelen Ş, Özkale D, Atayar YY, et al.
The effects of first trimester subchorionic hematomas on preg-
nancy outcome. Türkiye Klinikleri J Gynecol Obst 2004; 14: 247-51.
24. Uluğ U, Jozwiak EA, Tosun S, Bahçeci M. Preterm delivery risk
among pregnancies with history of first trimester vaginal bleeding
and intrauterin hematoma. Zeynep Kamil Tıp Bülteni 2006; 37: 47-51.
25. Özkaya E, Altay M, Gelişen O. Significance of subchorionic hae-
morrhage and pregnancy outcome in threatened miscarriage to
predict miscarriage, pre-term labour and intrauterine growth rest-
riction. J Obstet Gynaecol 2011; 31: 210-2.
26. Jauniaux E, Watson AL, Hempstock J, Bao YP, Skepper JN, Burton
GJ. Onset of maternal arterial blood flow and placental oxidative
stres. A possible factor in human early pregnancy failure. Am J
Pathol 2000; 157: 2111-22. [CrossRef]
 THIEME
Original Article 309

Abortion in the Structure of Causes of Maternal

Mortality
Aborto na estrutura das causas da mortalidade materna
Valery G. Volkov1 Nina N. Granatovich1 Elena V. Survillo1 Leontina V. Pichugina1 Zarina S. Achilgova1

1 Department of Gynecology and Obstetrics, Medical institute, Tula Address for correspondence Valery G. Volkov, Tula State University,
State University, Тula, Russia 300012, 92, Lenin Ave., Tula, Russia (e-mail: valvol@Yandex.ru).

Rev Bras Ginecol Obstet 2018;40:309–312.

Abstract Objective To study the structure of maternal mortality caused by abortion in the Tula
region.
Methods The medical records of deceased pregnant women, childbirth, and post-
partum from January 01, 2001, to December 31, 2015, were analyzed.
Results Overall, 204,095 abortion cases were recorded in the Tula region for over
15 years. The frequency of abortion was reduced 4-fold, with 18,200 in 2001 to 4,538 in
2015. The rate of abortions per 1,000 women (age 15–44 years) for 15 years decreased
by 40.5%, that is, from 46.53 (2001) to 18.84 (2015), and that of abortions per 100 live
births and stillbirths was 29.5%, that is, from 161.7 (2001) to 41.5 (2015). Five women
died from abortion complications that began outside of the hospital, which accounted
for 0.01% of the total number. In the structure of causes of maternal mortality for
Keywords 15 years, abortion represented 14.3% of the cases. Lethality mainly occurred in the
► abortion period from 2001 to 2005 (4 cases). Among the maternal deaths, many women died in
► pregnancy rural areas after pregnancy termination at 18 to 20 weeks of gestation (n ¼ 4). In
► maternal mortality addition, three women died from sepsis and two from bleeding.
► family planning Conclusion The introduction of modern, effective technologies of family planning
► sepsis has reduced maternal mortality due to abortion.

Resumo Objetivos Estudar a estrutura da mortalidade materna causada pelo aborto na região
de Tula.
Métodos Os registros médicos de mulheres grávidas falecidas, de parto e de pós-
parto, de 01 de janeiro de 2001 a 31 de dezembro de 2015, foram analisados.
Resultados No geral, 204.095 casos de aborto foram registrados na região de Tula,
em um período de 15 anos. A frequência de aborto foi reduzida a 1/4, passando de
Palavras-chave 18.200 abortos em 2001 para 4.538 em 2015. A taxa de abortos a cada 1.000 mulheres
► aborto (com idades entre 15 e 44 anos) diminuiu 40,5% em 15 anos, isto é, de 46,53 (2001)
► gravidez para 18,84 (2015), e a taxa de abortos a cada 100 nascidos vivos e natimortos foi de
► mortalidade materna 29,5%, isto é, de 161,7 (2001) para 41,5 (2015). Cinco mulheres morreram de
► planeamento familiar complicações do aborto que começaram fora do hospital, o que representou 0,01%
► sepse do número total. No quadro geral de causas de mortalidade materna neste período de

received DOI https://doi.org/ Copyright © 2018 by Thieme Revinter

January 16, 2018 10.1055/s-0038-1657765. Publicações Ltda, Rio de Janeiro, Brazil
accepted ISSN 0100-7203.
April 10, 2018
published online
June 12, 2018
310 Abortion in the Structure of Causes of Maternal Mortality Volkov et al.

15 anos, o aborto representou 14,3% dos casos. A letalidade ocorreu, principalmente,

no período de 2001 a 2005 (4 casos). Entre as mortes maternas, muitas mulheres
morreram em áreas rurais após a interrupção da gravidez, com 18 a 20 semanas de
gestação (n¼ 4). Além disso, três mulheres morreram por sepse, e duas, por
sangramento.
Conclusão Com a introdução de tecnologias de planejamento familiar modernas e
eficazes, a mortalidade materna devido ao aborto vem sendo reduzida.

Introduction examination, and statistical data. Overall, the data were

The Millennium Development Goal 5 calls for a 75% reduc-
tion in the maternal mortality ratio (MMR) between 1990
and 2015. Maternal mortality is one of the most important
indicators of women’s health and the quality of care at
national and international levels.1,2 A decrease in maternal
mortality can only happen based on the evaluation of each
case at the regional level, which will serve as the basis for
developing priority actions that reduce the rate throughout
the country.3 Since 2012, in Russia, birth is recognized as a
term for a pregnancy of 22 weeks or more, in which the
child’s weight at birth is 500 g (or less than 500 g, in case of
multiple births), and the body length of the newborn is
25 cm (in case the newborn’s weight is unknown). The
abortion issue always stands out for its socio-political signif-
icance, because it is closely connected with the socio-eco-
nomic situation of the country, the state’s attitude toward
women’s reproductive health, and basic demographics.4
Legislative initiatives at the federal and regional levels
aimed at reducing the availability of abortion were intro-
duced in Russia with enviable regularity.4
This study aimed to analyze and study the structure of
maternal mortality due to abortion in the Tula region.
Methods
Maternal death is defined as the death of a woman while
pregnant or within 42 days of pregnancy termination, irre-
spective of the duration and site of pregnancy, from any
cause related to or aggravated by the pregnancy or its
management, but not from accidental or incidental causes.1
This study analyzed the dynamics and structure of causes
of maternal mortality in the Tula region within a period of
15 years, according to government statistics. The data were
obtained from official statistics and published national stud-
ies. This study retrospectively analyzed anonymized copies
of primary medical records, autopsy protocols, forensic
analyzed in 5-year periods: 2001 to 2005, 2006 to 2010,
and 2010 to 2015. The present study was approved by the
institutional review board and the need to obtain an in-
formed consent from the patients was waived.
We searched for the abortion incidence data in the region
of Tula from 2000 to 2015. The data were obtained from
official statistics and published or unpublished regional and
national studies.
All statistical analyses were performed using the software
package Statistical version 6.0 (StatSoft, Tulsa, OK, USA). The
results were considered statistically significant when
p < 0.05.
The study was performed according to the plan of the Tula
State University: Project No. 115102710029/ 49–16
Results
In 15 years of the 21st century (2001–2015), in the Tula
region, 35 women died for reasons connected with pregnan-
cy, childbirth, and puerperium (42 days after delivery).5
During the same period, the region had 287,387 living
children. When calculating per 100,000 live births, the
maternal mortality rate accounted for an average of 12.2%.
In the period from 2001 to 2005, the maternal mortality rate
was 25.5%; from 2006 to 2010 it was 17.4%; from 2011 to
2015 it was 9.26% per 100,000 live births. Official statistics
show that the absolute numbers of live births have a positive
trend, particularly in the last 5 years, and the maternal
mortality rate decreased by 52.25%.5
For 15 years in the Tula region, medical statistics revealed
204,095 abortion cases (►Table 1).
The table shows that in 15 years, the abortion rate per
1,000 women of fertile age decreased by 40.5%, and the rate
of abortions per 100 live births and stillbirths by 29.5%.
Note that deaths due to medical legal (artificial) abortion
and abortion on medical and social grounds during the study
period were not registered. Regarding maternal deaths due

Table 1 Dynamics of abortion in the Tula region (2001–2015)

Study time periods (year)

2001–2005 2005–2010 2010–2015
Total cases of abortion 93,298 67,457 43,340
Estimated abortion rates per 1,000 women aged 15–44 years 43.94 41.27 29.13
Abortion rate per 100 live births and stillbirths 141.3 97.6 57.3

Rev Bras Ginecol Obstet Vol. 40 No. 6/2018

 Abortion in the Structure of Causes of Maternal Mortality
to complication of abortions that began outside the hospital,
five deaths were registered, which accounted for 0.01%. In
general, in the structure of maternal mortality causes in
these 15 years, abortion accounted for 14.3%.
A significant difference in maternal mortality from abor-
tion was noted over the 5-year periods. During the period
from 2001 to 2005, there were 4 cases of maternal deaths
(25%), with 6.4% per 100,000 live births; during the period
from 2006 to 2010, 1 case was recorded corresponding to
8.3%, with an index equal to 1.45. During 2011–2015, no
cases of maternal mortality from abortion were registered.
A detailed analysis of each case found that four of the five
women were from rural areas. The average age was 36.6 years
(range, 22–41 years). All five women were admitted to the
hospital with incipient abortion, of which two were
instructed on out-of-hospital intervention. The greatest
number of deaths were registered after pregnancy termina-
tion at 18 to 20 weeks (n ¼ 4), with one case at 10 to
11 weeks.
The direct causes of the deaths of women due to unsafe
abortion in three cases were sepsis, multiple organ failure,
hemorrhage (two cases), hemorrhagic shock, disseminated
intravascular coagulation, and multiple organ failure. All the
analyzed observations had underestimated the severity of
the patients’ condition upon admission to the hospital in
terms of bad survey, late diagnosis of sepsis, multiple curet-
tage of the uterus, delay in operational use, and blood
transfusion.
Discussion
According to the Ministry of Health, Russia has experienced a
steady decline in the absolute number of abortions in 2000 to
2014, going from 1,961,539 in 2000 to 814,162 in 2014
(58.4%). The number of abortions per 100 live births has
decreased by 26.8% from 2000 to 2014. In 2014, in the Far
Eastern Federal District in Russia, there was a decrease in the
number of abortions at 8,675 (absolute number) or 15.5%
compared with that in 2013.6 Therefore, the rate of abortion
in the Tula region correlated with the index in Russia and
reflects the overall downward trend. Similar dynamics of the
frequency of abortions is observed in the countries of the
former USSR.7,8 When comparing the estimated abortion
rates per 1,000 women aged 15 to 44 years with European
countries during 2010 to 2015, it was established that the
figure is lower than that in Eastern Europe at 42% (90%
uncertainty interval [UI] 38–51) and Southern Europe at
26% (90% UI 18–57) and higher than that in Northern Europe
at 18% (90% UI 17–20) and Western Europe, also at 18% (90%
UI 14–31) during the period from 2010 to 2014.9 The decline
in the number of abortions in Russia is confirmed by official
statistics and results of sample surveys of women. A partic-
ularly rapid decline in abortions is typical in young women;
Russia lost the said leadership on the level of teenage
pregnancies, and the abortion rate among adolescents in
Russia is lower than that of many Western countries. The
decomposition of fertility according to the Bongaarts model
shows that the role of contraception in the structural meth-
Volkov et al. 311
ods of family birth control in Russia at present is far superior
to the role of induced abortions. The effectiveness of family
planning in the country increased.10
Despite the decline in abortion rates, their level remains
high and is accompanied by adverse changes in their struc-
ture, in which the share of spontaneous abortions increased.
The proportion of spontaneous abortion was of 12.3% in
2015. The increase in the prevalence of spontaneous abor-
tions shows a decrease in the level of reproductive health of
modern Russian women.11
In addition, a positive trend is observed on reducing the
number of abortions per 1,000 women aged 15–44 years
worldwide, that is, 40 in 1990–1994 and 35 in 2010 to 2014.
However, due to population growth, the annual number of
abortions in the world increased by 5.9 million from
50.4 million in 1990 to 1994 to 56.3 million in 2010 to
2014. In developed countries, the abortion rate decreased
by 19 points from 46 to 27. In developing countries, the same
slight decrease is noted at 39 to 37 points. Approximately
25% of pregnancies ended in abortion in 2010 to 2014.9 In
France, around 220,000 abortions annually were observed at
a steady rate for many decades (prior to 14 weeks of gesta-
tion).12 In Russia, no statistical data were found of abortion
with respect to the marital status of women. In the period
from 2010 to 2014, 73% of abortions were performed by
married women compared with the 27% of unmarried wom-
en worldwide.9
At the same time, in Russia, an extremely unfavorable
growth was observed in 2014 for the maternal deaths from
abortions initiated outside the hospital and undetermined
cases of abortion (8 cases in 2013 to 11 in 2014; with 0.42 to
0.57 per 100,000 live births, respectively, that is, 35.7%).
The Tula region, as well as all of Russia, has a positive
dynamic of reducing maternal mortality due to abortion. In
St. Petersburg, there is clearly a strong positive dynamic of
reduction of mortality due to abortion, that is, 19.6 per
100,000 in 1988 to 1990, and 2.6 per 100,000 live births in
2006 to 2009.13
Mainly in the Tula region, women died from abortion in
2000 to 2005, which roughly coincides with data from other
regions in Russia. Hence, for 10 years (1998–2007) in the
Kemerovo region, 27 of 145 patients died from sepsis that
developed after an abortion.14 During these years, the ma-
ternal death rate from abortions alone took first place in the
Khabarovsk region, at 9.3 points in the overall structure,
which significantly exceeded the figure for the Russian
Federation in 2010 (1.8 per 100,000 live births).15
The general trend is that the majority of deaths occurs
after abortion at 18–20 weeks of gestation.14
Most women who died due to abortion (4 out of 5) lived in
rural areas, indicating a lack of aid to rural areas that has been
emphasized by many Russian authors. 4,14
The direct causes of maternal deaths, as a rule, were sepsis
and multiple organ failure. The primary role of sepsis as the
immediate cause of maternal mortality due to abortion is
noted in several other studies, both in the whole territory of
Russia or in individual regions.14–17 The second cause of death
was bleeding, which results from the typical underestimation
Rev Bras Ginecol Obstet Vol. 40 No. 6/2018
312 Abortion in the Structure of Causes of Maternal Mortality
of the severity of the condition, repeated curettage of the
uterine cavity, and later surgery.
One of the target indicators of the state program of
healthcare development of the Russian Federation (adopted
by the decree of the RF Government No. 2511-p on Decem-
ber 24, 2012) is the proportion of women who decided to
carry on with the pregnancy, and the number of women
applying for abortion in medical facilities.10
Measures to reduce abortion in our country have shifted
instead of introducing effective methods of contraception
among adolescents and students,18 it is recommended that
abortion be rejected in favor of birth if an unwanted preg-
nancy occurs.
Conclusion
With the introduction of modern, effective technologies of
family planning, abortion lost its role in the structure of
maternal mortality in the region of Tula.
Conflicts of Interest
The authors have no conflicts of interest to declare.
References
1 Alkema L, Chou D, Hogan D, et al; United Nations Maternal Mortality
Estimation Inter-Agency Group collaborators and technical advi-
sory group. Global, regional, and national levels and trends in
maternal mortality between 1990 and 2015, with scenario-based
projections to 2030: a systematic analysis by the UN Maternal
Mortality Estimation Inter-Agency Group. Lancet 2016;387
(10017):462–474. Doi: 10.1016/S0140-6736(15)00838-7
2 Main EK, Menard MK. Maternal mortality: time for national
action. Obstet Gynecol 2013;122(04):735–736. Doi: 10.1097/
AOG.0b013e3182a7dc8c
3 Zagidullina VM, Ryzhova AS. [Maternal mortality as an integral
indicator, reflecting the health of women]. Voprosy Jekonomiki
Prava. 2015;83:163–166
4 Filippov OS, Tokova ZZ, Gata AS, Kuzemyn AA, Gudimova VV.
[Abortion: special statistics in the federal districts of Russian
Federation]. Gynecology 2016;18:92–96
Rev Bras Ginecol Obstet Vol. 40 No. 6/2018
Volkov et al.
5 Volkov VG, Granatovich NN. [The main causes of maternal mortality
in the Tula region in the twenty-first century]. Akusherstvo Gine-
kologiya Novosti Mneniya Obuchenie 2017;2:10–14
6 Pestrikova TYu. [Major indicators of reproductive health of the
population of the Far Eastern Federal District in 2014]. Vestnik
Obshhestvennogo Zdorov’ja Zdravoohranenija Dal’nego Vostoka
Rossii. 2015; (4): 2. http://www.fesmu.ru/voz/20154/2015402.
aspx. Accessed December, 10, 2017
7 Petrenko SA, Mirovich ED, Suhurova LS, Meljohina LM. [A com-
parative analysis of birth and abortion rates in Ukraine and in
Donetsk region]. Bull Urgent Recover Med 2012;1:164–166
8 Mambetov MA, Bolbachan OA, Bujlashev TS, Ibraimova DD. [Fre-
quency and structure of abortions among women of reproductive age
in the Kyrgyzstan]. Nauka Novye Tehnologii Innovacii 2016;5:68–69
9 Sedgh G, Bearak J, Singh S, et al. Abortion incidence between 1990
and 2014: global, regional, and subregional levels and trends.
Lancet 2016;388(10041):258–267. Doi: 10.1016/S0140-6736
(16)30380-30384
10 Denisov BP, Sakevich VI. [Abortion in post-soviet Russia: is there
any reason for optimism?] Demograficheskoe Obozrenie. 2014;
1:144–169
11 Bantyeva MN. [The abortion problem situation in Russia in 2008–
2015 years]. Obstet Gynecol Reprod. 2016;10:47–52. Doi:
10.17749/2313-7347.2016.10.2.047-052
12 Vigoureux S. [Epidemiology of induced abortion in France]. J
Gynecol Obstet Biol Reprod (Paris) 2016;45(10):1462–1476.
Doi: 10.1016/j.jgyn.2016.09.024
13 Repina MA. [Obstetrics technology in XXI century and maternal
mortality in Sankt-Peterburg]. Herald of the Northwestern State
Medical University Named After I.I. Mechnikov. 2010;2:49–59
14 Ushakova GA, Artymuk NV, Zelenina EM, et al. [Sepsis and
maternal mortality in the Kemerovo region]. Rossijskij Vestnik
Akushera-Ginekologa 2010;10:7–10
15 Granatovich NN, Volkov VG. Sepsis in childbirth and the postnatal
period as a cause of the regional maternal mortality rate. V.F.
Snegirev Arch Obstet Gynecol. 2017;4:36–39. Doi: 10.18821/
231387262017413639
16 Stupak VS. [Maternal Mortality in the Khabarovsk region: analysis
of structure and ways of its reduction]. Dal’nevostochnyj Medi-
cinskij Zhurnal 2013;1:50–53
17 Kovalev BV, Bashmakova NV, Kajumova AV, Mazurov AD.
[Dynamic peculiarities of the structure of maternal mortality in
the large industrial region]. Ural Med J. 2008;12:119–122
18 Survillo EV. [Comparative analysis of reproductive attitudes in
university female students]. Bull N Med Technol 2016;2:2–8
Cárdenas et al. Reproductive Health (2018) 15:150
https://doi.org/10.1186/s12978-018-0597-1

RESEARCH Open Access

“It’s something that marks you”: Abortion

stigma after decriminalization in Uruguay
Roosbelinda Cárdenas1,2* , Ana Labandera3, Sarah E. Baum4, Fernanda Chiribao3, Ivana Leus3, Silvia Avondet3
and Jennifer Friedman1

Abstract
Background: Abortion stigma is experienced by women seeking abortion services and by abortion providers in a
range of legal contexts, including Uruguay, where abortion was decriminalized up to 12 weeks gestation in 2012.
This paper analyzes opinions and attitudes of both abortion clients and health professionals approximately two
years following decriminalization and assesses how abortion stigma manifests among these individuals and in
institutions that provide care.
Methods: In 2014, we conducted twenty in-depth, semi-structured interviews with abortion clients (n = 10) and
health care professionals (n = 10) in public and private facilities across Uruguay’s health system. Interviews were
recorded, transcribed, and then coded for thematic analysis.
Results: We find that both clients and health professionals express widespread satisfaction with the implementation of
the new law. However, there exist critical points in the service where stigmatizing ideas and attitudes continue to be
reproduced, such as the required five-day waiting period and in interactions with hospital staff who do not support
access to the service. We also document the prevalence of stigmatizing ideas around abortion that continue to
circulate outside the clinical setting.
Conclusion: Despite the benefits of decriminalization, abortion clients and health professionals still experience
abortion stigma.
Keywords: Uruguay, Latin America, Abortion stigma, Decriminalization, Abortion

Plain English summary found that both clients and health professionals express
Abortion stigma is experienced by women seeking legal widespread satisfaction with the implementation of the
induced abortion services and by abortion providers in a new law. However, despite clear improvements in quality
range of legal contexts. This paper analyzes abortion of care, there exist critical points in the service where
stigma in Uruguay, where abortion was decriminalized stigmatizing ideas and attitudes continue to be repro-
up to 12 weeks gestation in 2012. In it, we explore the duced. Overall, we conclude that despite the benefits of
opinions and attitudes of both abortion clients and decriminalization, abortion clients and health profes-
health professionals approximately two years after sionals still experience abortion stigma both inside and
decriminalization in order to assess if and how stigma outside the clinical setting.
manifests within institutions that provide abortion
services.
Respondents were interviewed after participating in a Background
survey at the clinical setting where they provide or receive Abortion stigma
reproductive health services. Our qualitative analysis Stigma has been found to be an obstacle in delivery of
some health services due to negative consequences for
* Correspondence: rooscardenas@gmail.com those who are, or who fear being, stigmatized [1, 2].
1
International Planned Parenthood/Western Hemisphere Region, New York, Erving Goffman, a key figure in the sociological defi-
USA
2
Hampshire College, Amherst, USA nition of stigma, conceptualizes it as “an attribute that is
Full list of author information is available at the end of the article deeply discrediting” that “reduces an individual from a
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Cárdenas et al. Reproductive Health (2018) 15:150
whole and usual person to a tainted, discounted one”
[3]. Goffman presents three types of stigma: blemishes
of character, deformations of the body, and group iden-
tity [3]. Link and Phelan, in response to the assertion
that stigma was “vaguely defined” and “individually fo-
cused,” explain it as a social process in which individuals
are marked as different, associated with negative attri-
butes, conceived of as “others,” separated from society,
and subject to loss of status and discrimination. This
process places them in a framework of economic,
political, and social power relations that perpetuate
stigma in order to maintain the status quo [4].
Every year over 40 million women in the world have
an abortion [5], making it one of the most common and
safe medical procedures [6]. Yet it is still loaded with
strong social stigma expressed in negative attitudes and
secrecy by both women who get abortions and clinicians
involved in the process. Thus, abortion stigma is one of
the main barriers to women seeking termination of an
unwanted pregnancy and a challenge to abortion service
providers. This stigma translates into shame and silence
for women and into marginalization for providers, and
creates or perpetuates myths and misunderstandings
about abortion [2, 7]. Stigma manifests differently de-
pending on legal frameworks, religious beliefs, and social
and cultural contexts [8].
Kumar, Hessini, and Mitchell define abortion stigma
as “a negative attribute ascribed to women who seek to
terminate a pregnancy that marks them, internally or ex-
ternally, as inferior to ideals of womanhood” [9]. They
explain that when a woman has an abortion, she trans-
gresses socially-accepted concepts, such as that sexual
relations are only for reproductive purposes; that mater-
nity is inherent in the condition of being a woman, and
therefore inevitable; and that the role established for
women is motherhood and the nurturing of children [9].
At the individual level, stigma can be classified into
three main manifestations: 1) perceived stigma, which
are ideas about what others may think about abortion
and about what could happen if their own experience is
made public (rejection by the family or partner, impaired
social relationships, loss of friendships, criticism, abuse,
and isolation); 2) experienced stigma, which are actual
acts of discrimination, harassment, and aggression by
others; and 3) internalized stigma, which refers to the
materialization of the two previous forms in feelings of
guilt, shame, anxiety, or other negative ideas [9, 10].
Shellenberg et al. [10] and Sorhaindo et al. [11]
focus on how internalized stigma was experienced by
women who had abortions in Mexico and Peru. Feel-
ings of guilt, sadness, and shame were common, as
well as widespread silence and secrecy around abor-
tion, especially in small communities. Some of the
women interviewed by Shellenberg et al. [10] initially
Page 2 of 11
said that their abortions were spontaneous, a strat-
egy to distance themselves from stigma, although
they later explained that they had induced abortions.
Some women in the study by Sorhaindo et al. [11],
said that they had changed their perception about
abortion based on their own experience. Yet despite
changing their prejudiced views of women who
terminate their pregnancies, they were unable to
approve of abortion even after having one. The ac-
counts in these studies reflect experiences of isola-
tion among women who choose to not share their
experiences or seek support [9, 10].
Health care providers who counsel women and
dispense abortion medication, as well as pharmacists
and other personnel who work in facilities that provide
abortion services are also affected by stigma [10–12].
This stigma often discredits them and excludes them
from full participation in their professional community.
For example, abortion providers have been called “dirty
workers” in the social psychology literature. “Dirty work”
refers to professions stigmatized by their associations
with contamination that is physical (grime, dirt), social
(interaction with stigmatized individuals), or moral
(primarily sin) [12]. Studies conducted with abortion
providers where abortion is illegal reveal that they fre-
quently feel isolated from the general medical commu-
nity and that they are afraid to speak openly about their
work [8, 12]. Under these conditions, many choose not
to get involved in abortion provision, or if they do, they
do not speak openly about it in their social and profes-
sional circles [13].
Even though research that specifically explores how
abortion stigma operates among Latin American women
and health professionals is incipient, there is a growing
body of work that provides solid bases with which to
develop theoretical frameworks that are grounded on
empirical evidence [10, 11, 16–19].
Although an increasing number of countries Latin
America have achieved partial decriminalization of abor-
tion in recent years, it is still estimated that the region
has the highest percentage of unsafe abortions in the
world [5, 14]. Furthermore, research shows that in set-
tings where abortion is legal, risks to the lives of women
and abortion-related stigma are lower than in those
where it is criminalized [14, 15]. Thus, this paper
emerges from the broad idea that perceptions and atti-
tudes toward abortion vary depending on legal contexts,
and that these tend to be more favorable when a
woman’s legal right to terminate her pregnancy is recog-
nized. The study’s overall objective was to uncover and
analyze these patients’ and health professionals’ percep-
tions and attitudes towards abortion. Specifically, to
explore if and how stigma continues to operate in decri-
minalized clinical abortion settings.1
Cárdenas et al. Reproductive Health (2018) 15:150
Legal framework
In 2012 (Law 18,987), Uruguay decriminalized medi-
cated and surgical abortion, without specifying grounds
but under strict compliance with two requirements: to
not exceed twelve weeks of pregnancy and that the
woman meet with a multidisciplinary team of three
health professionals (gynecologist, psychologist, and
social worker), which must ensure that she has all neces-
sary information available to make an informed and re-
sponsible decision. The law and its regulations (Decree
No. 375/012) state that a woman must attend four visits
and during the process, the woman must think over her
decision for five days except in cases where the
pregnancy represents a risk to the woman’s life, is a re-
sult of rape, or when there is fetal malformation. In
addition, the IVE2 manual published by the Ministry of
Health following decriminalization privileges medicated
abortion over surgical procedures. For this reason,
women who go through a regular abortion process will
routinely receive a medicated abortion and will not be
asked for their preference of method. All public facilities
in Uruguay’s Integrated Health System are required to
follow the law and conscientious objection is permitted
among physicians as long as the facilities where objec-
tors work inform women on how and where to access
services.3
In the Uruguayan model of care, teams of health pro-
fessionals in abortion services are organized in first level
clinics and in hospitals, and they include physicians,
nurses, midwives, psychologists, social workers, and
sonographers. Under the law, abortion clients must
follow the following steps: a first appointment where the
woman expresses her intent to terminate a pregnancy
(Visit 1), a second appointment with the interdiscipli-
nary team where she receives counseling and is informed
about the required reflection period (Visit 2), a five-day
waiting period, a third appointment where the woman
expresses her final decision and the procedure is initi-
ated (Visit 3), and a fourth appointment to confirm
whether the abortion has been completed (Visit 4).
Methods
Recruitment and data collection
In order to test whether the legal recognition of the right
to terminate a pregnancy has an impact on stigma, we col-
lected data from a group of abortion clients and a group
of health professionals who provide abortion care in
Uruguay in 2014, two years following decriminalization.4
In Uruguay, women were recruited at the Sexual and Re-
productive Health Service of the Complejo Hospitalario
Pereira Rossell, a major public hospital in the capital city,
Montevideo.5 At the end of the second appointment (Visit
2), following counseling by the interdisciplinary team,
women were invited by a nurse to participate in the study.
Page 3 of 11
Women received necessary information about the re-
search and, if they were interested in participating, pro-
vided their verbal consent and contact information to be
contacted later. Interviews were conducted in person or
by telephone following the fourth appointment (Visit 4).
The interviews analyzed in this paper are a subsample of a
larger group of abortion clients who completed a survey
for a quantitative analysis. Of a total of 203 abortion cli-
ents recruited for the quantitative study, ten were chosen
by convenience sampling to be interviewed in person.
Semi-structured in-depth interviews (from 30 to 90 min
long) were conducted with participants aged 22 to
38 years. Although most lived in Montevideo, some
respondents lived outside Uruguay’s capital city. Health
professionals were also invited to participate in an inter-
view following participation in a quantitative study.
Among a sample of 72 health professionals in facilities
around the country who completed the quantitative
survey, ten completed an in-depth interview including
seven women and three men. These included physicians,
midwives, social workers, and a psychiatrist. Interviews
lasted from 20 to 60 min. Most interviews were conducted
in person by trained study coordinators; some were
conducted by telephone due to long travel distances. This
study was approved by the Allendale Investigational
Review Board (Old Lyme, CT, USA).
All interviews were recorded, transcribed, and coded
for analysis using Dedoose software. The research team
jointly developed two codebooks, one for interviews with
health professionals and one for interviews with women.
The codebooks were created independently to capture
unique topics in the semi-structured interview guides
and in vivo codes that emerged directly from the partici-
pants; however the codebooks reflected similar overarch-
ing themes such as attitudes towards the abortion law,
disclosure and interactions with people in their commu-
nity, and experiences in different phases of the abortion
process, among others. Analysis was led by a team of
two researchers and two coders who jointly developed a
codebook and carried out thematic analysis of the data.
Each of the codes was individually scrutinized first and
subsequently the team identified key themes and
patterns in responses.
Results
Opinions and attitudes among abortion clients
Attitudes towards abortion and women who have abortions
While some women believe that Uruguay continues to
be a conservative country where abortion is still taboo,
others said they saw major progress in social attitudes,
including the fact that decriminalization had been
achieved. Almost all interviewees felt that abortion is
their right and that they have the prerogative to decide
what to do with their bodies and their lives. In general,
Cárdenas et al. Reproductive Health (2018) 15:150
abortion is seen as an individual experience that is only
incumbent on the person who has to get one. Although
most spoke with their partner, family members, or
friends, a few did not share the experience with anyone
other than the legal abortion team that provided care
during the process.
“I have nothing to say; what needed to be said got said
and that’s that. I did it, I’m fine, and ciao.” (Age 23).
“I didn’t talk about it with my husband, or my sister,
or my friends, or with anybody. The topic is now
closed, that’s that.” (Age 34).
Religious ideas were almost nonexistent in interviewees’
discourse. However, they all reported some level of guilt,
describing “pangs of conscience,” and other feelings, such
as “a non-physical pain,” shame, sadness, anger, depres-
sion, and loneliness, and some referred to themselves as
selfish. All interviewees shared the idea that the abortion
was an experience that marked them for life:
“[…] I think I’m going to carry this until I die.” (Age 23).
“I think it is a trauma that one does not get over, even
though one learns to live with it […] this guilt is going
to be lifelong.” (Age 22).
“When I think about going to the gynecologist and
they are going to ask me about my medical history,
I’m ashamed to have to tell them that I just had an
abortion.” (Age 38).
Still, one abortion client expressed positive feelings
about having access to a legal abortion as compared to
an unsafe option:
“It was strange because it was a new experience, but it
was a lifesaver. You avoid the trauma of doing it in a
clandestine place where they can do anything to you
and where no one is going to take responsibility for
anything.” (Age 29).
Despite recurring feelings of guilt, none of the partici-
pants said they regretted their abortion. However, these
clients experienced their process as something that they
do not want to have to go through again. In fact, all of
them said that, until discovering an unwanted preg-
nancy, they saw abortion as a very remote possibility,
something that they would not have to go through or
that they would not be capable of doing.
Page 4 of 11
“[…] I had sworn to myself that I would never have an
abortion and I ended up doing it. It was kind of ironic
and I was surprised to find myself contradicting myself
about something that I said I wouldn’t do.” (Age 23).
“[…] I said it would never happen to me and it
happened.” (Age 34).
Several of them said they were against abortion even after
having terminated a pregnancy, while others expressed a
change of opinion prompted by the experience.
“I’m against abortion, so it was a very difficult decision
to make and to this day it still weighs on me.” (Age 31).
“[..] I was against abortion until it was my turn.” (Age 22).
“In line with my upbringing, I had always been against
it; I imagined it to be pretty cruel because of what
they say and they tell you.” (Age 27).
They all confirmed that it was the best decision they
could make, given that it was not the right time to have
a child because of various reasons: poor economic or
health situations, instability with a partner, or because
they already had several children.
Interestingly, with the exception of one interviewee, par-
ticipants harshly judged other women who have abortions,
and even more severely those who have more than one. Al-
though they fully justified their own abortion saying things
like “I didn’t want to do it, but of course my situation
wasn’t easy” (Age 27), they saw other women’s abortions as
acts of irresponsibility, selfishness, and immaturity.
“If you already did it once, why are you going to do
the same thing again? Once is fine, but those who do
it two, three, four times, [it’s] like they kind of do it
just for fun.” (Age 22).
“I see many women who do it like just for fun […]
people who say: ‘well, I got pregnant and I can do it
one, two, and even three times.’” (Age 31).
“[…] others get pregnant real easy and have abortions
[as easily/often as] they change their jeans.” (Age 23).
“[…] there are other cases of women where it’s like
they don’t care if they get pregnant and abort and go
Cárdenas et al. Reproductive Health (2018) 15:150
back and repeat the story […] it’s different for those
who want to come every year to do it, but for women
whose case is like mine, it’s okay.” (Age 38).
“I think there should be limits because they’re going
to get pregnant ten times and they’re going to take
the life of an innocent being […] Names and record
numbers should be recorded and tell them ‘look,
there’s a limit, you can’t get pregnant five times and
get rid of it every time you feel like it.’” (Age 22).
Attitudes towards abortion health professionals and
services
For the women interviewed, the most common feelings
before visiting facilities to request an IVE or legal abor-
tion service were shame, fear of rejection, or fear of
undergoing a procedure that could endanger their
health.
“At first, I was a little afraid of the whole procedure.
After the counseling, I felt safe and calm. I felt
confident.” (Age 29).
Overall, women had positive experiences with the
health care teams at the facility where they received their
service. Almost all said that they did not feel judged by
the interdisciplinary team. Rather, they said they were
surprised by the thorough information they received and
that they felt welcomed and well-understood.
“I thought they would be a little more hostile, because
of the fact that one is killing a person, but no,
everything [was] just fine.” (Age 22).
“You arrive afraid that you’re going to be judged by
the same doctors whose job is to save lives, but it was
nothing like that, everything super good, marvelous,
in fact, they protect you.” (Age 29).
Only one of the clients reported having felt rejected by
one of the health professionals who treated her:
“When I came in for the ultrasound, the person who
was doing it looked at me and said ‘I don’t do IVE
and they looked me up and down. When I gave them
the paper, they looked at it and said that the doctor
didn’t do IVE and the other went and told them: ‘it
doesn’t matter, she’s a patient and you have to take
care of her’. She went and took her the paper and the
woman came and told me to my face, ‘I don’t do IVE.
There were a lot of people outside the examining
Page 5 of 11
room and even though not everyone knows what IVE
is, it was like […] they were judging me.” (Age 38).
During the interview, women were asked about a
hypothetical doctor refusing to provide abortion ser-
vices. Even though they talked about how disappointing
and upsetting it would be for a doctor to disapprove of
their decision and said they might have changed their
minds had they encountered something like this, they
did agree that health professionals should be allowed to
object to providing abortion services.
All abortion clients in our sample had a medicated
abortion. Despite having expressed a high level of
satisfaction with the overall service, many of the
women said they would have liked to have been able
to choose between a medicated and surgical proce-
dure. Two women said they would have preferred a
surgical abortion because they perceived the hospital
to be a safer place to have the procedure.
“I thought they were going to do the procedure
here, not that it had to be in my home. I was very
scared. If I had been given a choice, I would have
liked to be admitted because I would have felt
calmer” (Age 22).
“When they sent me home to take the pill I thought it
was risky and that it would be much better to be seen
in a hospital” (Age 22).
Opinions on the Uruguay abortion law
Almost all the women interviewed knew about
decriminalization of abortion from seeing it on television or
in the press, which suggests that the issue had been present
in the public discourse. Most found the facility where they
obtained abortion services by searching online. All said they
were relieved that they did not have to have an illegal or
clandestine abortion and saw decriminalization as a major
advance with regard to the rights of women in Uruguay.
Further, they believed that decriminalization had contri-
buted to changing Uruguayans’ overall attitude towards
abortion.
“Since there’s the law, more [people] are in favor [of
women’s right to choose].” (Age 22).
“Hopefully no one stops this law, it saves us all, it’s
a choice so that one can live as one wants, as one
likes. It makes no sense to have children to keep
them deprived. It’s a choice they give us to live
well.” (Age 29).
Cárdenas et al. Reproductive Health (2018) 15:150
These abortion clients became aware of the details of
the law and the service—such as the gestational age limit
and the abortion method specified in the medical
guides—during their first visit to the health care center.
When asked about their opinion about the specific as-
pects of the law, almost all felt that the twelve-week
limit was appropriate. Some even felt that it should be
earlier due to preconceived—and sometimes inaccur-
ate—views that they held regarding the risks involved
and the state of development of the fetus.
“Up to 12 weeks is okay and that is already a lot,
because the baby [sic] is already formed and it’s
somewhat traumatic, it gives you quite a shock, it had
everything: its fingers were formed, even the features
on its face. I say that eight weeks would be okay.”
(Age 29).
However, the majority of those interviewed were in
disagreement with the required five-day reflection
period, calling it excessive, unnecessary, and torturous.
“Those five days were endless for me, because when
you are sure and you want to be done with it, you
want it to be now.” (Age 38).
“If it is already a difficult decision and they make you
wait, it becomes torture.” (Age 22).
“You want to be done with it. When they give you
that requirement, they don’t strictly consider it to be
five days. In my case, it was fifteen days.” (Age 29).
For these women, there was nothing to think over
since they had made up their minds before setting foot
in the facility for the first time.
Opinions and attitudes among health professionals who
participate in abortion services
Attitudes towards abortion and women who have abortions
In general, health professionals who participate in
abortion services in Uruguay had positive opinions
about the right to choose and they supported women
and their choices. Although each health professional
has their own limits with regard to the different as-
pects of the process, all felt that their perspectives
should not influence the care they give their patients.
The health professionals interviewed said that they
saw abortion as a woman’s right and that the decision
to terminate a pregnancy is her own business. They
believe that each woman has her reasons, that these
Page 6 of 11
reasons are worthy, and that their role as medical
professionals is not to judge.
“The reasons are worthy; no one can decide what a
woman should do or what is best for her.” (Physician).
“Every woman has the right to terminate a pregnancy
for whatever reason. I don’t think that it’s right or
wrong.” (Physician).
“One doesn’t stop being a person, but my feelings
don’t matter when I’m supporting the women. If a
woman comes in who is using contraceptives, lives
alone, has four children, does not have a pension, and
gets pregnant, of course we’ll feel more empathy than
for a woman who does not take care of herself, who
doesn’t care whether she gets pregnant; but regardless
of my feelings and opinions, the decision is the
woman’s.” (Physician).
All participants felt that their professional duty was
strictly to provide information and services. One health
professional expressed this recurrent feeling eloquently
by explaining that their professional duty is defined in
terms of how they can support the patient’s needs:
“What matters most to me is to support the patient;
that’s why I became a gynecologist.” (Physician).
In general, health professionals saw abortions as diffi-
cult situations for women; as an experience that no
woman wants to have to begin with, and certainly as one
that none would want to repeat. Thus, they see abortion
overall as a watershed experience in their lives.
“The experience is an abortion in general, whether
medicated or surgical. The experience marks a before
and an after.” (Physician).
In terms of their opinion of abortion itself, several health
professionals saw it simply as one more sexual and repro-
ductive health service; as a routine procedure in their daily
professional life, the same as a gynecological exam or a
pelvic exam on a pregnant woman. With regard to repeat
abortions, most saw them as a result of errors of a medical
system that is unable to provide effective training on
contraception and the Uruguayan mentality that still sees
sexuality as a taboo. But nonetheless, they did not believe
that women use abortion as contraception.
“It’s mostly the system’s fault, due to a lack of
understanding, time, or information. It is not an ideal
Cárdenas et al. Reproductive Health (2018) 15:150
situation; it’s not that I like it, but I don’t place the
blame on the patient.” (Physician).
We did not find a clear trend regarding health profes-
sionals’ preference about whether or not to talk about
providing abortion services outside the workplace. Some
health professionals talk about it openly:
“I talk about my job with everyone. Family, friends,
colleagues. At the family level, sometimes there are
differences on the subject of principles or religious
values.” (Physician).
While others prefer discretion, noting that they only
“talk about [their] job with few people.” (Midwife).
In general, these health professionals expressed great
satisfaction with the increase of legal abortion services
in the country, without denying that abortion stigma still
exists in Uruguayan society. When asked directly about
its existence, the interviewed health professionals de-
scribed this stigma in the following ways:
“[…] it shows in abortion clients’ fear, and is
manifested quietly, with rejection and with
indifference.” (Physician).
“[…] it exists. I don’t know if it’s to such an extent as
to produce consequences. When the law was being
defended, a segment of society demonstrated their
opposition.” (Physician).
“Many patients who do terminate [pregnancies] want
to keep it a secret for fear of what others might say.
Where I work, it’s a small town; people gossip about
this and are judgmental. These comments affect
patients emotionally.” (Physician).
“Uruguay is a stigmatizing society around abortion
and a number of other issues.” (Psychiatrist).
Attitudes towards health professionals who participate in
abortion services
In general, health professionals said they were comfortable
with their work teams and believe that their experiences
since decriminalization have been positive. Only one health
professional reported difficulties in the social context where
they work, which is not in the city of Montevideo:
“Since it’s a small town, people ask questions and try
to judge, but we try to maintain confidentiality.”
(Physician).
Page 7 of 11
One of the most common complaints was that there is
great demand for abortion services and few service
health professionals:
“[…] the greatest obstacle is patient demand where
sometimes we feel a little overloaded; more human
resources are needed and more time given to visits.”
(Physician).
High demand sometimes hinders the process:
“Delays in the process make [some] women still prefer
clandestine abortions. The process is very long; so
they prefer to do it outside.” (Midwife).
Although all of those interviewed respected the right
of other health professionals to object, they see objection
as a significant obstacle, since it can affect women’s
decisions and hinder overall service. Some health profes-
sionals also mentioned health centers that have not been
able to put together abortion teams because in some
cases there is a scarcity of gynecologists who are willing
to prescribe the abortion medication.
Health professionals felt that administrative staff
within hospitals also needed further training, given that,
together with the objectors, when they manifest stigma-
tizing views they too constitute a substantial barrier that
negatively impacts the quality of abortion services.
“Improving access to the different services and the
interaction among them, for example, with the
administrative side, nursing, medical staff, laboratory,
they should have periodic meetings to fine-tune
issues. Administrators and doctors see voluntary
termination of pregnancy in totally different ways.”
(Physician).
“Not a single administrator works with us [the IVE
teams]; there is a lot of turnover in receptionists and
they aren’t trained.” (Midwife).
“Very good work is done on logistics, on timing,
coordination. The only detail is with the
sonographers, because this needs special handling and
technicians are not always trained and can intimidate
patients.” (Physician).
The majority of the health professionals who participate
in legal abortion services reported having received training
before the law went into effect. However, all participants
expressed interest in receiving further training in abortion
service delivery, including some who want to be trained in
Cárdenas et al. Reproductive Health (2018) 15:150
vacuum aspiration procedures or care for complications
from incomplete abortions.
Health professionals mentioned the bias that exists in the
type of abortion procedure they provide, which is almost al-
ways medicated abortion. They all confirmed that women
are not given a choice between a surgical and medicated
procedure. One reason they preferred to provide medicated
abortion was because they perceived surgical abortion to
have more complications and to cost more.
“It is an option that suits all parties: the woman,
because she can do it at home in a setting that is not
unfamiliar and if we talk about it as a law, that
abortion is medicated and not surgical, it serves the
state itself and the different institutions, and health
professionals. It’s more economical than hospitalizing
all those women.” (Physician).
Others explain the preference for medicated abortion in
terms of training, in other words, many health profes-
sionals have not been trained to provide aspiration abor-
tions. But in general, most are quite pleased with the
widespread use of medicated abortion. Some health pro-
fessionals also described preference for providing the pills
because they could avoid being present during expulsion.
Some even said that if they had to perform aspiration
abortions they would become objectors.
“If the woman requests the surgical method, I
withdraw. I wouldn’t have my colleagues’ support. The
situation would get messy. I believe that the woman
has to accept that she is the one who is terminating
the pregnancy.” (Physician).
“I always say what I do, and that I don’t have to
actively participate in the termination. If I had to
participate actively I would conscientiously object. I
had a very bad experience with a fetus when I was a
resident, and I said that I wouldn’t do that again
because it was very traumatic.” (Physician).
However, several health professionals believe that pa-
tients should be able to choose their preferred abortion
method and that health professionals should adhere to
their role of providing complete and accurate informa-
tion on the available options. For most, their primary
concern was to not endanger the woman’s life and to
prevent complications in order to minimize the risk of
empowering their opponents:
“We take care of the woman and we take care of the
law because if a complication occurs the opponents
will take advantage of it.” (Physician).
Page 8 of 11
Opinions on the Uruguay abortion law
Some health professionals believed that following
decriminalization in 2012, attitudes in the medical
community changed and that the right to choose is
increasingly being seen in a better light.
“Yes, I have seen colleagues who were not very
convinced that this is a right […], and there are others
who are conscientious objectors. But in general, the
attitude [towards abortion] is more open now.”
(Physician).
“Discussion about the issue is a little more fluid and
open; even though you may or may not agree, the
woman’s decision is respected.” (Physician).
“Colleagues who were very negative seem calmer
now.” (Physician).
Almost everyone believes that implementation of legal
abortion services has been very successful across the
country. However, the health professionals interviewed
outside the capital thought that this success is more
obvious in Montevideo and that women outside the
capital continued to experience much more difficulty in
accessing services.
Opinion was divided on the five-day reflection period.
Some think that rather than being a time for reflection,
the five days are disrespectful to the patient and
stigmatize her, because they challenge a decision that
has already been made.
“I don’t think it’s advisable, I think it’s more a
contradiction: we say that we respect the patient and
then we tell her to go think about her decision.”
(Physician).
“Most women have already thought about it and they
come in to terminate; very few decide to continue
with the pregnancy after counseling.” (Physician).
“There shouldn’t be a set time period. For some it
simply does more harm. The person already thought
about it before coming to the clinic.” (Midwife).
Some health professionals would prefer to have this re-
quirement removed. Other health professionals believe
that it is an adequate period, as long as the wait does
not result in exceeding the legal gestational age limit.
Others believed that the five days were critical because
Cárdenas et al. Reproductive Health (2018) 15:150
they enabled women to think without pressure and, in
some cases, to continue their pregnancies.
There was consensus that the gestational age limit was
appropriate although some believe the limit should be
lowered to ten weeks. This is due to the overall view that
“[t]he more weeks that go by, the greater the risk to the
patient.” (Physician).
Discussion
Qualitative studies in Uruguay before decriminalization
of abortion discussed how the restrictive context was
creating high levels of fear, uncertainty, and anxiety
among women seeking to terminate a pregnancy. Not
only was there a high risk to the health and lives of these
women, but some were also exposed to painful emo-
tional experiences and to stigma related to clandestine
abortion [20, 21]. This paper sought to take the pulse of
this abortion stigma after the legal context changed in
Uruguay, following the decriminalization of abortion up
to 12 weeks of pregnancy. Therefore, attitudes and
perceptions were assessed not only from legal abortion
clients, but also from health professionals who partici-
pated in abortion services.
It is likely that Uruguay is a unique country in the
region in two ways: first, there is a deep commitment by
the health professionals who have been advancing the
sexual and reproductive rights agenda, in particular
through the development and implementation of an in-
novative harm-reduction model, which helped increase ac-
cess to safe abortion and usher in decriminalization.
Second, in Uruguay there seems to be surprisingly little
influence of religious sectors and of religious beliefs on
sexual and reproductive health issues. For both abortion
clients and health professionals, decriminalization in
Uruguay followed logically from this unique history of ex-
perimentation with a harm-reduction model that signifi-
cantly reduced maternal morbidity and mortality. Both
health professionals and abortion clients in this study saw
decriminalization as a key factor that contributed to miti-
gating negative social views surrounding abortion and to a
substantial reduction of clandestine abortions. In this
sense, it is undeniable that decriminalization has contrib-
uted towards reducing abortion stigma for both women
and health professionals [22, 23].
That said, abortion stigma continues to exist for both
women seeking an abortion and health professionals
involved in abortion services. In particular, there are
several key moments within the service where stigma is
more likely to emerge. The first of these involves the
mandated five-day reflection period, which almost all cli-
ents and some of the health professionals saw as onerous
and unnecessary. This requirement has the potential to
reproduce stigma because it carries within it an implicit
distrust of women’s decision and an assumption that
Page 9 of 11
women have not fully considered its consequences
before arriving to seek care.
Secondly, the exclusive use of medicated abortion also
has the potential to reproduce stigmatizing ideas about
abortion as “dirty work.” On the one hand, some health
professionals see the preferential use of medicated abor-
tion as a welcome means to avoid hands-on participation
in a medicated procedure deemed undesirable. On the
other hand, as evidenced by our data, the near-exclusive
use of medicated abortion allows some providers to shift
the moral and de facto onus of interrupting a pregnancy
entirely to women. The implicit message in both of these
cases is clear: these professionals prefer to separate them-
selves from “participating” in abortions, thereby emphasi-
zing the idea that abortion is “dirty work.” Finally,
although there is strong scientific evidence to support the
prevalent use of medicated abortions [3, 24, 25], the failure
to provide women with a choice may negatively impact
their experience with the service. In an ideal setting, as
our informants corroborate, women would be given an
opportunity to choose their preferred abortion method.
Since the law permits both types of procedures, it is clear
that in the Uruguayan case there is space for additional
training that expands medical expertise in the epide-
miology and technical aspects of various methods, in par-
ticular vacuum aspiration.
Finally, with respect to the operation of stigma within
the clinical setting, both health professionals and clients
identified clinical personnel who do not participate in
abortion services as potential perpetuators of stigma. Clin-
ical personnel who were not involved in abortion services
can be divided into two types: broad administrative staff
and objectors. The latter were identified as enhancers of
stigma when their behavior chastised or otherwise “ex-
posed” clients as wrongdoers. In the case of administrative
personnel more broadly, both clients and health profes-
sionals identified some of them as de facto gatekeepers
who actively obstruct access to abortion services or treat
abortion clients differently than clients seeking other ser-
vices. Health professionals in particular saw this as a
shortcoming in the structure of service provision resulting
from a lack of training and awareness-raising for hospitals’
technical and administrative personnel with whom
women are obliged to interact.
Health professionals were generally comfortable about
their jobs in abortion teams and expressed overwhelmingly
positive attitudes towards the law. Women also expressed
that they felt supported by health professionals who
through their compassionate and efficient care often dissi-
pated many of the fears and preconceptions that women
held before arriving at the clinic. Health care providers and
women benefited from strong professional abortion teams,
which provided emotional and technical support to all in-
volved. This aspect of clinical care is reflected in other
Cárdenas et al. Reproductive Health (2018) 15:150
decriminalized contexts and is a component of the
Uruguayan model that should be considered for replication.
Both clients and health professionals felt that social atti-
tudes were visibly changing as a result of decriminalization.
Future research should continue to document the unfold-
ing of long-term impact of decriminalization on women’s
access to safe abortion provision as well as perceived and
experienced stigma.
It is clear from our interviews, however, that both women
and health professionals believed that abortion is always
and necessarily a traumatic experience for women; an ex-
perience that marks them for life. That is, although percep-
tions of the law, of safe abortion, and of the rights of
women were generally positive, women and providers still
looked down on women that had one or more abortions,
saw abortion as a weight that women were to carry for the
rest of their lives, and that necessarily marked a before and
after. In many of these cases the persistence of guilt or
judgment reveals the persistence of social stigma despite
the legal change. Thus, it is recommended that interven-
tions designed to reduce stigma should not be limited to
clinical settings, but rather should include community-level
interventions aimed at interrupting stigmatizing social
views, and providing spaces for the reproduction of ideas
and practices that normalize abortion and contribute to-
wards further de-stigmatization.
Finally, we would like to point to some of the limita-
tions of this study. In particular, the fact that women
were interviewed immediately following their fourth visit
meant that the data cannot track whether attitudes to-
wards abortion changed substantially over longer periods
of time. It is also important to note that we only inter-
viewed women and providers involved in legal abortion
services and therefore this study cannot speak towards
the circulation of stigma in clandestine settings.
Conclusion
Overall, this study reveals that although decriminalization
does contribute to mitigating abortion stigma, even in
legal clinical settings, there can remain practices that per-
petuate the notion that abortion is a dirty and morally
questionable practice. For example, the refusal to carry
out surgical procedure replicates the idea that direct in-
volvement is “dirty work.” Medicated abortion devolves
the moral responsibility to women and since it is the only
method available de facto, it limits opportunities for
women to choose the way the termination will be carried
out. Likewise, the five-day reflection period questions a
woman’s motives and would seem to implicitly suggest
that the ideal decision would be to continue the preg-
nancy. Further, while abortion clients reported high levels
of satisfaction with services, we have identified several key
points where stigma is prone to reappearing in service
delivery. For example, stigma affects services when women
Page 10 of 11
interact with personnel that do not participate in the
abortion teams and who are not sensitive to the issue, or
when women are unable to obtain care when encounter-
ing objectors. Among women and health professionals
alike the idea prevails that abortion is something that
leaves a mark, and in the case of women this is accompa-
nied by a negative moral judgment toward other women
who have abortions, in particular those who have more
than one abortion, and those who do not show remorse.
Yet, almost all women said that they themselves did not
feel judged during the procedure and the health profes-
sionals stated that they did not feel rejected by their
colleagues, including those are objectors. It is important
to underscore that the legal framework has had a decisive
impact on abortion stigma and greatly improves women’s
experience seeking abortion care.
Endnotes
1
Hereon after, we will refer to abortion providers as
health professionals who participate in abortion services,
or simply as health professionals. We do this in order to
highlight the broad spectrum of work that these profes-
sionals are involved in, rather than pigeonholing their
work as simply abortion provision.
2
IVE is the acronym for Interrupción Voluntaria del
Embarazo (Voluntary Interruption of Pregnancy), which
has become a term in its own right in Uruguay, and is
often used instead of the word abortion. Accordingly,
IVE1, IVE 2, IVE3 and IVE 4 are used to refer to each of
the four mandatory clinical visits established by the clin-
ical guides. In this piece, we primarily use the word
abortion but have opted to keep IVE when its meaning
is not fully captured by the term abortion. In addition,
we have used Visit 1, 2, 3, and 4 to substitute for the
IVE terminology described above.
3
Note that in August 2015, a ruling by the Court of
Administrative Disputes overturned 7 of the 11 articles
in the decree, which were challenged by a group of
gynecologists arguing that it restricted their right to
conscientious objection. As a result of this ruling, the
scope of objection was expanded to include not only
gynecologists who prescribe the drug, but also other
health providers (e.g., sonographers and nurses) who are
involved in preparatory procedures and consultations
prior to the termination where information and counse-
ling are provided (Visits 1 and 2).
4
It bears to note that in Uruguay abortion outside the
health system continues to be penalized.
5
Within the hospital, recruitment and analysis was
done in partnership with Iniciativas Sanitarias, a leading
coalition of sexual and reproductive health professionals
whose work advances sexual and reproductive health
and rights as a basic human right for women and men
in Uruguay.
Cárdenas et al. Reproductive Health (2018) 15:150
Acknowledgements
The authors would like to acknowledge the women who participated in the
interviews and shared their experiences.
Funding
The funding for this research was made possible by anonymous private
donors.
Availability of data and materials
The datasets used and/or analyzed during the current study are available
from the corresponding author on reasonable request.
Authors’ contributions
RC participated in the research design, data collection, analysis and write up
of the article. AL participated in the research design and helped facilitate
local data collection by identifying interviewers and streamlining recruitment
of participants. SB participated in the research design, data collection,
analysis and write up of the article. FC coordinated all local interviewers,
oversaw participant recruitment and follow up, and revised preliminary drafts
of the manuscript. IL recruited and interviewed research participants and
revised preliminary drafts of the manuscript. SA recruited and interviewed
research participants and revised preliminary drafts of the manuscript. JF
secured funding for this research project, managed local and international
research teams, participated in research design and revised preliminary drafts
of the manuscript.
Ethics approval and consent to participate
All participants in this study were explained the objectives and risks in this
study and gave their consent to participate.
This study was approved by the Allendale Investigational Review Board (Old
Lyme, CT, USA).
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1 reduction strategy against unsafe abortion in Uruguay: from a university
International Planned Parenthood/Western Hemisphere Region, New York,
USA. 2Hampshire College, Amherst, USA. 3Iniciativas Sanitarias, Montevideo,
Uruguay. 4Ibis Reproductive Health, Oakland, USA.
Received: 23 April 2018 Accepted: 30 August 2018
References
1. Ellison MA. Authoritative knowledge and single women’s unintentional
pregnancies, abortions, adoption, and single motherhood: social stigma and
structural violence. Med Anthropol Q September. 2003;17:322–47.
2. Major B, Gramzow RH. Abortion as stigma: cognitive and emotional
implications of concealment. J Pers Soc Psychol October. 1999;77:735–45.
3. Goffman E. Stigma; notes on the management of spoiled identity.
Englewood cliffs, N.J: Prentice-Hall; 1963.
4. Link BG, Phelan JC. Conceptualizing Stigma. Annu Rev Sociol. 2001;27:363–85.
5. Sedgh G, Henshaw S, Singh S, Åhman E, Shah IH. Induced abortion:
estimated rates and trends worldwide. Lancet October. 2007;370:1338–45.
6. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence
and disparities, 2006. Contraception November 2011;84:478–485.
7. Cockrill K, Nack A. ‘I’m not that type of person’: managing the stigma of
having an abortion. Deviant Behav December. 2013;34:973–90.
8. Norris A, Bessett D, Steinberg JR, Kavanaugh ML, Zordo SD, Becker D.
Abortion stigma: a reconceptualization of constituents, causes, and
Consequences Womens Health Issues May 2011;21 Suppl 3: 49–54.
9. Kumar A, Hessini L, Mitchell EMH. Conceptualising abortion stigma. Cult
Health Sex August. 2009;11:625–39.
Page 11 of 11
10. Shellenberg KM, Moore AM, Bankole A, Juarez F, Omideyi AK, Palomino N,
et al. Social stigma and disclosure about induced abortion: results from an
exploratory study. Glob Public Health September 2011;6 Suppl 1:111–125.
11. Sorhaindo AM, Juárez-Ramírez C, Díaz Olavarrieta C, Aldaz E, Mejía Piñeros
MC, Garcia S. Qualitative evidence on abortion stigma from Mexico City and
five states in Mexico. Women Health. 2014;54:622–40.
12. Joffe CE. Doctors of conscience: the struggle to provide abortion before
and after roe v. Wade. Boston: Beacon Press; 1995.
13. Harris LH, Debbink M, Martin L, Hassinger J. Dynamics of stigma in abortion
work: findings from a pilot study of the providers share workshop. Soc Sci
med 1982. October. 2011;73:1062–70.
14. World Health Organization: Trends in maternal mortality: 1990 to 2015.
http://www.who.int/reproductivehealth/publications/monitoring/maternal-
mortality-2015/en/ (2015). Accessed 23 Aug 2016.
15. Organización Mundial de la Salud: Estadísticas Sanitarias Mundiales 2012.
http://www.who.int/gho/publications/world_health_statistics/2012/es/
(2012). Accessed 23 Aug 2016.
16. Lamas M. Entre el estigma y la ley: La interrupción legal del embarazo en el
DF. Salud Públ Méx February 2014;56(1):56–62.
17. Galli B, Sydow E. Autonomia Reprodutiva EM Questão: Relatos De Mulheres
sobre Aborto E Estigma EM Mato Grosso do Sul (reproductive autonomy at
stake: Women’s histories on abortion and stigma in Mato Grosso do Sul,
Brazil). Social Science Research Network. 2010; http://papers.ssrn.com/
abstract=2703948 Accessed 15 Jun 2016
18. Zordo SD. Representações e experiências sobre aborto legal e ilegal dos
ginecologistas-obstetras trabalhando em dois hospitais maternidade de
Salvador da Bahia. Ciênc Saúde Coletiva. 2012;17:1745–54.
19. Faúndes A, Duarte GA, Osis MJD. Conscientious objection or fear of social
stigma and unawareness of ethical obligations. Int J Gynecol Obstet. 2013;
123 Suppl 3:57–9.
20. Lopez GA, Berro EC. Efectos del aborto clandestino en la subjetividad de las
mujeres: resultados de una investigación cualitativa en Uruguay. BDDOC
CSIC: Sumarios ISOC - Ciencias Sociales y Humanidades. 2010; http://
revpubli.unileon.es/ojs/index.php/cuestionesdegenero/article/view/3784
Accessed 23 Aug 2016
21. Rostagnol S, Viera M, Grabino V, Mesa S. Transformaciones y continuidades
de los sentidos del aborto voluntario en Uruguay: del AMEU al misoprostol.
Bagoas. 2013;7:17–42. http://www.mec.gub.uy/innovaportal/file/48018/1/
transformaciones-y-continuidades-de-los-sentidos-del-aborto-voluntario-en-
uruguay.pdf . Accessed 15 Jun 2016
22. Briozzo, L. From risk and harm reduction to decriminalizing abortion: the
Uruguayan model for women’s rights. Int J Gynaecol Obstet 2016; 134
Suppl1: 3–6.
23. Labandera A, Gorgoroso M, Briozzo L. Implementation of the risk and harm
hospital to the entire country. Int J Gynaecol Obstet. 2016;134(Suppl 1):7–11.
24. Zamberlin N, Romero M, Ramos S. Latin American women’s experiences
with medical abortion in settings where abortion is legally restricted.
Reprod Health; December 2012;9:34.
25. Fiol V, Rieppi L, Aguirre R, Nozar M, Gorgoroso M, Coppola F, Briozzo L.
The role of medical abortion in the implementation of the law on
voluntary termination of pregnancy in Uruguay. Int J Gynaecol Obstet.
2016;134(Suppl 1):12–5.
CEOG Clinical and Experimental
Obstetrics & Gynecology

The importance of some angiogenic markers

in spontaneous abortion

N. Ozturk1, I. Gozukara2, Z. Kamalak2, M.A. Gul1, Z. Bayraktutan3, N.K. Baygutalp1,

A. Kızıltunc1, E. Bakan1, E.U. Karakilic2
1 Ataturk University, Faculty of Medicine, Department of Medical Biochemistry, Erzurum
2 Nenehatun Obstetrics Hospital, Erzurum; 3 Regional Training and Research Hospital, Department of Biochemistry, Erzurum (Turkey)

Summary
Aim: In this study, the authors aimed to determine the serum levels of vascular endothelial growth factor (VEGF), angiopoietin-1 (ang-
1) and angiopoietin-2 (ang-2) factors as indicators of placental angiogenesis and vasculogenesis in abortion cases. Materials and Meth-
ods: This study was conducted in 40 women who were pregnant for 7-20 weeks and diagnosed with an incipient abortion and 40
pregnant healthy women with similar ages, gestational weeks, and body mass index (BMI) values. Serum VEGF, ang-1, and ang-2 lev-
els were measured with ELISA methods. Results: The authors found that the serum VEGF levels were higher and ang-1 levels were sig-
nificantly lower in pregnant women whose pregnancies failed with abortion, compared to control group. There was no significant
difference in terms of ang-2 levels between groups. Conclusion: A strong relationship was found between VEGF and ang-1 early preg-
nancy loss, and significant changes of these factors may also be associated with the physiopathology of abortion incipience. Evaluat-
ing these factors may be benefical for prediction and designing of treatment modalities on spontaneous abortion.

Key words: Abortus; VEGF; Angiopoietin-1 (Ang-1); Angiopoietin-2 (Ang-2).

Introduction ates the vascular regression and cell death by disrupting

Normal embryonic development and growth is dependent
on formation and sustained fetoplacental blood vessels [1].
Angiogenesis and vasculogenesis that are important stages
in the development of fetal and placental vascular struc-
tures are complex processes that occur as a result of inter-
action between growth factors and cells. Vasculogenesis is
the development of primitive vascular structure from he-
mangiogenic stem cells. Angiogenesis is the formation of
new capillaries from pre-existing vessels. These processes
are regulated by many growth factors, so vascular network
is controlled on the basis of the interactions of these fac-
tors [1-6].
Vascular endothelial growth factor (VEGF) is a multi-
functional cytokine. VEGF provides the formation, migra-
tion, and proliferation of endothelial cells, and plays a
central role in the regulation of placental angiogenesis [2,
3, 7]. Angiopoietins are vascular growth factors which have
functions in the regulation of embryonic and postnatal an-
giogenesis. Angiopoietin-1 (ang-1) and angiopoietin-2
(ang-2), produced by placenta, are important for restruc-
turing of vessels and the endothelial cell survival [1]. Ang-
1 mediates stabilization of developing vessels, maintains
vessel integrity, and provides angiogenic progression [1, 2,
8]. Despite ang-1 and ang-2 share a similar structure, they
have different effects on the same receptors. Ang-2 initi-
connections between endothelial and perivascular cells [1,
2, 4, 9]. In the presence of proangiogenic factors such as
VEGF, the destabilization caused by the ang-2 results in
the formation and progress of new vessels [8].
Approximately 15% of clinically diagnosed pregnancies
end in abortion through the first trimester due to different
etiologic factors [10]. Recently, researchers have tried to
show the relationship between angiogenic factors and re-
current pregnancy loss in a number of studies [1, 11, 12].
In this study, the authors aimed to compare the serum lev-
els of VEGF, ang-1, and ang-2, possible placental angio-
genesis and vasculogenesis indicators, between pregnant
women diagnosed with incipient abortion and healthy
women with similar ages.
Materials and Methods
The local ethics committee approved the study (protocol num-
ber: 22.03.2013/8) and participants gave written informed con-
sent. This study included 40 women who were between 7-20
weeks of pregnancy and presented with vaginal bleeding, pain,
and cervical dilation complaints and also diagnosed with incipi-
ent abortion. Control group consisted of 40 pregnant healthy
women with similar ages, gestational weeks and body mass index
(BMI) values. Serum samples were stored at -800C until assay.
Serum VEGF levels measured with ELISA kit and an ELISA
reader according to the kit insert. Also ang-1 and ang-2 serum lev-

Revised manuscript accepted for publication March 9, 2016

Clin. Exp. Obstet. Gynecol. - ISSN: 0390-6663 7847050 Canada Inc.
XLIV, n. 3, 2017 www.irog.net
doi: 10.12891/ceog3627.2017
 N. Ozturk, I. Gozukara, Z. Kamalak, M.A. Gul, Z. Bayraktutan, N.K. Baygutalp, A. Kızıltunc, E. Bakan, E.U. Karakilic 445

Table 1. — The clinical characteristic of healthy and in- Discussion

cipient abortion pregnant subjects. Spontaneous abortion (SA), a common finding affecting
Control Incipient abortion p value
20% of pregnancies, usually occurs at an early stage of
Age (years) 29.76 ± 4.1 29.40 ± 4.3 > 0.05
pregnancy. Until now, various factors have been identified
Gravidity 2.2 ± 0.4 2.1 ± 0.3 > 0.05
Pregnancy weeks that influence miscarriage such as genetic, endocrine, in-
13.4 ± 5.5 12.5 ± 4.4 > 0.05 fectious, anatomical, nutritional and environmental, but
(menstruating)
VEGF (pg/ml) 14.17 ± 4.18 56.66 ± 16.17 < 0.001 exact pathogenesis is not known [13, 14]. However inap-
Ang-1 (ng/ml) 114.96 ± 15.09 86.91 ± 12.73 < 0.001 propriate angiogenesis and blood flow pattern have been
Ang-2 (pg/ml) 688.80 ± 131.56 648.76 ± 128.04 > 0.05 attributed to miscarriage and implantation failure [15, 16].
VEGF: vascular endothelial growth factor, Ang-1: angiopoietin-1, Inhibition of angiogenesis in pregnant mice results in com-
Ang-2: angiopoietin-2. plete failure of embryonic growth owing to interference
with placental and yolk sac formation and embryonic vas-
cular development [17]. Nonetheless some angiogenesis
factors like ang-1, ang-2, and VEGF are suggested to have
els were measured by ELISA kits. important roles in the abortion cases. In this study, the au-
Statistical analyses were performed using the SPSS 20.0 pro- thors found increased serum VEGF levels and decreased
gram. Compliance with the normal distribution of parameters was serum ang-1 levels in pregnancies resulting in abortion,
assessed by Kolmogorov-Smirnov test. Independent samples t- compared to the control group. These results suggest that
test was used for evaluation of parameters normally distributed.
The correlation analyses between parameters were evaluated by
there is a strong relationship between these factors and
Pearson correlation analysis. early pregnancy loss and significant changes of these fac-
tors also may be associated with the pathology of abortion
incipience.
Results VEGF is a specific mitogen that has been documented to
Serum VEGF levels were higher (p < 0.001) and ang-1 participate in many phases of the reproductive process such
levels were significantly lower (p < 0.001) in pregnant as embryo implantation and placental growth [18, 19]. Dur-
women that had an abortion compared to control group ing early gestation, VEGF is related with oocytes matura-
(Table 1). There was no significant difference in terms of tion, trophoblastic proliferation, implantation and
ang-2 levels between groups (p = 0.172) (Table 1). Again, development of the embryo, angiogenesis of the placenta,
a significant weak correlation (p < 0.05, r < 0.6) was found and the growth of maternal and fetal blood vessels in the
between serum ang-1 and VEGF levels in patient group uterus [20, 21]. A crucial role of VEGF in fetal and pla-
(Figure 1). cental angiogenesis has been also supported from gene

Figure 1. — Scatter plot graph between ang-1 and VEGF levels for the patient group (p = 0.026, r = 0.351). Scatter plot graph between
ang-1 and VEGF levels for the control group (p = 0.036, r = 0.332).
446 The importance of some angiogenic markers in spontaneous abortion
knockout studies [22, 23]. Pang et al. [24] reported that in
hypoxia cases, like poor vascularization at the early phases
of placental development, maternal serum VEGF levels in-
crease and the pregnancy results in abortion due to en-
dothelial dysfunction. VEGF, that modulates placental
vascular development, was also high in patients with abor-
tion in the present series. This finding may be explained as
increased blood vessel density in decidua parietals was re-
lated with spontaneous human first trimester abortion, sim-
ilar with previous studies [25]. Increased vascularization is
considered a consequence of hypoxia. This often occurs
with increased microvascular permeability and increased
capillary density under the condition of tissue ischemia and
hypoxia [26]. Meanwhile, in vitro experiments have indi-
cated that hypoxia could enhance VEGF secretion [27].
Among other biomolecules, ang-1 maintains vessel in-
tegrity and probably plays a role in the later stages of vas-
cular remodeling. Ang-2 is a functional antagonist of ang-1
and leads to vascular dilatation, loosening of cell/cell inter-
actions, and disruption of vessel integrity [28]. From ob-
stetric aspect, circulating levels of ang-1 and ang-2 are
associated with poor pregnancy outcomes, and low serum
levels of these factors have been reported with predictive
for potential consequences in cases of abortion or ectopic
pregnancy [8]. Schneuer et al. [8] reported that patients with
adverse pregnancy outcome have lower levels of ang-2.
Similar to these results, in a case-control study by Daponte
et al. [29] reported that serum ang-1 and ang-2 levels at six
to eight weeks of gestation were significantly lower in failed
pregnancies compared to normal pregnancies. Researchers
concluded that ang-1 and ang-2 levels may be used as bio-
markers of ectopic pregnancy and missed abortion by means
of a single measurement of their serum levels at six to eight
weeks of gestation. In the present study, serum ang-1 con-
centrations were significantly lower in abortion incipience
compared to the control group and it showed positive cor-
relation with serum VEGF levels. Although this correlation
was not statistically significant, ang-2 levels were also de-
creased in abortion incipience group. Similar to the present
study, reduction of ang-2 was also observed in women with
a history of recurrent miscarriage. The estimated increased
VEGF and reduced ang-2 may contribute to the advanced
vessel maturation observed in this group of patient [30].
In conclusion, the implantation process of embryo and
steadiness of pregnancy seems to depend on proper blood
supply to fetal placental tissue that is regulated with an-
giopoietic factors like VEGF, ang-1, and ang-2. These fac-
tors may have a predictive potential for spontaneous
abortion and also new treatment modalities, and may have
beneficial effect on prevention of SA.
References
[1] Kappou D., Sifakis S., Konstantinidou A., Papantoniou N., Spandi-
dos D.A.: “Role of the angiopoietin/Tie system in pregnancy (Re-
view)”. Exp. Ther. Med., 2015, 9, 1091.
[2] Zhang E.G., Smith S.K., Baker P.N., Charnock-Jones D.S.: “The reg-
ulation and localization of angiopoietin-1, -2, and their receptor Tie2
in normal and pathologic human placentae”. Mol. Med., 2001, 7, 624.
[3] Suri C., Jones P.F., Patan S., Bartunkova S., Maisonpierre P.C., Davis
S., et al.: “Requisite role of angiopoietin-1, a ligand for the TIE2 re-
ceptor, during embryonic angiogenesis”. Cell, 1996, 87, 1171.
[4] Dunk C., Shams M., Nijjar S., Rhaman M., Qiu Y., Bussolati B.,
Ahmed A.: “Angiopoietin-1 and angiopoietin-2 activate trophoblast
Tie-2 to promote growth and migration during placental develop-
ment”. Am. J. Pathol., 2000, 156, 2185.
[5] Wulff C., Wilson H., Dickson S.E., Wiegand S.J., Fraser H.M.: “He-
mochorial placentation in the primate: expression of vascular en-
dothelial growth factor, angiopoietins, and their receptors throughout
pregnancy”. Biol. Reprod., 2002, 66, 802.
[6] Demir R., Yaba A., Huppertz B., Hurliman A.K., Speroff L., Stouffer
R.L.: “Vasculogenesis and angiogenesis in the endometrium during
menstrual cycle and implantation”. Acta Histochem., 2010, 112, 203.
[7] Patton P.E., Lee A., Molskness T.A.: “Changes in circulating levels
and ratios of angiopoietins during pregnancy but not during the men-
strual cycle and controlled ovarian stimulation”. Fertil. Steril., 2010,
93, 1493.
[8] Schneuer F.J., Roberts C.L., Ashton A.W., Guilbert C., Tasevski V.,
Morris J.M., Nassar N.: “Angiopoietin 1 and 2 serum concentrations
in first trimester of pregnancy as biomarkers of adverse pregnancy
outcomes”. Am. J. Obstet. Gynecol., 2014, 210, 345.e1.
[9] Maisonpierre P.C., Suri C., Jones P.F., Bartunkova S., Wiegand S.J.,
Radziejewski C., et al.: “Angiopoietin-2, a natural antagonist for
Tie2 that disrupts in vivo angiogenesis”. Science, 1997, 277, 55.
[10] Yakut S., Toru H.S., Çetin Z., Özel D., Şimşek M., Mendilcioğlu İ.,
Lüleci G.: “Chromosome abnormalities identified in 457 sponta-
neous abortions and their histopathological findings”. Turk. Patoloji.
Derg., 2015, 31, 111.
[11] Banerjee P., Ghosh S., Dutta M., Subramani E., Khalpada J., Roy-
choudhury S., et al.: “Identification of key contributory factors re-
sponsible for vascular dysfunction in idiopathic recurrent
spontaneous miscarriage”. PLoS One, 2013, 8, e80940.
[12] Andraweera P.H., Dekker G.A., Roberts C.T.: “The vascular en-
dothelial growth factor family in adverse pregnancy outcomes”.
Hum. Reprod. Update, 2012, 18, 436.
[13] Rai R., Regan L.: “Recurrent miscarriage”. Lancet, 2006, 368, 601.
[14] Stephenson M.D.: “Frequency of factors associated with habitual
abortion in 197 couples”. Fertil. Steril., 1996, 66, 24.
[15] Habara T., Nakatsuka M., Konishi H., Asagiri K., Noguchi S., Kudo
T.: “Elevated blood flow resistance in uterine arteries of women with
unexplained recurrent pregnancy loss”. Hum. Reprod., 2002, 17,
190.
[16] Quenby S., Nik H., Innes B., Lash G., Turner M., Drury J., Bulmer
J.: “Uterine natural killer cells and angiogenesis in recurrent repro-
ductive failure”. Hum. Reprod., 2009, 24, 45.
[17] Klauber N., Rohan R.M., Flynn E., D’Amato R.J.: “Critical compo-
nents of the female reproductive pathway are suppressed by the an-
giogenesis inhibitor AGM-1470”. Nat. Med., 1997, 3, 443.
[18] Clark D.E., Smith S.K., He Y., Day K.A., Licence D.R., Corps A.N.,
et al.: “A vascular endothelial growth factor antagonist is produced
by the human placenta and released into the maternal circulation”.
Biol. Reprod., 1998, 59, 1540.
[19] Torry D.S., Holt V.J., Keenan J.A., Harris G., Caudle M.R., Torry
R.J.: “Vascular endothelial growth factor expression in cycling
human endometrium”. Fertil. Steril., 1996, 66, 72.
[20] Jelkmann W.: “Pitfalls in the measurement of circulating vascular
endothelial growth factor”. Clin. Chem., 2001, 47, 617.
[21] Su M.T., Lin S.H., Lee I.W., Chen Y.C., Kuo P.L.: “Association of
polymorphisms/haplotypes of the genes encoding vascular endothe-
lial growth factor and its KDR receptor with recurrent pregnancy
 N. Ozturk, I. Gozukara, Z. Kamalak, M.A. Gul, Z. Bayraktutan, N.K. Baygutalp, A. Kızıltunc, E. Bakan, E.U. Karakilic
loss”. Hum. Reprod., 2011, 26, 758.
[22] Carmeliet P., Ferreira V., Breier G., Pollefeyt S., Kieckens L., Gert-
senstein M., et al.: “Abnormal blood vessel development and lethal-
ity in embryos lacking a single VEGF allele”. Nature, 1996, 380, 435.
[23] Ferrara N., Carver-Moore K., Chen H., Dowd M., Lu L., O’Shea
K.S., et al.: “Heterozygous embryonic lethality induced by targeted
inactivation of the VEGF gene”. Nature, 1996, 380, 439.
[24] Pang L., Wei Z., Li O., Huang R., Qin J., Chen H., et al.: “An in-
crease in vascular endothelial growth factor (VEGF) and VEGF sol-
uble receptor-1 (sFlt-1) are associated with early recurrent
spontaneous abortion”. PLoS One, 2013, 8, e75759.
[25] Vailhe B., Dietl J., Kapp M., Toth B., Arck P.: “Increased blood ves-
sel density in decidua parietalis is associated with spontaneous
human first trimester abortion”. Hum. Reprod., 1999, 14, 1628.
[26] Cao Y., Linden P., Shima D., Browne F., Folkman J.: “In vivo angio-
genic activity and hypoxia induction of heterodimers of placenta
growth factor/vascular endothelial growth factor”. J. Clin. Invest.,
1996, 98, 2507.
[27] Hornig C., Barleon B., Ahmad S., Vuorela P., Ahmed A., Weich
H.A.: “Release and complex formation of soluble VEGFR-1 from
endothelial cells and biological fluids”. Lab. Invest., 2000, 80, 443.
447
[28] Geva E., Jaffe R.B.: “Role of angiopoietins in reproductive tract an-
giogenesis”. Obstet. Gynecol. Surv., 2000, 55, 511.
[29] Daponte A., Deligeoroglou E., Pournaras S., Tsezou A., Garas A.,
Anastasiadou F., et al.: “Angiopoietin-1 and angiopoietin-2 as serum
biomarkers for ectopic pregnancy and missed abortion: a case-con-
trol study”. Clin. Chim. Acta, 2013, 415, 145.
[30] Lash G.E., Innes B.A., Drury J.A., Robson S.C., Quenby S., Bulmer
J.N.: “Localization of angiogenic growth factors and their receptors
in the human endometrium throughout the menstrual cycle and in
recurrent miscarriage”. Hum. Reprod., 2012, 27, 183.
Corresponding Autthor:
N. KILIC-BAYGUTALP, Ph.D
Faculty of Medicine, Ataturk University
Department of Medical Biochemistry
25240 Erzurum (Turkey)
e-mail: eczbaygutalp80@gmail.com
 International

Journal of Human Sciences

ISSN:2458-9489

Volume 18 Issue 3 Year: 2021

Role of biochemical
Birinci trimester düşük
parameters in the
tehdidi olan hastalarda
differential diagnosis of
anembriyonik gebelik,
viable pregnancy,
intrauterin eksitus ve
anembryonic pregnancy and
sağlıklı gebeliğin ayırıcı
intrauterine fetal exitus in
tanısında biyokimyasal
cases of first trimester
parametrelerin yeri
threatened abortion

Ozan Özolcay1
Bulat Aytek Şık2

Abstract
It is aimed to establish criteria about the
prognosis and life potential of pregnancy by
using ultrasonographic imaging techniques and
hormonal parameters to evaluate embryonic life
potantial in threatened miscarriage patients. Our
study consists of 45 pregnant patients who were
admitted for vaginal bleeding during pregnancy
and were diagnosed as a threatened miscarriage.
The study group consisted of pregnant women
diagnosed with threat of miscarriage pregnancy
week is lower than 20 weeks according to their
last menstrual period. Estradiol, Progestrone, β-
hCG hormone level are measured from
patients, the same day after the ultrasound
examination. The group whose pregnancy
resulted with live birth and the group whose
pregnancy ended with spontaneous abortion
were statistically compared according to their
hormonal parameters; it was found to be
Özet
Düşük tehdidi olan hastalarda embriyonik
yaşamın devamını değerlendirmek için
ultrasonografik görüntüleme teknikleri ve
hormonal belirteçleri kullanarak gebeliğin
prognozu ve yaşam potansiyeli hakkında
kriterler oluşturmak amaçlanmıştır. Çalışmamız,
gebelikte vajinal kanama nedeniyle başvuran ve
düşük tehdidi tanısı alan 45 gebe hastadan
oluşmaktadır. Herhangi bir sistemik hastalığı
bulunmayan ek bir jinekolojik patolojisi
olmayan ve son adet tarihinden kesin olarak
emin olan hastalar çalışma gruplarına dahil
edildi. Çalışma grubu son adet tarihine göre 20
hafta ve daha küçük gestasyonel haftadaki düşük
tehdidi tanısı alan gebelerden oluştu.
Hastalardan Estradiol, Progestrone, β-hCG
ölçümleri yapıldı. Gebeliği canlı doğum ile
sonuçlanan grup ile gebeliği spontan abortusla
sonlanan grubun β-hCG, P4, E2 degerleri

1 Op. Dr., Kadın Hastalıkları ve Doğum Bölümü, Taksim Eğitim ve Araştırma Hastanesi, ozan.ozolcay@gmail.com
Orcid ID: 0000-0002-9416-6153
2 Op. Dr. Kadın Hastalıkları Doğum ve Tüp Bebek Bölümü, Şişli Kolan İnternational Hospital, bulataytek@gmail.com

Orcid ID: 0000-0002-4165-9405

Submitted: 21/05/2020 Published: 02/07/2021
 343
Özolcay, O., & Şık, B. A. (2021). Birinci trimester düşük tehdidi olan hastalarda anembriyonik gebelik, intrauterin eksitus
ve sağlıklı gebeliğin ayırıcı tanısında biyokimyasal parametrelerin yeri. Journal of Human Sciences, 18(3), 342-348.
doi:10.14687/jhs.v18i3.6019

significantly lower in the group that resulted in istatiksel olarak karşılaştırıldığında; canlı doğum
live birth (p <0.01). Sensitivity, specificity, ile sonuçlanan grupta anlamlı olarak düşük
negative and positive predictive values of β- bulunmuştur (p<0.01). Abortus imminensli
hCG, E2, P4 levels were found to be significant hastalarda β-hCG, E2, P4 düzeylerinin sensivite
in patients with threatened miscarriage. Increase spesifite, negatif ve pozitif prediktif değerleri
both time loss and correct diagnosis rate, after anlamlı çıkmıştır. Abortus imminensli hastalarda
vaginal speculum examination the first choice in vaginal muayene sonrası yapılacak ilk iş hem
patients with abortus imminens is to request a vakit kaybını hem de doğru tanı oranını
transvaginal ultrasonographic examination and arttırmak için ilk olarak transvajinal
then assesment of hormonal parameters (β- ultrasonografik inceleme ve ardından gerekirse
hCG, progesterone, estradiol) if necessary. hormonal parametreleri (β -hCG, progesteron,
estradiol) istemek doğru olacaktır.
Keywords: First trimester; Abortus imminens;
Transvaginal ultrasonography; Estradiol; Anahtar Kelimeler: Birinci trimester; Abortus
Progesterone; β-hCG. imminens; Transvajinal ultrasonografi;
Estradiol; Progesteron; β-hCG.
(Extended English summary is at the end of
this document)

Giriş
Düşük tehdidi klinik olarak saptanmış gebeliklerin %25 gibi oldukça büyük bir kısmında
görülebilen bir durumdur (Hertz 1984; Canavagh & Comas 1982; Fantel & Shepard 1981).
Gebeliğin devamını sağlamak için uygulanan çeşitli tedavilere rağmen, bu gebeliklerin yaklaşık yarısı
düşükle sonuçlanmaktadır (Ansan 1989; Filly 1988; Scott 1986). Bu hastalarda, embriyonun
genellikle ilk kanama anında kalp atışları durmuştur veya uzun bir zamandan beri kalp atışları
durmuşta olabilir. Bu nedenle kalp atışları durmuş gebeliklerde abortusu engelleyecek ilaçların
kullanılması etkisizdir, süreci uzatır ve koryonik doku hala aktif kalıp gebelik testlerinin pozitif
çıkmasına sebep olur (Ansan 1989; Scott 1986; Glass et al 1989).
Erken sağlıklı gebelik, anembriyonik gebelik ve intrauterin fetal/embriyonal eksitus
olgularının ayırıcı tanısı ebeveynlerde bu sonuçlara neden olabilecek genetik faktörlerin
araştırılmasında uyarıcı olabileceği gibi assiste reprodüktif teknolojilerin başarısının ve embriyo
kalitesinin değerlendirilmesinde önemini korumaktadır (Homan et al. 2000; Hsu et al. 1998). Erken
gebelik kaybının nedenlerini belirlemeye yönelik önemli araştırma girişimlerine rağmen hala tam
olarak kesin sonuca ulaşılamamıştır. Kesin düşükle sonuçlanacak gebelikleri öngörmedeki başarı
sınırlıdır. Erken gebelik kaybının öngörülmesi için fetal, plasental ve over kökenli hormonların,
proteinlerin ölçümü, biyofiziksel testler ve ultrason muayenesinin spesifitesi ve sensitivitesi için
çeşitli gruplar bir takım çalışmalar yapmıştır (Stabile et al. 1989; Westergaard et al. 1985; Salem et
al. 1984).
Yardımla üreme tedavileri, yumurtlama ve gebe kalma zamanlamasının doğru izlenmesi ile
gebe kalması muhtemel kadınların yakın ve dikkatli incelenmesine olanak vermis, gebe kalma
döngüsü ve erken hamilelik sırasında meydana gelen olaylara odaklanmıştır. Daha önceki çalışmalar,
gebelik sonucunun öngörülmesinde hormonal izleme potansiyelini göstermiştir (Yovkh 1986;
Yovich et al. 1986).
Bu çalışmada düşük tehdidi semptomları olan hastalarda embriyonik yaşamı değerlendirmek
için ultrasonografik görüntüleme teknikleri ve hormonal belirteç olarak da serum β-hCG, Estradiol,
Progesteron seviyesi kullanılarak gebeliğin prognozu ve yaşam potansiyeli hakkında kriterler
oluşturmak amaçlanmıştır.
 344
Özolcay, O., & Şık, B. A. (2021). Birinci trimester düşük tehdidi olan hastalarda anembriyonik gebelik, intrauterin eksitus
ve sağlıklı gebeliğin ayırıcı tanısında biyokimyasal parametrelerin yeri. Journal of Human Sciences, 18(3), 342-348.
doi:10.14687/jhs.v18i3.6019

Materyal ve Metod
Çalışmamız, İstanbul Taksim Eğitim ve Araştırma Hastanesi Gebe Polikiniğine gebelikte
vajinal kanama nedeniyle başvuran ve düşük tehdidi tanısı alan 45 gebe hastadan oluşmaktadır.
Çalışma; Hastane eğitim planlama ve etik kurulun onayını takiben, aynı hastanenin Kadın
Hastalıkları ve Doğum servisinde yürütülmüştür. Herhangi bir sistemik hastalığı bulunmayan ek bir
jinekolojik patolojisi olmayan ve son adet tarihinden kesin olarak emin olan hastalar çalışma
gruplarına dahil edildi. Vajinal muayene sonrası kanamanın bir servikal polip, erozyon veya
eversiyondan kaynaklandığı kesinleşen gebeler, çoğul gebelikler, ektopik ve kimyasal gebelik tanısı
alanlar çalışma dışında bırakıldılar. Çalışma grubu son adet tarihine göre 20 hafta ve daha küçük
gestasyonel haftadaki düşük tehdidi tanısı alan gebelerden oluştu.
Çalışmaya dahil edilen tüm hastaların antekübital venlerinden 10 cc kan alındı ve analiz
edildi. Toplanan kan örneklerinin hepsinden aynı zamanda Estradiol (E2), Progestrone (P4), β-
hCG ölçümleri yapıldı. Estradiol ve progesteron ölçümleri solid faz radioimmunoassay tekniği ile
çalışan Coast A-Count Estradiol ve Progesteron kitleri ile yapıldı. β-hCG, ölçümleri ise sandwich
radioimmunoassay tekniğine dayalı kitler olan IRMA-mat β-hCG, ile yapıldı.
Hastaların önce detaylı sistemik, jinekolojik ve obstetrik anamnezleri alındı ve Shimadzu
marka SDU-350A model real time lineer konveks problu ultrasonografi cihazı ve EUP-V12 model
5mHz lik vajinal prob kullanılarak transvajinal sonografik pelvis incelemeleri yapıldı.
Ultrasonografik incelemede ana amaç fetal kalp hareketlerini saptamaktı. Embriyonun
görülemediği erken gebeliklerde, gebelik kesesinin boyutunu 3 kadranda ölçüp ortalamasını almak
suretiyle ortalama gebelik kesesi çapı (OGKÇ) bulundu. Fetal kalp hareketlerinin (FKH)
saptanamadığı OGKÇ’nin 25 mm’den büyük olduğu gebelikler anembriyonik gebelik olarak kabul
edildi ve terapotik küretaj uygulandı. FKH'nin saptanamadığı OGKÇ' nin 25 mm’ den küçük veya
CRL ‘nin l0 mm den küçük olduğu hastalarda bu incelemeye ek olarak Radioimmunoassay
yöntemiyle β-hCG, progesteron, estradiol seviyesi ölçülmek üzere kan örneği alınıp bir hafta sonra
kontrole çağrılmıştır. Fetus görülebiliyorsa CRL ve BPD ölçülmüş ve fetal kalp atım hareketlerine
bakılmıştır. FKH saptanamayan l0 mm'den büyük embriyolar missed abortus olarak kabul edilmiş
ve küretaj yapılmıştır. Ultrasonografi de sadece koryo-desidual dokusu saptanıp embriyo ve amnios
mayii görülemedi ise ve serviks sonografik olarak 0.5 cm’den daha fazla dilate ise inkomplet abort
olarak kabul edilmiş ve küretaj uygulanmıştır. Uygulanan bütün küretaj materyelleri histopatolojik
olarak incelenmiştir.
Elde edilen verilerin istatistiksel karşılaştırılmasında; niceliksel veriler ortalama +/-SS
(standart sapma) olarak sunuldu. Ayrıca Kruskall-Wallis testiyle, Man-Whitney U testi kullanıldı.

Bulgular
Çalışmaya alınan 45 hastanın %72‘si canlı doğum ile %28‘i abort ile sonuçlanmıştır.
Hastalara ait klinik ve demografik özellikler Tablo 1. de verilmiştir.

Tablo 1. Hastalara ait klinik ve demografik özellikler

Canlı Doğum Abort
n=32 % n=13 %
Kanamanın 5-9. hafta 20 62 6 46
Başladığı 10-14.hafta
Devre 12 38 6 46
14-20. hafta - - l 8
Ilk kanama 1 gun 8 25 4 31
Atağının 2 gun
Süresi
7 22 2 15
3 veya daha fazla 17 53 7 54
 345
Özolcay, O., & Şık, B. A. (2021). Birinci trimester düşük tehdidi olan hastalarda anembriyonik gebelik, intrauterin eksitus
ve sağlıklı gebeliğin ayırıcı tanısında biyokimyasal parametrelerin yeri. Journal of Human Sciences, 18(3), 342-348.
doi:10.14687/jhs.v18i3.6019

Ortalama ss En Küçük En Büyük

Yaş 29.62 6.14 16 40

BMI 23.37 11.32 18.50 28.96
Gravida 2.48 1.35 1 7
Parite 1.29 1.03 0 5.00
Abort 0.22 0.55 0 3.00
Gebelik Haftası 10.72 1.32 5.00 16.00

Gebeliği canlı doğum ile sonuçlanan grup ile gebeliği spontan abortusla sonlanan grubun
β-hCG, P4, E2 degerleri istatiksel olarak karşılaştırıldığında; canlı doğum ile sonuçlanan grupta
anlamlı olarak yüksek bulunmuştur (p<0.01). (Tablo 2.)

Tablo 2. Canlı Doğum ve Abortus gruplarının hormon parametreleri

β-hCG (IU/ml) Progesteron (ng/ml) Estradiol (ng/ml)
Ortalama SS Ortalama SS Ortalama SS
Canlı
Doğum 32 30,95 16,81 42,78 13,15 12,50 3,84

Abortus 13 12,82 7,00 12,66 4,028 7,48 1,92

p 0,0140 0,0113 0,005

Abortus imminensli hastalarda β-hCG E2 P4 düzeylerinin sensivite spesifite, negatif ve

pozitif prediktif değerleri anlamlı çıkmıştır (Tablo 3.)

Tablo 3. Abortus imminensli olgularda β-hCG, Progesteron, Estradiol degerlerinin

sensitivite, spesifite, pozitif ve negatif prediktif değerleri
β-hCG Progesteron Estradiol
Sensitivite %87.5 %100 %66.6
Spesifite %83.7 %95 %83.3
Pozitif prediktif deger %53 %84.6 %40
Negatif prediktif
%96 %100 %83
deger

Tartışma
Bu çalışmaya dahil edilen abortus imminens tanısı alan hastaların demografik özelliklerinin
gebeliğin prognozuna göre dağılımı incelendiğinde, jinekolojik ve sistemik hastalıklar, gravidite,
daha önce küretaj geçirmiş olmasının prognozu etkilemediği görülmüştür. Sadece daha önce
spontan abort geçiren hastalarda spontan düşük oranı daha yüksek olarak görülsede, aradaki bu
farka habituel abortuslann etkisi ve etiyolojileri açısından yaklaşmak için hasta sayılarımız
yetersizdir. Çalışmamızda vaginal kanamanın ilk başladiği hafta itibarıyla prognoz açısından anlamlı
bir fark saptanmamıştır. Kanama süresi ile düşük insidansi arasında anlamlı bir ilişki
bulunamamıştır. Oysa yapılan bir çalışmada üç gün ve daha fazla kanamanın devam ettiği vakalarda
düşük riskinin belirgin olarak arttığı bildirilmiştir (Mantoni 1985).
Çalışmamızda β-hCG değerleri esas alındığında, abortus imminensli hastalarda serum β-
hCG değerlerinin düşük olmasının sensitivitesi %87.5, spesifitesi %83.7, pozitif prediktif değeri %
53, negatif prediktif değeri % 96 olarak saptanmıştır. Düşük seviyelerdeki β-hCG değerlerine sahip
hastalar abortusla sonuçlanmıştır (Nygren et al. 1973). Bizim çalışmamızda ise gebeliği abortusla
sonuçlanan hastaların %87.5’inde β-hCG değerleri düşük bulunmuştur. Progesteron seviyelerinin
 346
Özolcay, O., & Şık, B. A. (2021). Birinci trimester düşük tehdidi olan hastalarda anembriyonik gebelik, intrauterin eksitus
ve sağlıklı gebeliğin ayırıcı tanısında biyokimyasal parametrelerin yeri. Journal of Human Sciences, 18(3), 342-348.
doi:10.14687/jhs.v18i3.6019

düşük olmasi intrauterin viable bir gebeliği ekarte ettirir fakat ektopik gebelik ile intrauterin
nonviable bir gebeliği ayırt etmede yetersizdir.
Yapılan çeşitli araştırmalarda serum progesteron seviyelerinin 4-10 'uncu gebelik haftaları
arasında ortalama 25 ng/ml olduğu ve 12. gebelik haftasından sonra giderek arttığı saptanmıştır
(Sproff et al. 1994). Bu çalışmada abortus imminens olgularında, serum progesteron seviyelerinin
düşük olmasının sensitivitesi %100, spesifitesi %95, pozitif prediktif değeri % 84,6, negatif prediktif
değeri %100 olarak saptanmıştır. Hertz ve ark. abortus imminens olgularında progesteronun pozitif
prediktif değerini %100, negatif prediktif değerini %80 olarak bulmuşlardır (Hertz 1984).
Witt ve ark. abortus imminens prognozunu belirlemede en iyi biyokimyasal parametrenin
progesteron, ikinci sırada ise β -hCG olduğunu bildirmişlerdir (Witt et al. 1990). Bizim
çalışmamızda da benzer olarak en iyi biyokimyasal parametre olarak progesteronu saptadik. β -hCG
ikinci sırada yer alırken estradiol gebelik prognozunu belirlemede son sırada yer almiştır. Estradiol
fetoplasental fonksiyonunun bozulmasının erken göstergelerinden biridir (Siiteri et al. 1966). Buna
karşılık negatif prediktif değeri için Hertz ve ark. %87, Eriksen ve ark. %52 gibi düşük oranlar
yayınlamışlardır (Hertz 1984; Eriksen & Philipsen 1980). Çalışmamızda serum estradiol değerinin
düşük olmasının abortus imminens için sensitivitesi %66,6, spesifitesi %83,3 pozitif prediktif değeri
%40, negatif prediktif değeri %83 olarak bulunmuştur.
Anembriyonik ve intrauterin fetal/embriyonal eksitusu olan gebelikler düşükle
sonuçlanmadan önce bir müddet uterusta kalma eğilimindedirler. Bu süre içinde kanama ve
enfeksiyon gibi komplikasyonları engellemek ve abort tehdidi olan olguların hastanede kalış süresini
kısaltmak için güvenilir tanı yöntemlerine ihtiyaç vardır. Son yıllarda hızlı teknolojik ilerlemeye
paralel olarak geliştirilen transvajinal ultrason probları ile gerek pelvik organlara anatomik olarak
transabdominal problardan daha yakın olması, gerekse sahip oldukları yüksek frekans ile kaliteli
görüntü sağladıkları için özellikle erken gebelik tanı ve takibinde çalışmamızda çıkan sonuçlara
benzer bir şekilde daha yararlı olduğu ortaya konulmuştur (Cullen et al. 1989; Penmell et al. 1991).

Sonuç
Düşük tehdidi, klinik olarak saptanmış gebeliklerde % 25 gibi yüksek bir oranda görülen ve yaklaşık
olarak %50 oranında düşükle sonuçlanan bir erken gebelik komplikasyonudur. Hastada uzamış kan
kaybı, enfeksiyon ve endişeli bekleyişe yol açmadan ilk başvuru anında embriyonun canlı olup,
olmadığının kesin olarak saptamak klinisyenin ana amacıdır. Bu nedenle vajinal muayene sonrası
yapılacak ilk iş hem vakit kaybını hem de doğru tanı oranını arttırmak için ilk olarak transvajinal
ultrasonografik inceleme ve ardından gerekirse hormonal parametreleri (β -hCG, progesteron,
estradiol) istemek olacaktır.

Kaynaklar
Ansan, K. (1989). Duşuk (Abortus) Dogum Bilgisi Cilt 11,3. Baski Istanbul, Qeltut Matbaacilik,
s.876
Canavagh, D. & Comas, HR (1982). Spontaneous abortion. In Danforth DN (ed): Obstetrics and
Gynecology. Philadelphia, Harper & Row Pubs,p.378
Cullen, MT., Green, JJ., Reece, EA., Hobbins JC. (1989). Comparison of transvaginal and
abdominal ultrasound in visualizing the first trimester conceptus. J Ultrasound Med.; 8: 565-
9.
Eriksen, PS., Philipsen, T (1980). Prognosis in threated abortion evaluated by hormone assay
ultrasound scanning. Obstet Gynecol, 55:435.
Fantel, AG., Shepard, TH. (1981). Basic aspects of early (first trimester) abortion. Principles and
Practice of Obstetrics and PerinataIogy, Vol 1. New York, John Wiley & Sons, 1981, p.553
Filly, AR. (1988). The first trimester. In Cullen WP (ed): Ultrasonography in Obstetrics and
Gynecology. Philadelphia, W.B. Saunders Company, p.19
 347
Özolcay, O., & Şık, B. A. (2021). Birinci trimester düşük tehdidi olan hastalarda anembriyonik gebelik, intrauterin eksitus
ve sağlıklı gebeliğin ayırıcı tanısında biyokimyasal parametrelerin yeri. Journal of Human Sciences, 18(3), 342-348.
doi:10.14687/jhs.v18i3.6019

Glass, HR. (1989). Habituel Abortion. In Creasy and Resnic (ed) Matemal-Fetal Medicine:
Principles and Practise. Second edition^ Philadelphia, W.B. Saunders Company, 1989,
p.437
Hertz, JB. (1984). Diagnostic procedures in threatened abortion. Obstet Gynecol, 66:223.
Homan, G., Brown, S., Moran, J., Homan, S., Kerin, J. (2000). Human chorionic gonadotropin as
predictor of outcome in assited reproductive technology prognoces. Fertil Steril; 73 (2): 270-
4.
Hsu, MI., Kolm, P., Leete, J., Dong, KW., Muasher, S., Oehninger, S. (1998). Analysis of
implantation in assisted reproduction through the use of serial human chorionic
gonadotropin measurements. J Assist Reprod Genet; 18 (8): 496-503.
Mantoni, M. (1985). Ultrasound signs in thereated abortion and their prognostic significance. Obstet
Gyncol, 65:471.
Nygren, KG., Johansson, EDB., Wide L. (1973). Evaluation of the prognosis of thereatened
abortion from the peripheral plasma levels of the progesteron, estradiol and human
chorionic gonadotropin. Am J. Obstet Gynecol, 7:116.
Penmell, RG., Nededlenon, L., Pajak, T., Baltarovich, D.(1991). Prospective comparison of vaginal
and abdominal sonography in normal early pregnancy. Ultrasound Med. ; 10: 63-7.
Salem, HT., Ghaneimah S.A., Shaaban M.M., Chard,T. (1984). Prognostic value of biochemical
tests in the assessment of fetal outcome in Threatened Abortion. Br J Obstet Gynaecol;
91(4):382-5.
Scott, RJ. (1986). Spontaneous Abortioa in Danforth ND (ed): Obstetrics & Gynecology： Fifth
edition. Philadelphia, JB. Lippincott Company, p.378
Siiteri, PK., Mac Donald, PC (1966). Placental estrogen biosynthesis during human pregnancy. J.
Clin Endocrin Metab, 26:751.
Sproff, L., Glass, HR., Kase, NG. (1994). Clinical Gynecologic Endocrinology and infertility.
Williams and Wilkins Fifth ed, 251-80.
Stabile, I., Campbell, S., Grudzinskas, J.G. (1989). Ultrasound and circulating placental protein
measurements in complications of early pregnancy. Br. J. Obstet. Gynaecoi, 96, 1182-1191.
Westergaard, J.G., Teisner, B., Sinosich, M.J., Madsen, L.T., Grudzinskas, J.G. (1985). Does
ultrasound examination render biochemical tests obsolete in the prediction of early
pregnancy failure? Br. J. Obstet. Gynaecoi., 92, 77-83.
Witt, BR., Wolf, GC., Weinright, CJ. (1990). Relaxin Cal25, progesteron, estradiol, schwangerschaft
protein and HCG as predictors of outcome in threatened and nonthreatened pregnancies
Fertil Steril, 53:1029-36.
Yovkh, J.L. (1986). Placental hormone and protein measurements during conception cycles and
early pregnancy. In Thomsen,K. and Ludwig.H. (eds), Proceedings of the Xl. World
Congress K. of Gynecology and Obstetrics. Springer-Verlag,Berlin pp 854-857
Yovich, J. L., Willcox, D. L., Grudzinskas, J. G., Bolton.A.E. (1986). The prognostic value of hCG,
PAPP-A , oestradiol-17 beta and progesterone in early human pregnancy. Aust.N.Z. J
Obstet. Gynaecol. ,26,59-64.

Extended English Summary

In this study, it was aimed to establish criteria about the prognosis and life expectancy
of pregnancy by using ultrasonographic imaging techniques and serum β-hCG, Estradiol,
Progesterone levels as hormonal parameters to evaluate embryonic life potential in threatened
miscarriage patients.
Our study consists of 45 pregnant patients who were admitted to Istanbul Taksim Training
and Research Hospital Pregnant Outpatient Clinic due to vaginal bleeding during pregnancy and were
diagnosed as threatened miscarriage. The study is designed in İstanbul Taksim Training and Research
Hospital Obstetrics and Gynecology service, following the approval of the planning and ethics
 348
Özolcay, O., & Şık, B. A. (2021). Birinci trimester düşük tehdidi olan hastalarda anembriyonik gebelik, intrauterin eksitus
ve sağlıklı gebeliğin ayırıcı tanısında biyokimyasal parametrelerin yeri. Journal of Human Sciences, 18(3), 342-348.
doi:10.14687/jhs.v18i3.6019

committee. Patients who did not have an additional gynecological pathology without any systemic
disease and who were absolutely sure of their last menstrual date were included in the study groups.
Pregnant women who were determined to have bleeding after vaginal examination due to a cervical
polyp, erosion or eversion, multiple pregnancies, those diagnosed with ectopic and chemical
pregnancy were excluded from the study. The study group consisted of pregnant women diagnosed
as abortus imminens of 20 weeks or less gestational week compared to the last menstrual date. 10 cc
blood was taken from the antecubital veins of all patients included in the study and analyzed. Estradiol
(E2), Progestrone (P4), β-hCG measurements were made at the same time from all blood samples
collected. Estradiol and progesterone measurements were made with Coast A-Count Estradiol and
Progesterone kits working with solid phase radioimmunoassay technique. β-hCG was measured with
IRMA-mat β-hCG, kits based on the sandwich radioimmunoassay technique. Initially detailed
systemic, gynecological and obstetric anamnesis of each patient were taken and then transvaginal
sonographic pelvic examinations were performed by using Shimadzu brand SDU-350A model real
time linear convex probe ultrasonography device and EUP-V12 model 5mHz vaginal probe. The
main purpose in ultrasonographic examination was to detect fetal heart movements. In early
pregnancies where the embryo was not visible in transvaginal ultrasound examination, the mean
gestational sac diameter (OGKÇ) was found by measuring the size of the gestational sac by 3
dimension and averaging it. Pregnancies in which OGKÇ is over 25 mm, in which fetal heart
movements (FKH) could not be detected, was accepted as an anembryonic pregnancy and
therapeutic curettage was applied. In addition to this examination, ß-hCG, progesterone, estradiol
level blood samples were taken in all groups. If the fetus is visible, CRL and BPD were measured and
fetal heartbeat movements were detected. Embryos larger than 10 mm without fetal cardiac activity
were accepted as missed abortion and curettage was performed. In ultrasonography, if only chorio-
decidual tissue was detected, the embryo and amniotic fluid could not be seen, cervix was
sonographically dilated more than 0.5 cm, is accepted an incomplete abortion. All curettage materials
send to histopathological examination. In the statistical comparison of the data obtained; quantitative
data are presented as mean +/- SD (standard deviation). In addition, Kruskall-Wallis test and Man-
Whitney U test were used.
Of the 45 patients included in the study, 72% resulted in live birth and 28% resulted in
abortion. The group whose pregnancy resulted with live birth and the group whose pregnancy
terminated with spontaneous abortion were statistically compared according to their hormonal
parameters; it was found to be significantly higher in the group that resulted in live birth (p <0.01).
Sensitivity, specificity, negative and positive predictive values of β-hCG, E2, P4 levels were found to
be significant in patients with threatened miscarriage.
Threatened miscarriage treatments have allowed close examination of women likely to
conceive and attention has focused on the conception cycle and events occurring during
early pregnancy, with accurate monitoring of the timing of ovulation and conception. There was
adverse influence of maternal age and abortion history on outcomes in pregnancies with threatened
miscarriages Most studies have demonstrated the potential for hormonal monitoring in the
prediction of pregnancy outcome. Also bleeding amount and characteristics are related with poor
fetal outcome. The threat of miscarriage is an early pregnancy complication that occurs in clinically
established pregnancies as high as 25% and results in approximately 50% miscarriage. It is the
clinician's main goal to determine whether the embryo is alive or not at the time of initial examination
without causing prolonged blood loss, infection and anxious wait. For this reason, the first thing to
do after the vaginal examination would be to request transvaginal ultrasonographic examination first
and then, if necessary, hormonal parameters (β-hCG, progesterone, estradiol) if necessary.
 Laboratorijska študija / Laboratory study

Določanje anevploidij z metodo pomnoževanja od ligacije odvisnih

prob v fetalnih tkivih splavkov
Detection of aneuploidy using multiplex ligation–dependent probe
amplification in fetal tissues from aborted pregnancies

Avtor / Author Boris Zagradišnik1, Špela Stangler Herodež1, Alenka Erjavec-

Škerget1,2, Andreja Zagorac1, Nadja Kokalj-Vokač1,2
Ustanova / Institute 1Univerzitetni klinični center Maribor, Laboratorij za medicinsko genetiko, Maribor, Slovenija,
Univerza v Mariboru, Medicinska fakulteta, Maribor, Slovenija,
2

 University Medical Centre Maribor, Laboratory of Medical Genetics, Maribor, Slovenia,

1

University of Maribor, Faculty of Medicine, Maribor, Slovenia

2

Izvleček Abstract

Ključne besede:
pomnoževanje od ligacije odvisnih
prob, številčne kromosomske
preureditve, kariotip
Key words:
multiplex ligation–dependent
probe amplification; numeric
chromosome aberration;
karyotype
Članek prispel / Received
26.01.2011
Članek sprejet / Accepted
30.09.2011
Naslov za dopisovanje /
Correspondence
Špela Stangler Herodež
Univerzitetni klinični center Maribor,
Laboratorij za medicinsko genetiko,
Ljubljanska 5, SI –2000 Maribor,
Slovenija
Telefon +386 23212737,
Faks: +386 23212755,
E–pošta: spela.sh@ukc–mb.si
Namen: Spontani splavi se pojavlja-
jo v približno 10–15% prepoznavnih
nosečnosti. V prvem trimesečju je pri-
bližno ≈50% splavov posledica kromo-
somskih napak, v večini primerov so to
kromosomske anevploidije. Klasična
metoda določanja anevploidij je citoge-
netska analiza. Citogenetska analiza
zgodnjih spontanih splavov je težavna
zaradi pogoste odsotnosti celične rasti
ali slabe kvalitete kromosomov. V teh
primerih se poslužujemo drugih metod,
neodvisnih od rasti celične kulture.
V študiji smo uporabili metodo po-
množevanja od ligacije odvisnih prob
(MLPA). V primerjavi s klasično ci-
togenetsko analizo smo na vzorcu em-
brionalnih tkiv potrdili ustreznost in
kompatibilnost metode.
Metode: Vsi vzorci embrionalnih tkiv
po spontanih splavih so bili kultivira-
ni, kariotipizirani, prav tako je bila
izolirana genomska DNA. Za MLPA
Purpose: About 10–15% of all
pregnancies terminate as spontane-
ous miscarriages. In the first trimes-
ter, ≈50% of spontaneous miscar-
riages are the result of chromosomal
aberrations, mostly chromosomal an-
euploidies. Cytogenetic analyses are
used to confirm aneuploidy in failed
pregnancies. Culture failure or poor–
quality chromosomes are often prob-
lems in those cases. In such situa-
tions, methods that are independent
of tissue culture are used, and we
employed multiplex ligation–depen-
dent probe amplification (MLPA).
We determined if MLPA is an ap-
propriate and compatible method
compared with classical cytogenetic
analyses on fetal tissues.
Methods: All fetal samples received
from spontaneous abortions were cul-
tured, karyotyped (if possible) and
genomic DNA extracted. MLPA

ACTA MEDICO–BIOTECHNICA 51
2011; 4 (2): 51–60
 Laboratorijska študija / Laboratory study
analizo smo uporabili komercialne komplete s subtelomerno
specifičnimi DNA sondami. V primeru odsotnosti celične ra-
sti so bile anevploidije ugotovljene z MLPA analizo, potrjene
s primerjalno genomsko hibridizacijo (PGH).
Rezultati: MLPA analiza je potrdila neuravnotežene kro-
mosomske nepravilnosti, ugotovljene s citogenetsko analizo
pri vseh vzorcih, kjer je bila uspešna celična rast, in hkrati
omogočila analizo v primerih, kjer celična rast ni bila uspe-
šna. Ugotovljene so bile mnoge številčne kromosomske spre-
membe, redke trisomije in druge neuravnotežene kromosom-
ske preureditve.
Zaključek: MLPA analiza omogoča pridobitev informacij
o številu kromosomov v primerih, ko citogenetska analiza ni
možna zaradi odsotnosti celične rasti ali slabe kvalitete kro-
mosomov. Iz dobljenih rezultatov ugotavljamo, da je MLPA
potencialno tudi zelo uporabna metoda za hitro in kvalite-
tno prenatalno diagnostiko.
INTRODUCTION
Chromosome aberrations are the most important
cause of abnormal development in early human life.
Aneuploidy is present in ≈60% of spontaneous abor-
tions, which occur predominantly in the first trimes-
ter (1). Most cases (>85%) are due to numeric abnor-
malities (which include autosomal trisomies and 45,X,
monosomy) as well as polyploidy, whereas structural
chromosomal changes can be observed in ≈5% (2, 3).
Chromosome aberrations are also frequently detected
in pregnancies with diagnosed congenital anomalies,
and are an important reason for elective late termina-
tions of pregnancy (2, 4).
After >30 years of successful application, cytogenetic
analyses remain the method of choice for the identifi-
cation of aneuploidy. Despite being time–consuming,
labor–intensive and tissue culture–dependent, karyo-
typing is the “gold” standard and all other methods
can be used only as rapid screening methods preced-
ing it (5). Different approaches have been developed
to detect aneuploidy faster and without employing tis-
sue culture (6). Quantitative–fluorescent polymerase
chain reaction (QF–PCR) (7) and interphase fluores-
52 ACTA MEDICO–BIOTECHNICA
2011; 4 (2): 51–60
analyses were undertaken using subtelomeric probe kits.
Additionally, comparative genomic hybridization (CGH)
was used to confirm aneuploidy detected by MLPA in
cases of failed culture growth.
Results: MLPA analyses confirmed an unbalanced chro-
mosome abnormality identified by cytogenetic analyses
in all cases in which tissue culture was successful, and
provided data in cases of failed culture growth. Several
common numeric chromosome aberrations were detected,
as well as rare trisomies and other unbalanced chromo-
some rearrangements.
Conclusions: MLPA analyses can provide informa-
tion about the karyotype of a DNA sample if cytogenetic
analyses are not possible because of a lack of viable cells
or if only a small amount of genomic DNA is available.
These data indicate that MLPA may also be a very useful
method for early prenatal aneuploidy screening.
cent in–situ hybridization (interphase FISH) (8) are
the most frequently used methods for rapid detection
of trisomies of chromosomes 13, 18 and 21, as well
as numerical aberrations of sex chromosomes. Both
methods have been extensively tested and have a place
in routine prenatal genetic laboratory analyses (9–13).
QF–PCR and FISH are usually employed to detect the
most common trisomies, but each method can also
identify other numeric chromosome aberrations (14,
15). Among available methods, comparative genom-
ic hybridization can be used to detect chromosome
aberrations (16, 17), whereas real–time PCR (18, 19)
has been adopted for identification of aneuploidy.
Increasingly popular array–based methods such as ar-
ray– comparative genomic hybridization (CGH) anal-
yses can also provide a wealth of information on the
number and structure of chromosomes (20, 21, 22).
The spectrum of methods that can be used to identify
aneuploidy has been recently augmented by multiplex
ligation–dependent probe amplification (MLPA) (23).
MLPA was developed for accurate detection of copy
number variations in a sample of extracted nucleic ac-

ids. Up to 50 loci can be simultaneously analyzed in
a single MLPA reaction, and quantitative differences
in the genetic material present in prenatal aneuploidy
cases can be readily and reliably detected. MLPA has
been successfully used for the screening of the most
common aneuploidies (trisomies of chromosomes 13,
18, and 21) (24, 25) in amniotic fluid samples. For this
analysis, kits containing chromosome–specific probes
(P001, P095) are available from the manufacturer:
MRC–Holland (Amsterdam, the Netherlands; www.
mrc–holland.com). However, a single MLPA reaction
enables the quantification of all chromosomes if kits
with subtelomeric probes (P019/P020, P036B, P069,
P070; MRC–Holland) are used for the analysis. These
kits were developed for the analysis of subtelomeric
regions of chromosomes that are prone to variation
in copy number (26). The kits (which contain probes
from all subtelomeric regions) have been used in stud-
ies of idiopathic mental retardation in humans (27,
28). In the case of an altered number of a particular
chromosome, MLPA analyses with a subtelomeric kit
would show a change in the quantity of both specific
probes, which are located on different arms of the
chromosome. In addition, any unbalanced structural
chromosome rearrangements that involve subtelo-
meric regions would be observed. Therefore, a single
MLPA reaction should permit the detection of ≈80%
(2, 5) of prenatal chromosome aberrations.
In the present study, the ability of MLPA to identify
aneuploidy was compared with cytogenetic analyses
on fetal tissues from terminated pregnancies.
MATERIAL AND METHODS
Ethical approval of the study protocol
Ethical approval was granted from University Clini-
cal Centre Maribor (Maribor, Slovenia). All patients
provided written informed consent to be involved in
the study.
Samples
A total of 71 cases of spontaneously aborted preg-
nancies or induced abortions because of diagnosed
severe malformations were included. Tissue samples
were chorionic villi or fetal skin. These samples are
Laboratorijska študija / Laboratory study
routinely sent for karyotyping in the Medical Genet-
ics Laboratory, Maribor Teaching Hospital (Maribor,
Slovenia). Samples of peripheral venous blood were
obtained from parents for karyotyping in several cases
to clarify the results of fetal tissue analyses.
Cytogenetic analyses
Fetal tissues and blood were cultured and chromo-
somes harvested according to standard cytogenetic
procedures. They were analyzed by the GTG banding
method (G bands produced with Giemsa and trypsin).
DNA extraction
Genomic DNA was extracted from tissue samples us-
ing a modified method (29). Briefly, ≤100 mg of fe-
tal tissue was incubated overnight in lysis buffer (5%
sodium dodecyl sulfate (SDS), 10 mM NaCl, 10 mM
tris–HCl, 166.7 µg/ml proteinase K) at 37˚C. DNA
was then precipitated from the supernatant after the
addition of 9.5 M ammonium acetate and ice–cold 2–
propanol. It was then dried and dissolved in Tris–eth-
ylenediamine tetra–acetic acid (EDTA) storage buffer
(10 mM Tris–HCl, 1 mM EDTA).
MLPA
MLPA was undertaken using commercial MLPA
kits containing subtelomeric probes (P0036B, P070;
MRC Holland) according to manufacturer protocols
(23). Briefly, probe hybridization on sample DNA
was carried out overnight, followed by ligation of an-
nealed probes using a thermostable ligase enzyme.
The ligation products were amplified by PCR with
one D4–labeled and one unlabeled oligonucleotide.
The analysis of PCR products was done using a Beck-
man–Coulter CEQ8000 capillary electrophoresis sys-
tem (Beckman–Coulter, Brea, CA, USA). All samples
were tested with both kits, and samples with an abnor-
mal result were retested to confirm the MLPA analysis.
Analyses of MLPA data
Data from capillary electrophoresis were processed
with CEQ8000 software for fragment analyses. These
data were then exported to a Microsoft Excel spread-
sheet program to complete the analyses. To produce
normalized ratios reflecting the relative probe dosage,
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 Laboratorijska študija / Laboratory study

each peak area was divided by the sum of all peaks Table 1. Clinical data on included samples
from the sample trace. For each probe, this ratio was Number of cases 71
divided by the same ratio from an unaffected control
Chorionic villi 34
DNA run in the same experiment. An expected nor-
Fetal skin 37
malized value of 1.0, a ratio <0.8 in the case of a dele-
tion (monosomy) and a ratio >1.3 for a duplication IVF procedures 10
(trisomy) were adopted for the study. Duration of gestation (weeks) 14.7 (range, 7–34)

Spontaneous abortion 47
CGH
Artificial termination of pregnancy 24
Samples with abnormal MLPA results but unavailable
karyotypes were also analyzed by CGH for additional Average maternal age (years) 32.2 years
(range, 23–45)
confirmation. CGH was done as described previously
(30). Briefly, the patient’s DNA and normal reference
DNA were labeled with Spectrum Green and Spec- methods were used to identify: 19 normal female
trum Orange (Vysis, Chicago, IL, USA). A total of karyotypes (46,XX); 10 normal male karyotypes
1 µg of DNA and 30 µg Cot1 DNA were hybridized (46,XY); 4 trisomies of chromosome 21; 2 trisomies
to normal metaphase chromosomes. Slides were hy- of chromosome 18, 2 monosomies of chromosome X;
bridized for 3 days, washed and counterstained with 1 double trisomy of chromosomes 20 and 21 (Figure
4,6–diamidino–2–phenylindole (DAPI). CGH image 1); 1 trisomy of chromosome 16; 1 trisomy of chro-
capture was undertaken with the Cytovision system
(Applied Imaging, San Jose, CA, USA) interfaced
with a fluorescence microscope (Axioplan; Zeiss,
Oberkochen, Germany). In each case, ≥10 metaphas-
es were analyzed. The average green–to–red ratio fluo-
rescence intensity ratio profile was calculated for each
chromosome. In regions of normal sequence copy
numbers, the average green–to–red ratio was found to
be ≈1.0. Chromosomal regions with a ratio >1.2 were
considered to be gained, whereas regions with a ratio
below 0.8 were deemed to be deleted (31).

RESULTS
A total of 71 samples of fetal tissue (Table 1), 34 sam-
ples of chorionic villi and 37 samples of fetal skin re-
ceived from the Gynecology and Perinatology Depart-
ment of Maribor Teaching Hospital were included in
the study. In 10 cases, pregnancy was achieved using
IVF procedures. The mean duration of gestation was
14.71 weeks (range, 7–34 weeks). The pregnancy was
artificially terminated in 24 cases, whereas it ended
spontaneously in 47 cases. The mean age of women
was 32.24 years (range, 23–45 years).
Cytogenetic analyses were undertaken in 53 cases,
whereas in 18 cases tissue culture was unsuccessful.
MLPA analyses were done on all 71 samples. Both
Figure 1. Trisomies of chromosome 20 and 21 in
samples of female fetal tissue. (a) Case electropho-
retogram: arrows point to absent signals from Yq11–
specific probes and to increased signals from 20ptel–,
20qtel–, 21q11– and 21qtel–specific probes compared
with control signals (kit P036B; MRC–Holland). (b)
Control electrophoretogram. (c) Graphic presentation
of ratios between the case and the control. (d) Karyo-
type 48,XX,+20,+21.

54 ACTA MEDICO–BIOTECHNICA
2011; 4 (2): 51–60

mosome 15; 1 trisomy of chromosome 12; 1 trisomy
of chromosome 2; 1 case of 47,XXX; and 1 case of
47,XXY. Both unbalanced chromosome rearrange-
ments (45,XY,der(14),t(14;18)(q10;q10), 46,XX,del(4)
(q32.2),dup(16)(qtel)) (Figure 2) were correctly de-
tected by MLPA as quantitative changes in the sub-
telomeric regions of the rearranged chromosomes.
Additional cytogenetic analyses of the parents showed
that the rearrangement between chromosomes 14
and 18 was de novo, whereas the rearrangement be-
tween chromosomes 4 and 16 was inherited from the
father. MLPA analyses identified a possible trisomy
of chromosome 21, but the existence of isochromo-
some i(21q) was not observed. Karyotyping detected
1 case with 46,XY,inv(2) and 2 cases of pericentric
inversion on chromosome 9 (46,XX,inv(9)(p11;q13);
46,XY,inv(9)(p11;q13)), which could not be detected
by MLPA analyses. In 1 case of XX/XY mosaicism ob-
served on cytogenetic analyses, MLPA analyses yielded
Figure 2. Partial monosomy of 4q and partial triso-
my of 16q in samples of female fetal tissue. (a) Case
electrophoretogram: arrows point to absent signals
from Yq11–specific probes, to a decreased signal from
the 4qtel–specific probe, and to an increased signal
from the 16qtel–specific probe when compared with
control signals (kit P070; MRC–Holland). (b) Con-
trol electrophoretogram. (c) Graphic presentation of
ratios between the case and the control; d) karyotype
46,XX,del(4)(q32.2),dup(16)(qtel) (father’s karyotype
was 46,XY,t(4;16)(q32.2;q24)).
Laboratorijska študija / Laboratory study
a result compatible with a normal male karyotype (sig-
nals for chromosome Y–specific probes were ≥1.0). In
addition, a normal female karyotype was found on
MLPA analyses to correspond to a normal male (chro-
mosome Y–specific signals were not decreased; data
not shown).
In 18 cases with failed tissue culture in which a cyto-
genetic result could not be obtained, MLPA analyses
identified 10 normal females, 4 normal males and 4
chromosomal abnormalities: 1 trisomy of chromo-
some 16, 1 trisomy of chromosome 13, 1 trisomy of
chromosome 10 (Figure 3) and 1 duplication of the
3qtel region (Figure 4). CGH analyses confirmed the
presence of excess chromosomal material in these four
cases (Figures 3 and 4). Duplication of the 3q subtelo-
meric region corresponded to the possible karyotype
46,XY,der(15),t(3,15)(q26.2;p11.2), which occurred
because the mother was a carrier of the 46,XX,t(3;15)
(q26.2;p11.2) chromosome rearrangement.
Figure 3. Trisomy of chromosome 10 in samples of
male fetal tissue (possible karyotype 47,XY,+10).
(a) Case electrophoretogram: arrows point to signals
from Yq11–specific probes and increased signals from
10qtel– and 10ptel–specific probes when compared
with control signals (kit P070; MRC–Holland). (b)
Control electrophoretogram. (c) Graphic presentation
of ratios between the case and control. (d) CGH den-
sitograms: gain of whole chromosome 10, presence of
whole chromosome Y and loss of whole chromosome X
(control DNA was normal female; CGH analyses were
done on male chromosome spreads).
ACTA MEDICO–BIOTECHNICA 55
2011; 4 (2): 51–60
 Laboratorijska študija / Laboratory study
Figure 4. Partial trisomy of 3q in samples of male
fetal tissue (possible karyotype 46,XY,der(15),t(3,15)
(q26.2;p11.2); mother’s karyotype 46,XX,t(3;15)
(26.2;p11.2)). (a) Case electrophoretogram: arrows point
to signals from Yq11–specific probes and an increased
signal from the 3qtel–specific probe when compared with
control signals (kit P070; MRC–Holland). (b) Control
electrophoretogram. (c) Graphic presentation of ratios be-
tween the case and control. (d) CGH densitograms: gain
of 3q, presence of whole chromosome Y and loss of whole
chromosome X (control DNA was normal female; CGH
analyses were done on male chromosome spreads).
DISCUSSION
We evaluated the ability of MLPA to detect unbal-
anced chromosome rearrangements in fetal tissue
samples. The MLPA method was compared with
the gold–standard method: cytogenetic analyses.
All quantitative changes of chromosomal material
found by cytogenetic analyses were successfully iden-
tified by MLPA analyses (Table 2). Although MLPA
has been used to detect aneuploidy in fetal samples
(amniotic fluid) (24, 25), our results showed that a
single MLPA reaction could be used to identify all
unbalanced numerical chromosome abnormalities
in a test sample of DNA. Because this type of genetic
change is by far the most important in spontaneous
abortions, MLPA may be used as an alternative to
karyotyping of fetal tissues from terminated preg-
nancies.
56 ACTA MEDICO–BIOTECHNICA
2011; 4 (2): 51–60
MLPA analyses also successfully identified 3 cases of
unbalanced structural chromosomal rearrangements
(Table 2). The identification succeeded because subtelo-
meric regions were involved and the MLPA kits used
included probes from these regions. Some unbalanced
rearrangements can be identified by MLPA as a change
in a single signal (peak) (Figure 4). These results have
to be differentiated from false–positives which can be
observed in MLPA analyses or from common polymor-
phisms typical of subtelomeric regions (32). To clarify
such findings, MLPA kits with different probes can be
used or another method (i.e., CGH) can be applied. If
both available MLPA subtelomeric kits (P036B, P070)
are used and they provide concordant abnormal re-
sults for a single chromosome arm, this indicates the
presence of a copy number change of that particular
subtelomeric region. The physical size of the affected
DNA fragment may be >50 kbp (see product manuals
for probe locations at www.mrc–holland.com). Such
results in fetal tissue from a failed pregnancy warrant
further investigation of the parents, including karyo-
typing. In 2 of the 3 cases, one of the parents was the
carrier of a balanced reciprocal translocation and preg-
nancy failure was the consequence of inheritance of an
unbalanced set of chromosomes (Table 2).
Although subtelomeric regions are involved in most
cases of unbalanced translocations, other rearrange-
ments are also possible. MLPA analyses, as used in
the present study, cannot be used to detect chromo-
some changes that are present elsewhere along the
chromosomes. With cytogenetic analyses, 2 cases of
pericentric inversion on chromosome 9 and 1 pericen-
tric inversion on chromosome 2 were detected. More
importantly, MLPA analyses also failed to detect the
presence of an isochromosome, i(21q), although the
additional copy of the long arm of chromosome 21
was correctly identified (Table 2). In the case with a
karyotype 46,XX,i(21q), further investigation of the
parents is warranted. One of them may be a carrier
of the isochromosome and the necessary karyotyping
may be omitted if only the MLPA result is available.
Another important chromosome abnormality, poly-
ploidy, would also be missed by MLPA analyses (2, 5).
If fetal cells contain at least one additional complete set
of chromosomes, then MLPA analyses would not de-
 Laboratorijska študija / Laboratory study

Table 2. Results of karyotyping and MLPA analyses

MLPA
Karyotype MLPA Cases
Yq11
46,XX No change — 19
46,XY No change + 10
46,XX No change + 1
46,XX/46,XY No change + 1
46,XX, No change — 1
inv(9)(p11q13)
46,XY, No change + 1
inv(9)(p11q13)
48,XX,+20,+21 Gain 20ptel, gain 20qtel, — 1
Gain 21q11, gain 21qtel
47,XX,+21 Gain 21q11, gain 21qtel — 2
47,XY,+21 Gain 21q11, gain 21qtel + 2
46,XX,i(21q) a Gain 21q11, gain 21qtel — 1
47,XX,+18 Gain 18ptel, gain 18qtel — 2
47,XY,+16 Gain 16ptel, gain 16qtel + 1
47,XX,+15 Gain 15q11, gain 15qtel — 1
47,XY,+13 Gain 13q11, gain 13qtel + 1
47,XX,+12 Gain 12ptel, gain 12qtel — 1
47,XX,+2 Gain 2ptel, gain 2qtel — 1
47,XXY Gain Xptel/Yptel, + 1
Gain Xqtel/Yqtel
47,XXX Gain Xptel/Yptel, — 1
Gain Xqtel/Yqtel
45,X Loss Xptel/Yptel, — 2
Loss Xqtel/Yqtel
46,XY,inv(2) a No change + 1
45,XY,der(14), Loss 18ptel + 1
t(14;18)(q10;q10) b
46,XX, Loss 4qtel, gain 16qtel + 1
del(4)(q32.2),dup(16)(qtel) c
No growth Gain 16ptel, gain 16qtel d + 1
No growth Gain 13q11, gain 13qtel d + 1
No growth Gain 10ptel, gain 10qtel d + 1
No growth Gain 3qtel d, e + 1
No growth No change — 10
No growth No change + 4
Total 71
a
No data available from parents
b
de novo rearrangement
c
Father’s karyotype was 46,XY,t(4;16)(q32.2;q24)
d
Confirmed using CGH
e
Mother’s karyotype was 46,XX,t(3;15)(26.2;p11.2)

tect such a change. The ability to identify quantitative
changes of loci using MLPA is dependent upon rela-
tive differences between analyzed loci (23). Polyploidy
represents an absolute increase of the entire genome
and is, as such, not identifiable by MLPA analyses.
Other approaches may be considered for the detection
of polyploidy (i.e., flow cytometry) (33). If these limita-
tions are considered, it is obvious that an important
segment of chromosome changes will be missed if the
MLPA analysis is not accompanied by karyotyping.

ACTA MEDICO–BIOTECHNICA 57
2011; 4 (2): 51–60
 Laboratorijska študija / Laboratory study
In cases of contamination of maternal cells, in
which a mosaic karyotype was detected by cytoge-
netic analyses (Table 2), the MLPA results suggested
a male karyotype. It is likely that contamination of
maternal cells was minimal or below the level of de-
tection by the MLPA method. In one case, a female
karyotype was observed after cytogenetic analyses,
whereas MLPA confirmed a chromosome Y–positive
karyotype. This observation was probably due to live
maternal cells besides the non–viable fetal male cells
in the tissue sample. Only the maternal cells grew,
and therefore the culture was karyotyped as a nor-
mal female. Such discordant observations point to
a possible problem of tissue culture in cytogenetic
analyses: an in vitro–induced change can influence
the final result. MLPA analyses are not affected
because genomic DNA extracted before the tissue
culture is used. Therefore, MLPA could be used to
clarify the status of certain suspicious abnormalities
detected by cytogenetic analyses.
A successful tissue culture is essential to karyotype fe-
tal tissues from terminated pregnancies. This is not
always achievable because the available tissue might
no longer be viable (e.g., due to asphyxia) or fetal cells
with a major chromosome abnormality may not grow
readily in culture (34, 35). This problem has been ad-
dressed using other methods capable of detecting an-
euploidy without the need for tissue culture (14, 22,
33). In the present study, cytogenetic analyses could
not be carried out in 18 out of 71 samples because
there was growth of fetal cells was absent. With MLPA
analyses, we could detect an additional 4 cases of an-
euploidy, which were confirmed by CGH (Table 2;
Figures 3 and 4). Consequently, a major shortcoming
of cytogenetic analyses, i.e., culture failure, has been
resolved by MLPA analyses. Combination of the two
methods may represent a sensible approach for han-
dling such cases by first screening with MLPA, then
independent confirmation of abnormal findings. We
used CGH even though other methods are also avail-
able. Consequently, the present study indicated that
numeric chromosome aberrations (trisomies, mono-
somies) could be reliably detected by MLPA if both
subtelomeric chromosome–specific probes exhibited
similar quantitative differences (Figure 1). This crite-
58 ACTA MEDICO–BIOTECHNICA
2011; 4 (2): 51–60
rion was sufficiently stringent to identify all detectable
abnormalities and to eliminate false–positive results.
The results of the present study suggested that MLPA
analyses could be used to detect nearly all the important
chromosome abnormalities present in fetal tissues from
terminated pregnancies that would be found by cytoge-
netic analyses with the notable exception of polyploidy.
Therefore MLPA is suitable as a rapid and sensitive sup-
plementary technique to cytogenetic analyses. Recently
developed and increasingly popular microarray–based
methods are quickly becoming invaluable tools for cy-
togenetic analyses (20, 21, 22). The amount of informa-
tion about chromosome structure obtained by MLPA
analyses is not comparable with the wealth of data that
can be provided by microarray–based techniques (e.g.,
array CGH). However, MLPA is a 24–h procedure and
the setup is simple, with all the necessary chemicals be-
ing included in the commercial kits. In addition, the
necessary equipment is identical to that required for
QF–PCR. Hence, any laboratory offering QF–PCR for
rapid detection of aneuploidy could also readily deploy
MLPA analyses. Finally, the cost of MLPA analyses is
significantly lower than the cost of microarray– based
methods.
In conclusion, MLPA analyses using subtelomeric
probe sets from all chromosomes can be used to detect
numeric chromosome abnormalities and unbalanced
structural changes that involve subtelomeric regions.
Although MLPA analyses cannot be used to identify
the entire spectrum of aberrations detectable by cyto-
genetic analyses, they can provide substantial informa-
tion on the structure and quantity of chromosomes.
In addition, MPLA can overcome the limitations of
karyotyping that result from problems with tissue cul-
turing. The procedure is simple to set up, relatively
inexpensive to operate, and easy to integrate into the
workflow of a routine genetic laboratory.
ACKNOWLEDGMENTS
The authors thank the contributing members of the
Gynecology and Perinatology Department of the Mari-
bor Teaching Hospital. This study was supported by
the Ministry of Science, Republic of Slovenia (grant
number 3311–03–831775).

References
1. Burgoyne PS, Holland K, Stephens R. Incidence
of numerical chromosome anomalies in human
pregnancy estimation from induced and spontane-
ous abortion data. Hum Reprod. 1991; 6: 555–65.
2. Milunsky A (ed). Genetic disorders and the fetus.
Baltimore The Johns Hopkins University Press.
1992.
3. Menasha J, Levy B, Hirschhorn K, Kardon NB. In-
cidence and spectrumof chromosome abnormali-
ties in spontaneous abortions: New insights from
a 12–year study. Genet Med. 2005; 7: 251–63.
4. Drummond CL, Gomes DM, Senat MV, Audibert F,
Dorion A, Ville Y. Fetal karyotyping after 28 weeks
of gestation for late ultrasound findings in a low risk
population. Prenat Diagn. 2003; 23: 1068–72.
5. Caine A, Maltby AE, Parkin CA, Waters JJ, Crolla JA;
UK Association of Clinical Cytogeneticists (ACC).
Prenatal detection of Down’s syndrome by rapid an-
euploidy testing for chromosomes 13, 18, and 21 by
FISH or PCR without a full karyotype: a cytogenetic
risk assessment. Lancet. 2005; 366: 123–8.
6. Mann K, Doanghue C, Fox SP, Docherty Z, Ogil-
vie CM. Strategies for rapid prenatal diagnosis of
chromosome aneuploidy. Eur J Hum Genet. 2004;
12: 907–15.
7. Mansfield ES. Diagnosis of Down syndrome and
other aneuploidies using quantitative polymerase
chain reaction and small tandem repeat polymor-
phisms. Hum Mol Genet. 1993; 2: 43–50.
8. Klinger K, Landes G, Shook D, Harvey R, Lopez
L, Locke P et al. Rapid detection of chromosome
aneuploidies in uncultured amniocytes by using
fluorescence in situ hybridization (FISH). Am J
Hum Genet. 1992; 51: 55–65.
9. Evans MI, Henry GP, Miller WA, Bui TH, Snidjers
RJ, Wapner RJ et al. International, collaborative
assessment of 146,000 prenatal karyotypes: ex-
pected limitations if only chromosome–specific
probes and fluorescent in–situ hybridization are
used. Hum Reprod. 1999; 14: 1213–6.
10. Mann K, Fox SP, Abbs SJ, Yau SC, Scriven PN,
Docherty Z et al. Development and implementa-
tion of a new rapid aneuploidy diagnostic service
Laboratorijska študija / Laboratory study
within the UK National Health Service and implica-
tions for the future of prenatal diagnosis. Lancet.
2001; 358: 1057–61.
11. Hulten MA, Dhanjal S, Pertl B. Rapid and simple
prenatal diagnosis of common chromosome disor-
ders: advantages and disadvantages of the molec-
ular methods FISH and QF–PCR. Reproduction.
2003; 126: 279–97.
12. Leung WC, Waters JJ, Chitty L. Prenatal diagnosis
by rapid aneuploidy detection and karyotyping: a
prospective study of the role of ultrasound in 1589
second–trimester amniocenteses. Prenat Diagn.
2004; 24: 790–5.
13. Liehr T, Ziegler M. Rapid prenatal diagnostics in
the interphase nucleus: procedure and cut–off
rates. J Histochem Cytochem. 2005; 53: 289–91.
14. Lebedev IN, Ostroverkhova NV, Nikitina TV, Sukh-
anova NN, Nazarenko SA. Features of chromo-
somal abnormalities in spontaneous abortion cell
culture failures detected by interphase FISH analy-
sis. Eur J Hum Genet. 2004; 12: 513–20.
15. Diego–Alvarez D, Garcia–Hoyos M, Trujillo MJ,
Gonzalez–Gonzalez C, Rodriguez de Alba M,
Ayuso C et al. Application of quantitative fluores-
cent PCR with short tandem repeat markers to the
study of aneuploidies in spontaneous miscarriag-
es. Hum Reprod. 2005; 20: 1235–43.
16. Yu LC, Moore DH 2nd, Magrane G, Cronin J, Pin-
kel D, Lebo RV et al. Objective aneuploidy detec-
tion for fetal and neonatal screening using com-
parative genomic hybridization (CGH). Cytometry.
1997; 28: 191–7.
17. Daniely M, Barkai G, Goldman B, Aviram–Gold-
ring A. Detection of numerical chromosome ab-
errations by comparative genomic hybridization.
Prenat Diagn. 1999; 19:100–4.
18. Zimmermann B, Holzgreve W, Wenzel F, Hahn S.
Novel real–time quantitative PCR test for trisomy
21. Clin Chem. 2002; 48: 362–3.
19. Hu Y, Zheng M, Xu Z, Wang X, Cui H. Quantitative
real–time PCR technique for rapid prenatal diag-
nosis of Down syndrome. Prenat Diagn. 2004; 24:
704–7.
ACTA MEDICO–BIOTECHNICA 59
2011; 4 (2): 51–60
 Laboratorijska študija / Laboratory study
20. Schaeffer AJ, Chung J, Heretis K, Wong A, Led-
better DH, Lese Martin C. Comparative genomic
hybridization–array analysis enhances the detec-
tion of aneuploidies and submicroscopic imbal-
ances in spontaneous miscarriages. Am J Hum
Genet. 2004; 74: 1168–74.
21. Rickman L, Fiegler H, Carter NP, Bobrow M. Pre-
natal Diagnosis by Array–CGH. Eur J Med Genet.
2005; 48: 232–40.
22. Benkhalifa M, Kasakyan S, Clement P, Baldi M,
Tachdjian G, Demirol A et al. Array comparative
genomic hybridization profiling of first–trimester
spontaneous abortions that fail to grow in vitro.
Prenat Diagn. 2005; 25: 894–900.
23. Schouten JP, McElgunn CJ, Waaijer R, Zwijnen-
burg D, Diepvens F, Pals G. Relative quantifica-
tion of 40 nucleic acid sequences by multiplex
ligation–dependent probe amplification. Nucleic
Acids Res. 2002 ; 30: 57–60.
24. Slater HR, Bruno DL, Ren H, Pertile M, Schouten
JP, Choo KH. Rapid, high throughput prenatal de-
tection of aneuploidy using a novel quantitative
method (MLPA). J Med Genet. 2003; 40: 907–12.
25. Gerdes T, Kirchhoff M, Lind AM, Larsen GV,
Schwartz M, Lundsteen C. Computer–assisted
prenatal aneuploidy screening for chromosome
13, 18, 21, X and Y based on multiplex ligation–
dependent probe amplification (MLPA). Eur J Hum
Genet. 2005; 13: 171–5.
26. Flint J, Thomas K, Micklem G, Raynham H, Clark
K, Doggett NA et al. The relationship between
chromosome structure and function at a human
telomeric region. Nat Genet. 1997; 15: 252–7.
27. Rooms L, Reyniers E, Van Luijk R, Scheers S,
Wauters J, Ceulemans B et al. Subtelomeric dele-
tions detected in patients with idiopathic mental
retardation using multiplex ligation–dependent
probe amplification (MLPA). Hum Mutat. 2004;
23: 17–21.
60 ACTA MEDICO–BIOTECHNICA
2011; 4 (2): 51–60
28. Koolen DA, Nillesen WM, Versteeg MH, Merkx
GF, Knoers NV, Kets M et al. Screening for sub-
telomeric rearrangements in 210 patients with un-
explained mental retardation using multiplex liga-
tion dependent probe amplification (MLPA). J Med
Genet. 2004 ; 41: 892–9.
29. Miller SA, Dykes DD, Polesky HF. A simple salt-
ing out procedure for extracting DNA from human
nucleated cells. Nucleic Acids Res. 1988; 16:
1215–19.
30. Kallioniemi A, Kallioniemi OP, Sudar D, Rutovitz D,
Gray JW, Waldmann F et al. Comparative genomic
hybridization for molecular cytogenetic analysis of
solid tumors. Science.1992; 258: 818–21.
31. Kirchoff M, Rose H, Lundsteen C. Deletions be-
low 10 megabase pairs are detected in compara-
tive genomic hybridization by standard reference
intervals. Genes Chromosomes Cancer. 1999;
25: 410–3.
32. Knight SJ, Lese CM, Precht KS, Kuc J, Ning Y, Lu-
cas S et al. An optimized set of human telomere
clones for studying telomere integrity and archi-
tecture. Am J Hum Genet. 2000; 67: 320–32.
33. Lomax B, Tang S, Separovic E, Phillips D, Hillard E,
Thomson T et al. Comparative genomic hybridiza-
tion in combination with flow cytometry improves
results of cytogenetic analysis of spontaneous
abortions. Am J Hum Genet. 2000; 66: 1516–21.
34. Persutte WH, Lenke RR. Failure of amniotic–flu-
id–cell growth: is it related to fetal aneuploidy?
Lancet. 1995; 345: 96–7.
35. Lam YH, Tang MH, Sin SY, Ghosh A. Clinical sig-
nificance of amniotic–fluid–cell culture failure.
Prenat Diagn. 1998; 18: 343–7.

ISSN 2548-2246 (online)
ISSN 2442-9139 (print)
Edited by:
Paramitha Amelia K
Reviewed by:
Evi Wahyuntari
*Correspondence: Safira Zakira
safirazakira-2017@fk.unair.ac.id
Received : 30 Desember 2020
Accepted : 05 Januari 2021
Published : 05 April 2021
Citation : Safira Zakira (2021)
Risk Factors Associated with
Spontaneous Abortion in Dr.
Soetomo General Hospital
Surabaya : a Case-control Study .
7:1. doi:
10.21070/midwiferia.v%vi%i.112
5 supervision.
Midwiferia Jurnal Kebidanan | https://journal.umsida.ac.id/index.php/midwiferia
RESEARCH ARTICLE
Published: 05 April 2021
DOI : 10.21070/midwiferia.v%vi%i.1125
Risk Factors Associated with Spontaneous Abortion in
Dr. Soetomo General Hospital Surabaya: a Case-control
Study
Safira Zakira1), Gatut Hardianto
1)
Fakultas Kedokteran Universitas Airlangga Surabaya
ABSTRAK
The Maternal Mortality Ratio (MMR) in Indonesia is still fairly high. One of
the top three causes of maternal death is bleeding. Spontaneous abortion is an
early pregnancy problem leading to the occurrence of bleeding and direct
maternal death. The causes of spontaneous abortion vary and can be caused by
multiple factors. Early identification of risk factors is necessary to reduce
mortality and morbidity due to spontaneous abortion and its complications. This
study's objective was to identify the risk factors of spontaneous abortion in Dr.
Soetomo General Hospital. This study was an observational analytic with a
case-control approach. The population was all pregnant women hospitalized at
the Obstetrics and Gynaecology Department in Dr. Soetomo General Hospital
from January 2017 to December 2018. The samples were 120 in total, included
40 cases and 80 controls taken by consecutive sampling. The data were analyzed
using univariate and bivariate analysis with the Chi-square test. The results
based on the bivariate analysis showed history of previous abortion (p <0.001),
chronic maternal disease (p <0.001), hemoglobin levels (p = 0.020), maternal
age (p= 0.026), gravidity (p= 0.036), and infection (p= 0.037) had significant
correlation with spontaneous abortion. In conclusion, risk factors associated
with spontaneous abortion in Dr. Soetomo General Hospital were history of
previous abortion, chronic maternal disease, anemia, advanced maternal age,
multigravidity, and infection. Positive pregnancy outcomes are expected to play
a role in reducing MMR in Indonesia. Therefore, high-risk pregnant women are
suggested to carry out regular Antenatal care recommendations with intensive
Kata kunci : Misscarriage, risk factors, spontaneus abortion
April 2021 | Volume 7 | Issue 65
 RESEARCH ARTICLE
Published: 05 April 2021
DOI : 10.21070/midwiferia.v%vi%i.1125

1. INTRODUCTION of pregnancies, meaning that one in 8

The Maternal Mortality Ratio (MMR) in pregnancies is at risk of becoming an abortion.
Indonesia is considerably high. According to The incidence of abortion in Indonesia reached
the Inter-Census Population Survey (SUPAS) over more than 2.3 million per year (Akbar,
in 2015, MMR in Indonesia reached 305 per 2019).
100,000 live births. In 2018, the MMR in East The causes of spontaneous abortion vary
Java Province reached 91.45 per 100,000 live widely and can be caused by a combination of
births. According to East Java Provincial various factors (multi factors). In theory, there
Health Office, the three highest causes of are risk factors that are thought to increase the
maternal death in East Java Province are the risk of spontaneous abortion occurrence. Some
result of other causes (32.57%), pre-eclampsia/ of these risk factors include fetal, maternal,
eclampsia (31.32%), and bleeding (22.8%). paternal, social-behavioral, and occupational-
Bleeding in pregnancy occurs at an early environmental factors.
gestational age or later in pregnancy. Fetal factors include chromosomal
Spontaneous abortion is one of the causes of abnormalities, placental abnormalities, and
bleeding in early pregnancy. The National embryos with local abnormalities
Center for Health Statistics, the Centers for (Sastrawinata et al., 2005). The most common
Disease Control and Prevention, and WHO maternal factors that cause spontaneous
define spontaneous abortion as spontaneous abortion are advanced maternal age, high
pregnancy loss before 20 weeks of gestation or parity, multigravidity, history of previous
a fetus weighing less than 500 grams abortion, obesity or underweight, infection,
(Cunningham et al., 2018). uterine abnormalities, chronic maternal
Around 75% of the incidence of disease, and anemia (Cunningham et al., 2018;
spontaneous abortion happens when Edmonds et al. ., 2018; Fraser et al., 2011;
gestational age is less than 16 weeks, and 80% Johnson et al., 2015; Konar, 2015;
of this percentage occurs before gestational Prawirohardjo, 2010; Sastrawinata et al.,
age reaches 12 weeks (Konar, 2015). 2005). Social-behavioral risk factors include
According to National Health Service, the consumption of cigarettes, alcohol,
spontaneous abortion occurs in at least 15-20% caffeine, drugs, and the use of contraception

Midwiferia Jurnal Kebidanan | https://journal.umsida.ac.id/index.php/midwiferia April 2021 | Volume 7 | Issue 66

 RESEARCH ARTICLE
Published: 05 April 2021
DOI : 10.21070/midwiferia.v%vi%i.1125

(Johnson et al., 2015; Konar, 2015). determine the risk factors associated with
Occupational-environmental factors come spontaneous abortion in Dr. Soetomo General
from exposure to radiation and chemicals Hospital Surabaya.
(Sastrawinata et al., 2005). Paternal factors
2. METHODS
such as sperm abnormalities are also
This research was an observational
associated with spontaneous abortion (Konar,
analytic with a case-control approach. This
2015).
retrospective study used secondary data
Spontaneous abortion can lead to severe
collected from Dr. Soetomo General Hospital
complications. According to Sujiyatini (2009),
Obstetrics and Gynecology Inpatient
complications of spontaneous abortion include
Installation's medical records. The population
bleeding, uterine perforation, infection, and
was all pregnant women who had been
shock. Prevention efforts are needed to be done
hospitalized at Dr. Soetomo General Hospital
to reduce mortality and morbidity due to
Obstetrics and Gynecology Inpatient
abortion and its complications. One way is to
Installation during the period from January
identify spontaneous abortion risk factors
2017 - December 2018. The samples were 120,
early. This action is expected to help lower the
which included 40 patients as cases and 80
number of MMR. The Medium-Term National
patients as controls (cases to controls ratio of
Development Plan (RPJMN) targeted to
1:2).
reduce national MMR to 183 cases per 100,000
The sampling technique was consecutive
live births in 2024.
sampling. The data analysis used univariate
Dr. Soetomo General Hospital Surabaya is
and bivariate analysis with Chi-square test,
one of the hospitals located in East Java
degree of significance α = 0.05. The Risk
Province as the central hospital of reference for
Estimate test was conducted to obtain the Odds
Indonesia's eastern part. The incidence of
Ratio (OR) value by interpreting a 95%
spontaneous abortion in Dr. Soetomo General
Confidence Interval (CI). Statistical tests were
Hospital Surabaya is quite a lot. According to
performed using SPSS statistical data
the research of Setiyawati (2013), the number
processing software version 25.
of spontaneous abortion incidence in 2012 was
553 cases in total. This study aimed to

Midwiferia Jurnal Kebidanan | https://journal.umsida.ac.id/index.php/midwiferia April 2021 | Volume 7 | Issue 67

 RESEARCH ARTICLE
Published: 05 April 2021
DOI : 10.21070/midwiferia.v%vi%i.1125

3. RESULTS While the distribution of respondents in

Forty cases from a total of 136 available the majority control group was mothers aged
cases of spontaneous abortion were included in less than 35 years (85.0%), low risk parity
this study. Based on the study results, the type (76.25%), multigravidas (52.5%), had no
of spontaneous abortion was mostly history of abortion (86.25%), low risk BMI
incomplete abortion, as many as 21 cases (80.0%), had no infection (91.25%), did not
(52.5%) followed by 8 cases of complete have uterine abnormalities (100.0%), did not
abortion (20.0%), 7 cases (17.5%) of missed have chronic maternal disease (77.5%), not
abortion, 2 cases of recurrent miscarriage anemic (95.0%), and no fetal anomalies
(5.0%), and one case each for septic abortion (93.75%), and no placental abnormalities
and threatened miscarriage (2.5%). (98.75%).
Univariate Analysis
The univariate analysis results are listed in
Table 1. Based on Table 1, the majority of
spontaneous abortion cases occurred in
mothers aged less than 35 years (67.5%), low
risk parity (62.5%), multigravidas (72.5%),
had a history of abortion (57.5%), low risk
BMI (70.0%), had no infection (77.5%), did
not have uterine abnormalities (89.6%), had
chronic maternal disease (57.5%), not anemic
(80.0%), and had no fetal anomalies (90.0%),
and no placental abnormalities (95.0 %).

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 RESEARCH ARTICLE
Published: 05 April 2021
DOI : 10.21070/midwiferia.v%vi%i.1125

Table 1. The distribution of respondents by maternal and fetal characteristic

1 Case Control Total
Characteristics
n % n % n %
Maternal Characteristics
Maternal age
High-risk group (≥ 35 years of age) 13 32.5 12 15.0 25 20.83
Low-risk group (< 35 years of age) 27 67.5 68 85.0 95 79.17
Total 40 100.0 80 100.0 120 100.0
Parity
High-risk group (P1 and ≥P4) 15 37.5 19 23.75 34 28.33
Low-risk group (P0 and P2 – 3) 25 62.5 61 76.25 86 71.67
Total 40 100.0 80 100.0 120 100.0
Gravidity
High-risk group (Multigravida) 29 72.5 42 52.5 71 59.17
Low-risk group (Primigravida) 11 27.5 38 47.5 49 40.83
Total 40 100.0 80 100.0 120 100.0
History of previous abortion
High-risk group (≥A1) 23 57.5 11 13.75 34 28.33
Low-risk group (A0) 17 42.5 69 86.25 86 71.67
Total 40 100.0 80 100.0 120 100.0
Body Mass Index
High-risk group (Underweight and obese) 12 30.0 16 20.0 28 23.33
Low-risk group (Normal and overweight) 28 70.0 64 80.0 92 76.67
Total 40 100.0 80 100.0 120 100.0
Infection
High-risk group (Yes) 9 22.5 7 8.75 16 13.33
Low-risk group (No) 31 77.5 73 91.25 104 86.67
Total 40 100.0 80 100.0 120 100.0
Uterine abnormalities
High-risk group (Yes) 4 10.0 0 0.0 4 3.33
Low-risk group (No) 36 90.0 80 100 116 96.67
Total 40 100.0 80 100.0 120 100.0
Chronic maternal disease
High-risk group (Yes) 23 57.5 18 22.5 41 34.17
Low-risk group (No) 17 42.5 62 77.5 79 65.83
Total 40 100.0 80 100.0 120 100.0
Hemoglobin levels
High-risk group (Anemia) 8 20.0 4 5.0 12 10.0
Low-risk group (Normal) 32 80.0 76 95.0 108 90.0
Total 40 100.0 80 100.0 120 100.0
Fetal Characteristics
Fetal anomalies
High-risk group (Yes) 4 10.0 5 6.25 9 7.5
Low-risk group (No) 36 90.0 75 93.75 111 92.5
Total 40 100.0 80 100.0 120 100.0
Placental abnormalities
High-risk group (Yes) 2 5.0 1 1.25 3 2.5
Low-risk group (No) 38 95.0 79 98.75 117 97.5
Total 40 100.0 80 100.0 120 100.0

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2 Table 2. Results of the bivariate analysis

OR
Variable P-value
(95% CI)
Maternal age
2.728
High-risk 0.026
(1.107 - 6.727)
Low-risk
Parity
1.926
High-risk 0.115
(0.847 - 4.380)
Low-risk
Gravidity
2.385
High-risk 0.036
(1.049 - 5.422)
Low-risk
History of previous abortion
8.487
High-risk <0.001
(3.474 - 20.733)
Low-risk
Body Mass Index
1.714
High-risk 0.222
(0.718 - 4.093)
Low-risk
Infection
3.028
High-risk 0.037
(1.035 – 8.857)
Low-risk
Uterine abnormalities
High-risk 0.011 -
Low-risk
Chronic maternal disease
4.660
High-risk <0.001
(2.058 - 10.555)
Low-risk
Hemoglobin levels
4.750
High-risk 0.020
(1.335 - 16.902)
Low-risk
Fetal anomalies
1.667
High-risk 0.479
(0.422 - 6.582)
Low-risk
Placental abnormalities
4.158
High-risk 0.257
(0.366 - 47.297)
Low-risk

3 Source : Medical Records

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Bivariate Analysis
Table 2. summarizes the results of the
bivariate analysis Chi-square test 2 x 2 with the
significance of α = 0.05 and Odds Ratio (OR)
95% Confidence Interval (CI). Based on the
results of the bivariate analysis with the Chi-
square test, it was found that the independent
variable with a significant p-value (p <0.05)
were history of previous abortion (p = <0.001),
chronic maternal disease (p = <0.001), uterine
abnormalities (p = 0.011), Hb level (p = 0.020),
maternal age (p = 0.026), gravida (p = 0.036),
and infection (p = 0.037), meaning Ho was
rejected which can be interpreted that there was
a significant relationship between abortion
history, chronic maternal disease, uterine
abnormalities, Hb level, maternal age, gravida,
and infection with spontaneous abortion. The
independent variables with a p-value p > 0.05
were fetal anomalies (p = 0.479), placental
abnormalities (p = 0.257), BMI (p = 0.222), and
the number of parity (p = 0.115), meaning Ho
was accepted which can be interpreted that there
was no significant relationship between fetal
anomalies, placental abnormalities, BMI, and
parity with spontaneous abortion.
The risk estimate test results obtained Odds
Ratio (OR) value of history of abortion (OR =
8,487; 95% CI 3,474 - 20,733), chronic maternal
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disease (OR = 4,660; 95% CI 2,058 - 10,555),
Hb levels (OR = 4,750; 95% CI 1,335 - 16,902)
, maternal age (OR = 2.728; 95% CI 1.107 -
6.727), gravida (OR = 2.385; 95% CI 1.049 -
5.422), and infection (OR = 3.028; 95% CI 1.035
- 8.857) had OR value > 1 and the confidence
interval does not include the value of 1, meaning
that history of abortion, chronic maternal
disease, Hb level, maternal age, gravida, and
infection were risk factors for spontaneous
abortion. The results of the risk estimate test for
the uterine abnormality variable could not obtain
an OR value because there was a cell count of 0
in the data for the control group with uterine
abnormalities. Thus, uterine abnormalities could
not be determined as a risk factor for
spontaneous abortion.
4. DISCUSSION
Maternal Age
The statistical analysis showed that the mean
maternal age of the case group (31.0 ± 6.397)
was higher than the control group (27.58 ±
6.527) and the proportion of high-risk groups (≥
35 years old) were more numerous in the case
group (32.5%) compared to control group
(15.0%). Chi-square test result indicated that
there was a significant association between
maternal age and spontaneous abortion (p =
April 2021 | Volume 7 | Issue 71

0.026, p<0.05). According to the risk estimate
test result, risk calculation obtained an OR of
2.728 (95% CI: 1.107 to 6.727), meaning
pregnant women aged ≥ 35 years may increase
the risk of spontaneous abortion up to 2.728
times compared to pregnant women aged less
than 35 years. These results are consistent with
the previous research conducted by Maconochie
et al. (2007), which stated that high-maternal age
was independently associated with increased risk
of spontaneous abortion.
The incidence rate of spontaneous abortion
in older women is higher, mainly caused by the
impairment of oocyte quality, chromosome
segregation defects, and aneuploidy (Mills and
Lavender, 2014). Advanced maternal age is
associated with the reduction in the number and
quality of remaining oocytes. At the age of 30 to
35 years, the number of oocytes reduces to about
100,000. The process of oocyte maturation and
ovulation becomes insufficient because of the
continuous loss of functional oocytes (Casanova
et al., 2019). In addition, advanced age pregnant
women also have a greater risk of recurrent
miscarriage (Johnson et al., 2015).
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Number of parity
The statistical analysis result showed that the
mean number of parity of the case group (1.08 ±
1.228) was higher than the control group (0.85 ±
1.115) and the proportion of high-risk groups
(P1 and ≥P4) were more numerous in the cases
(37.5%) compared to the control group
(23.75%). However, the Chi-square test result
indicated no significant association between the
number of parity and spontaneous abortion (p =
0.115, p>0.05). The previous research conducted
by Qubro et al. (2018) is in accordance with our
study's results, which concluded that there was
no association between parity and spontaneous
abortion at the Abdul Moeloek Bandar Lampung
Hospital (p = 0.298). These results differ from
Meti (2012) research in the RSIA Mutiara Hati
Pringsewu, which stated a significant
relationship between parity and the incidence of
spontaneous abortion (p= 0.000). The difference
in this study results may be due to the possibility
of a spontaneous abortion caused by factors
other than parity. In addition, women who have
given birth before tend to maintain their
pregnancy better because of their previous
successful pregnancy experience.
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According to Wiknjosastro (2005), the Temanggung District General Hospital, which

maternal mortality ratio is higher in primiparous stated that gravidity is a risk factor for
and multiparous women. The higher the parity, spontaneous abortion (p = 0.025).
the higher the chance of the unfavorable uterine Multigravida significantly has a greater risk
endometrium, the greater the risk of pregnancy for spontaneous abortion than primigravida
complications (Prawirohardjo, 2010). The (Fraser et al., 2011). According to Llewellyn-
former placental implantation in past Jones (2002), the number of spontaneous
pregnancies causes tissue degeneration and abortion cases increases along with the
necrosis. The decreased function and vascularity increasing number of gravidity. Increased
in the endometrium cause insufficient gravidity is associated with decreased
oxygenation and nutrient supply to products of endometrial function and vascularization in the
conception (POC), and the circulation to the uterine body, which resulted in weak
fetus is impaired (Manuaba, 2002). implantation of the product of conception
Gravidity leading to expulsion of a part of or all of the
The statistical analysis showed that the case product of conception (Purwaningrum &
group's mean gravidity (2.90 ± 1.780) was higher Fibriyana, 2017).
compared to the control group (2.00 ± 1.222) and History of previous abortion
the proportion of high-risk groups (multigravida) The results showed that the mean history of
were more numerous in the case group (72.5%) abortion in the case group (0.88 ± 1.017) was
than control group (52.5%). Chi-square test higher than the average history of abortion in the
result indicated that there was a significant control group (0.15 ± 0.393), and the proportion
association between the number of gravidities of high-risk groups were found more numerous
and spontaneous abortion (p = 0.036, p<0.05). in the cases (57.5%) than controls (13.75%).
According to the risk estimate test result, risk Chi-square test results showed a significant
calculation obtained an OR value of 2.385 (95% association between abortion history of previous
CI: 1.049 to 5.422), meaning that multigravidity spontaneous abortion (p = <0.001, p<0.05).
may increase the risk of spontaneous abortion up According to the risk estimate test result, risk
to 2.385 times. These results are supported by calculation obtained an OR of 8.487 (95% CI:
Purwaningrum & Fibriyana (2017) research in 3.474 to 20.733), which means that having a
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history of abortion is a risk factor for
spontaneous abortion. Pregnant women with a
history of previous abortion may increase the
risk of spontaneous abortion 8.487 times. The
results of a similar study by Putri (2018) showed
an association between a history of spontaneous
abortion with the incidence of spontaneous
abortion in Medika Aghisna Public Hospital of
Cilacap (p = 0,020). Mothers who have
experienced abortion are five times more likely
to undergo abortion in subsequent pregnancies
(OR = 5.870).
The results are consistent with the theory,
according to Edmonds et al. (2018), which stated
that the more history of abortion had ever
experienced, the greater the risk of abortion in
subsequent pregnancies. According
Prawirohardjo (2010), after suffering
spontaneous abortion once, the risk for abortion
in the future is around 15%. The risk would
increase to 25% if abortion happened twice.
Surgical management (curettage) in the previous
abortion increases the incompetent cervix's risk
because of continuous muscle stimulation to
keep the cervical area open. The procedure can
also change the muscle's permeability affecting
the decidua basalis in the implantation process of
subsequent pregnancy (Purwaningrum
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Fibriyana, 2017).
Body Mass Index (BMI)
The proportion of high-risk groups
(underweight or obese) were more numerous in
cases (30.0%) than controls (20.0%). Chi-square
statistical test result indicated no significant
relationship between BMI and spontaneous
abortion (p = 0.222, p>0.05). This result is in line
with Silitonga et al. (2017) research, which
showed no significant relationship between BMI
with abortion in the General Hospital Center Dr.
Mohammad Hoesin Palembang. However, these
results were contradictory with Metwally (2010)
results, which stated a relationship between BMI
and the occurrence of spontaneous abortion.
This result can be explained because this
to research only used BMI data after pregnancy.
a Data quality would be better if the BMI data
were compared with prepregnancy BMI.
According to Diouf et al. (2011), BMI can help
understand the relationships between maternal
nutritional status and the fetus' growth. Any
maternal weight changes before pregnancy can
be used as a reference to identify the
preconception energy balance and nutritional
status.
Cunningham et al. (2018) stated that
& pregnant women with obesity have high
April 2021 | Volume 7 | Issue 74

maternal complications, increasing the risk of
spontaneous abortion. Obesity in pregnancy
increases the risk of leptin resistance, which can
inhibit the fetus's growth (Hacker et al., 2016).
Increased risk of miscarriage in women who are
obese may also have relationships with insulin
resistance (Johnson et al., 2015).
If the mother is malnourished during
pregnancy, the risk and complications of
pregnancy include bleeding, lack of weight gain,
and infection susceptibility. Low nutritional
status can affect fetal growth in the womb
leading to abortion, stillbirth, congenital
abnormalities, anemia, neonatal mortality, and
low birth weight (LBW) (Waryana, 2010).
Infection
The proportion of high-risk groups
(infection) was found more numerous in the case
group (22.5%) than control (8.75%). Chi-square
test results showed a significant association
between infection with spontaneous abortion at
Hospital Dr. Soetomo (p = 0.037, p<0.05).
According to the risk estimate test result, risk
calculation obtained an OR of 3.028 (95% CI:
1.035 to 8.857), meaning that infection increases
the risk of spontaneous abortion 3.028 times
higher. This result is supported by Octarina et al.
(2018) research results at the Dr. Rasidin
Hospital and RSIA Siti Hawa Padang, which
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showed a relationship between C. trachomatis
infection and spontaneous abortion (p = 0.025).
Prawirohardjo (2010) stated that the
presence of toxic metabolites, endotoxins,
exotoxins, and cytokines directly impact the
fetoplacental unit. Infection of the fetus may
result in fetal death or severe disability that raises
fetal survival difficulties. Infection of the
placenta can lead to placental insufficiency and
may continue until the death of the fetus.
Chronic endometrial infection interferes
with implantation, amnionitis, and genetic and
anatomical changes in the embryo. Infection
generally occurs because of virus infection
during early pregnancy.
Uterine Abnormalities
The proportion of high-risk groups were
more numerous in the case group (10.0%) than
in control group (0.0%). Chi-square test results
showed a significant relationship between
uterine abnormalities with spontaneous abortion
at Hospital Dr. Soetomo (p = 0.011, p <0.05).
However, the risk of having uterine
abnormalities towards the incidence of
spontaneous abortion in Dr. Soetomo General
Hospital could not be determined because there
was a cell count with a value of 0 therefore
excluded as a risk factor for spontaneous
abortion.
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The uterine abnormalities found in this study
were one case of congenital uterine
abnormalities (septum uteri) and 3 cases of
acquired uterine abnormality (myoma uteri).
Leiomyoma or myoma uteri can cause
spontaneous abortion. In most cases, the location
of myomas is more influential than its size.
Myoma uteri, primarily located near the
placental implantation, can interfere with
implantation (Cunningham et al., 2018).
Submucosal fibroids have a more significant role
than other types (Casanova et al., 2019).
According to Konar (2015), submucosal myoma
uteri is associated with distortion or partial
obliteration of the uterine cavity.
Some congenital abnormalities such as
uterine unicornis, bicornis, and septate uteri may
increase the risk of miscarriage in the first
trimester, mid-trimester abortion, or premature
labor. Abnormalities of uterine development is a
consequence of an abnormal formation or fusion
of the Mullerian duct (Cunningham et al., 2018).
Congenital malformations of the uterine septum
may lead to abortion because of the reduced
volume of intra-uterine, reduced placental
vascularization, reduced uterine expansion
capabilities, and increased uterine irritability /
contractility (Konar, 2015).
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Maternal Chronic Disease
The proportion of high-risk groups were
found more numerous in the case group (57.5%)
than in the control group (22.5%). Chi-square
test results showed a significant association
between maternal chronic disease with
spontaneous abortion at Hospital Dr. Soetomo (p
= <0.001, p <0.05). According to the risk
estimate test result, risk calculation obtained an
OR of 4.660 (95% CI: 2.058 to 10.555), meaning
that pregnant women with maternal chronic
disease may increase the risk of spontaneous
abortion 4.660 times higher. The results of this
study are similar to the results of Rangkuti et al.
(2019) shows that there were influences of
maternal disease (p = 0.0001) OR = 26.0 (95%
CI 8.79 to 76.8) with the incident threatened
abortion in the General Hospital
Padangsidimpuan City.
Sinclair (2009) stated that one of the risk
factors for spontaneous abortion is chronic
medical problems. According to Cunningham et
al. (2018), maternal diseases that have a
prominent risk of spontaneous abortion include
uncontrolled diabetes mellitus, obesity, thyroid
disease, and autoimmune disease. Maternal
chronic diseases such as hypertension, kidney
disease, liver disease, diabetes mellitus can
April 2021 | Volume 7 | Issue 76

directly affect fetal growth through the placenta
(Manuaba, 2002).
Hemoglobin (Hb) Levels
Distribution respondents of both case and
control groups almost entirely were not anemic
mothers (cases = 80.0%; control = 95.0%). The
proportion of high-risk groups were found more
numerous in the case group (20.0%) than in the
control group (5.0%). Chi-square test results
showed a significant association between Hb
levels and spontaneous abortion in Dr. Soetomo
General Hospital (p = 0,020, p <0.05).
According to the risk estimate test result, risk
calculation obtained an OR of 4.750 (95% CI:
1.335 to 16.902), which means that pregnant
women with anemia may increase the risk of
spontaneous abortion 4.750 times higher. This
result is supported by Amalia and Sayono (2015)
results in the Islamic Hospital Sultan Agung
Semarang, which showed a significant
relationship between anemia with complete and
incomplete spontaneous abortion (p = 0.019).
Pregnant women who suffer from anemia are at
risk of experiencing abortion 2.547 times than
respondents without anemia (OR = 2.547).
The results are consistent with the theory
from Manuaba (2002), which stated that anemia
could directly impact the fetus through the
placental growth due to nutritional and
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circulation disorders to the uteroplacental.
According to Akbar (2019), iron deficiency
anemia in pregnancy increases the incidence of
spontaneous abortion. Iron is one of the essential
elements in hematopoiesis, a hemoglobin
synthesis in red blood cells. Pregnant women
with iron deficiency anemia can not give
sufficient iron stores for the fetus in the first few
months of pregnancy.
According to Widianti (2017), low
hemoglobin levels cause the decreased supply of
oxygen to the mother and fetus metabolism
hence the decreased blood oxygen level. If the
situation takes place for a long time can lead to
tissue necrosis, resulting in conception products
can not survive long enough in the womb.
Fetal Anomalies
The distribution of respondents both in case
and control groups were almost entirely did not
have fetal anomalies (cases = 90.0%; control =
93.75%). The proportion of high-risk groups
found more numerous in the cases (10.0%) than
controls (6.25%). Chi-square test results showed
no significant association between fetal
anomalies with spontaneous abortion at Dr.
Soetomo General Hospital (p = 0.479, p>0.05).
These results can be explained by Leveno
(2009) theory, which stated around 60% of
spontaneous abortion incidence are caused by
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chromosomal abnormalities. In this study, none generally more associated with antepartum
of the cases taken were found with chromosomal bleeding in late pregnancy than spontaneous
abnormalities. This is most likely because the abortion. The incidence of bleeding from a
samples had not been examined to detect fetal placenta previa accounts for 20% of all
chromosomal abnormalities because antepartum hemorrhage cases (Hacker et al.,
spontaneous abortion often happens before the 2016).
mothers realized that they were already According to the theory described by
pregnant. Cunningham et al. (2018), placental
Screening test for chromosomal abnormalities such as placenta previa can cause
abnormalities can be done around week 11 to 13 mid-trimester spontaneous abortion. Placental
in the first trimester of pregnancy. The test functional impairment, vascular and circulatory
includes a simple maternal blood test and an disorders can lead to spontaneous abortion
ultrasound (CDC, 2020). (Manuaba, 2002).
Placental Abnormalities
Distribution of respondents both case and 5. CONCLUSION
control groups almost entirely had no placental This study showed that a history of previous
abnormalities (cases = 95.0%; control = abortion, chronic maternal disease, anemia,
98.75%). The proportion of high-risk groups advanced maternal age, multigravidity, and
found more numerous in the case group (5.0%) infection were risk factors associated with the
than in the control group (1.25%). Chi-square occurrence of spontaneous abortion in Dr.
test results showed no significant correlation Soetomo General Hospital Surabaya.
between placental abnormalities with Positive pregnancy outcomes are expected
spontaneous abortion at Dr. Soetomo General to play a role in reducing MMR in Indonesia.
Hospital (p = 0.257, p>0.05). Therefore, pregnant women are suggested to
The type of placental abnormalities found in carry out regular antenatal care
this study was placenta previa. Placenta previa recommendations, and high-risk pregnant
is the most common type of abnormal women need to receive more intensive
placentation. However, placenta previa is supervision.

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6. REFFERENCES
Akbar, A. (2019). Faktor Penyebab Abortus Di
Indonesia Tahun 2010 - 2019: Studi Meta
Analisis. Jurnal Biomedik (JBM). 11(3). 182-
191. doi: 10.35790/jbm.11.3.2019.26660.
Retrieved
https://ejournal.unsrat.ac.id/index.php/biomedi
k/article/view/26660
Casanova, R. (2019). Beckmann and Ling's obstetrics
and gynecology. 8th Ed. Philadelphia: Wolters
Kluwer.
Centers for Disease Control and Prevention. (2020).
Diagnosis of Birth Defects. Retrieved from
https://www.cdc.gov/ncbddd/birthdefects/diag
nosis.html
Cunningham, F.G., K.J. Leveno, S.L. Bloom, J.S.
Dashe, B.L. Hoffman, B.M. Casey, C.Y.
Spong. (2018). Williams Obstetrics, 25th Ed.
New York: McGraw-Hill Education.
Diouf, Ibrahima, et al. (2011). Maternal Weight
Change Before Pregnancy In Relation To
Birthweight And Risks Of Adverse Pregnancy
Outcomes. Perinatal Epidemiology, Vol. 26,
789–796. Retrieved
https://pubmed.ncbi.nlm.nih.gov/21710259/
Edmonds, D.K., C. Lees, T. Bourne. (2018).
Dewhurst's textbook of obstetrics
gynecology, 9th Ed. New Jersey: John Wiley &
Sons Ltd.
Midwiferia Jurnal Kebidanan | https://journal.umsida.ac.id/index.php/midwiferia
RESEARCH ARTICLE
Published: 05 April 2021
DOI : 10.21070/midwiferia.v%vi%i.1125
Fraser, D.M. dan M.A. Cooper. (2011). Buku Ajar
Bidan, Edisi 14. Jakarta: EGC.
Hacker N.F., J.C. Gambone, C.J. Hobel. (2016).
Hacker & Moore's Essentials of Obstetrics and
Gynecology. 6th Ed. Elsevier.
from Johnson, C.T., J.L. Hallock, J.L. Bienstock, H.E. Fox,
E.E. Wallach. (2015). The johns hopkins
manual of gynecology and obstetrics. 5th Ed.
Wolters Kluwer.
Konar, H., 2015. DC Dutta's textbook of obstetric. . 5th
Ed. Jaypee Brothers Medical Publishers (P)
Ltd.
Leveno K.J., F.G. Cunningham, N.F. Gant, et al.
(2009). Obstetri Williams: Panduan Ringkas,
Edisi 21. Jakarta : EGC.
Manuaba. (2002). Ilmu Penyakit Kandungan dan
Keluarga Berencana Untuk Pendidikan Bidan.
Jakarta: Rineka Cipta.
Mills, T., & Lavender, T. (2014). Advanced maternal
age. Obstetrics, Gynaecology and
Reproductive Medicine, 24(3), 85-90. Elsevier
Prawirohardjo, S. (2010). Ilmu kebidanan Sarwono
Prawirohardjo (Edisi Keempat, Cetakan
from Ketiga). Jakarta: PT Bina Pustaka Sarwono
Prawirohardjo.
Purwaningrum, E.D. dan A. I. Fibriana. (2017).
Faktor Risiko Kejadian Abortus Spontan.
&
Higeia Journal Of Public Health Research And
Development. 1(3), 84-94. Retrieved from
April 2021 | Volume 7 | Issue 79
 RESEARCH ARTICLE
Published: 05 April 2021
DOI : 10.21070/midwiferia.v%vi%i.1125

https://journal.unnes.ac.id/sju/index.php/higeia
/article/download/16968/8982/
Sastrawinata, S., D. Martaadisoebrata, F.F.
Wirakusumah. (2005). Ilmu kesehatan
reproduksi obstetri patologi. Edisi Kedua.
Jakart: EGC.
Setiyawati. (2013). Gambaran kejadian abortus di
RSUD Dr. Soetomo Surabaya tahun 2012.
(skripsi). Retrieved from Repository
Universitas Airlangga.
Sinclair. (2009). Buku Saku Kebidanan. Jakarta :
EGC.
Sujiyatini. (2009). Asuhan Patologi Kebidanan.
Yogyakarta: Pustaka Nuha Medika.
Waryana. (2010). Gizi Reproduksi. Yogyakarta:
Pustaka Rihama.
Widianti L. (2017). Hubungan Anemia Defisiensi
Besi pada Ibu Hamil dengan Kejadian Abortus
di Ruangan Kasuari Rumah Sakit Umum
Anutapura Palu. Jurnal Kesehatan, 8(1). 36.
Retrieved from https://ejurnal.poltekkes-
tjk.ac.id/index.php/JK/article/view/393
Wiknjosastro, Hanifa. (2005). Ilmu Kebidanan.
Jakarta : Yayasan Bina Pustaka Sarwono
Prawirohardjo.

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748 RBMO VOLUME 41 ISSUE 4 2020

LETTER

Strong variation in progesterone production

of the placenta in early pregnancy – what are
the clinical implications?
Kay Neumann, Marion Depenbusch, Askan Schultze-Mosgau, Georg Griesinger*

W
e thank Dr Tesarik
(Tesarik, 2020) for his
interest in our study on
the onset of placental
progesterone production in patients
receiving dydrogesterone for
scheduling endometrial receptivity
and for supporting early pregnancy in
anovulatory (‘artificial’) frozen-thawed
embryo transfer cycles (FET) (Neumann
et al., 2020). In his letter, Dr Tesarik
suggests that the luteo-placental shift
can be delayed and that this delay could
be a cause for miscarriage. Indeed, in
our study a strong variation in placental
progesterone production between
individual singleton pregnancies can be
observed (Figure 4A, Neumann et al.,
2020). Csapo et al. (1973) performed
lutectomy in 11 spontaneously pregnant
patients approximately 50 days post
menstruation and observed a drastic
decline in serum progesterone levels to
approximately 5–6 ng/ml shortly after
lutectomy, followed by complete abortion
in seven and incipient abortion in four
out of eleven patients. Csapo et al. also
found that progesterone administration
could prevent abortion after lutectomy
at this time point. Furthermore,
lutectomy at approximately 58 days post
menstruation or beyond did not lead
to abortion (Csapo et al., 1974). In our
study, we observed mean serum placental
progesterone levels of 4.4±2.4 ng/ml
(95% confidence interval 3.4 to 5.4 ng/
ml) on day 30–36 post embryo transfer,
e.g. at the same approximate time that
Csapo et al. performed lutectomy
leading to abortion in the 1973 study,
and 9.3±3.4 ng/ml (95% confidence
interval 7.9 to 10.8 ng/ml) on day 37–43
post embryo transfer, e.g. the gestational
age at which the placenta has taken
over control according to the Csapo
experiments (Csapo et al., 1974). To
illustrate the inter-pregnancy variation in
the time-point at which this approximate
progesterone production can be
observed, we have plotted the cumulative
number of singleton pregnancies in our
cohort for which we estimate a placental
progesterone production resulting in a
serum concentration of at least 10 ng/ml
against the estimated post menstruation
gestational week (FIGURE 1). A variation
of approximately four gestational weeks
amongst ongoing, viable singleton
pregnancies in reaching this selected
threshold can be seen, and some
pregnancies reach this threshold as late
as the eleventh gestational week.
It is important to note that it is yet to
be determined if 30mg dydrogesterone
is indeed the optimal progestogenic
daily dose in an artificial FET cycle.
We therefore intend, as a next step, to
investigate the incidence of miscarriage
in FET cycles according to blood
concentration of dydrogesterone and
20α-dihydrodydrogesterone in a large
cohort of patients (clinicaltrials.gov:
NCT03507673). It is also important
to note that it is as yet unknown if
placental progesterone production
interacts with progestogenic activity
originating from the corpus luteum
or exogenous source. In our study, all
patients received 10mg dydrogesterone
three times daily and treatment was not
modified systematically in patients with
low progesterone, although physicians
were allowed to increase dydrogesterone
dosage up to 50mg at their discretion
after a positive pregnancy test. This
FET model with dydrogesterone usage
would allow the study of the interaction
of progestonic drug dose administered
and placental response. Furthermore,
this model would also allow a test of Dr
Tesarik's hypothesis that delayed luteo-
placental shift would cause miscarriage,
by identifying pregnancies with low
placental progesterone production and
by increasing and/or prolonging the
dydrogesterone administration within
the context of a randomized trial. In
our cohort, we observed a relatively
high miscarriage rate (39%). However,
we think that low progesterone levels
in miscarrying pregnancies are a
consequence of the demise of the
conceptus, rather than its cause, since
miscarriages can be predicted in our

Department of Gynaecological Endocrinology and Reproductive Medicine, University Hospital of Schleswig-Holstein,

Campus Luebeck, Ratzeburger Allee 160, Luebeck 23538, Germany

© 2020 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.
*Corresponding author. E-mail address: Georg.Griesinger@uni-luebeck.de (G Griesinger). https://doi.org/10.1016/j.
rbmo.2020.07.009 1472-6483/© 2020 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

FIGURE 1  Proportion of ongoing, singleton pregnancies having reached serum progesterone levels of >10ng/ml after a frozen-thawed single
blastocyt embryo transfer in an artificial cycle by gestational age post menstruationem (n = 28).
cohort by abnormally low hCG levels
earlier in pregnancy, rather than by
the onset of placental progesterone
production. Of note, a recent large trial
on vaginal progesterone for prevention of
threatened abortion has failed to identify
a causal link between early pregnancy
progesterone treatment and abortion
prevention, albeit in a different setting
than artificial FET (Coomarasamy et al.,
2019).
RBMO VOLUME 41 ISSUE 4 2020 749
REFERENCES Csapo, A.I., Pulkkinen, M.O., Kaihola, H.L.
The relationship between the timing of
luteectomy and the incidence of complete
Coomarasamy, A., Devall, A.J., Cheed, V., Harb,
abortions. American Journal of Obstetrics and
H., Middleton, L.J., Gallos, I.D., Williams,
Gynecology. 1974; 118: 985–989
H., Eapen, A.K., Roberts, T., Ogwulu, C.C.,
Neumann, K., Depenbusch, M., Schultze-Mosgau,
Goranitis, I., Daniels, J.P., Ahmed, A., Bender-
Atik, R., Bhatia, K., Bottomley, C., Brewin, J.,
A., Griesinger, G. Characterization of early
pregnancy placental progesterone production
Choudhary, M., Crosfill, F., Deb, S., Jurkovic,
by use of dydrogesterone in programmed
D. A Randomized Trial of Progesterone in
frozen-thawed embryo transfer cycles.
Women with Bleeding in Early Pregnancy. The
Reprod. Biomed. Online 2020; 40: 743–751
New England journal of medicine 2019; 380:
Tesarik, J. Can miscarriage caused by delayed
1815–1824
luteoplacental shift be avoided? Reprod.
Csapo, A.I., Pulkkinen, M.O., Wiest, W.G. Effects
Biomed. 2020; 40: 747
of luteectomy and progesterone replacement
therapy in early pregnant patients. American Received 27 June 2020; accepted 10 July 2020.
journal of obstetrics and gynecology 1973; 115:
759–765
WJ CC World Journal of
Clinical Cases
Submit a Manuscript: http://www.f6publishing.com
DOI: 10.12998/wjcc.v6.i13.675
Possible connection between elevated serum α-fetoprotein
and placental necrosis during pregnancy: A case report and
review of literature
Meng-Yao Yu, Lei Xi, Jie-Xin Zhang, Shi-Chang Zhang
Meng-Yao Yu, Jie-Xin Zhang, Shi-Chang Zhang, Department
of Laboratory Medicine, the First Affiliated Hospital of Nanjing
Medical University, Nanjing 210029, Jiangsu Province, China
Lei Xi, Department of Pathology, the First Affiliated Hospital of
Nanjing Medical University, Nanjing 210029, Jiangsu Province,
China
ORCID number: Meng-Yao Yu (0000-0001-8707-355X); Lei Xi
(0000-0003-2181-4970); Jie-Xin Zhang (0000-0003-1407-7562);
Shi-Chang Zhang (0000-0002-6587-2518).
Author contributions: Yu MY and Xi L participated in data
collection; Zhang JX and Zhang SC conceived and coordinated
the study; all authors participated in manuscript writing.
Supported by National Natural Science Foundation of China,
Nos. 81501817 and 81671836; Natural Science Youth Foundation
of Jiangsu Province, No. BK20151029; and the Key Laborato­
ry for Laboratory Medicine of Jiangsu Province of China, No.
ZDXKB2016005.
Informed consent statement: Informed consent was obta­
ined from the patient for publication of this report and any
accompanying images.
Conflict-of-interest statement: We declare that we do not have
any commercial or associative interest that represents a conflict
of interest in connection with the work submitted.
CARE Checklist (2013) statement: The authors have read the
CARE Checklist (2013), and the manuscript was prepared and
revised according to the CARE Checklist (2013).
Open-Access: This article is an open-access article, which was
selected by an in-house editor and fully peer-reviewed by external
reviewers. It is distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
WJCC|www.wjgnet.com
World J Clin Cases 2018 November 6; 6(13): 675-678
ISSN 2307-8960 (online)
CASE REPORT
Manuscript source: Unsolicited manuscript
Correspondence to: Shi-Chang Zhang, MD, PhD, Assistant
Professor, Department of Laboratory Medicine, the First
Affiliated Hospital of Nanjing Medical University, Guangzhou
Road 300, Nanjing 210029, Jiangsu Province,
China. zsc78@yeah.net
Telephone: +86-25-68103450
Received: July 31, 2018
Peer-review started: July 31, 2018
First decision: August 20, 2018
Revised: August 23, 2018
Accepted: August 28, 2018
Article in press: August 28, 2018
Published online: November 6, 2018
Abstract
Placenta previa is the main cause of bleeding thr­
oughout pregnancy, and it is associated with serious
complications, such as infection, that lead to a poor
prognosis. Gynecological sonography is recommended
as the first-line examination technique for the surveill­
ance and determination of vaginal bleeding and for
early intervention. We report the case of a patient with
gradually expanded hypoechoic lesion and extremely
high serum α-fetoprotein level during her third trimester,
and discuss their potential relationship in evaluating the
progression of placental necrosis.
Key words: Serum α-fetoprotein; Intermittent bleeding;
Necrosis; Gynecological sonography; Placenta previa
© The Author(s) 2018. Published by Baishideng Publishing
Group Inc. All rights reserved.
Core tip: Placental necrosis with extremely high mater­
675 November 6, 2018|Volume 6|Issue 13|
 Yu MY et al . Elevated serum AFP and placental necrosis
nal serum α-fetoprotein (AFP) is rare. We reported
a 23-year-old female patient with central placenta
previa suffered from repeated vaginal bleeding. Follow-
up ultrasonography revealed a gradually enlarging
hypoecho between the amniotic sac and the uterine
myometrium. Until 32 wk of gestation, laboratory results
showed extremely elevated maternal serum AFP. Both
intraoperative exploration of the placenta and histological
examination demonstrated the hypoechoic area was
necrotic tissue. To our knowledge, this is the first report
of a rare case of extreme AFP level in placental necrosis.
Clinicians should consider the combination usage of
quantitative ultrasound imaging and AFP as a practical
tool for assessing placental lesions.
Yu MY, Xi L, Zhang JX, Zhang SC. Possible connection between
elevated serum α-fetoprotein and placental necrosis during
pregnancy: A case report and review of literature. World J Clin
Cases 2018; 6(13): 675-678 Available from: URL: http://www.
wjgnet.com/2307-8960/full/v6/i13/675.htm DOI: http://dx.doi.
org/10.12998/wjcc.v6.i13.675
INTRODUCTION
Placenta previa refers to a clinical situation in which
the lower edge of the placenta reaches and covers
the internal orifice of the uterus, and its bulk position
[1]
is lower than that of the fetal presentation . During
the third trimester, both irregular contractions and
enlargement of the lower segment of the uterus cause
a separation of the uterine wall and the placenta leading
to sudden and repeated abdominal pain and vaginal
[2]
bleeding . α-fetoprotein (AFP) is currently used to
predict the quality of the fetus. Its elevation in amniotic
fluid may indicate the possibility of anencephalus
[3]
or neural tube defects . Moreover, the presence of
incipient abortion or stillborn fetus is associated with
the sudden upregulated AFP in maternal serum, which
could reach 380-500 ng/mL.
CASE REPORT
A 23-year-old female patient at 14 wk of gestation was
admitted for vaginal bleeding. This was the patient’s
first pregnancy with no medical history of miscarriage
or abortion. Gynecological sonography showed that
the lower margin of the placenta completely covered
the cervix, and there was a 3.1 cm × 1.5 cm hypoe­
choic area between the amniotic sac and the uterine
myometrium that had no significant blood flow signal.
A clinical diagnosis of central placenta previa combined
with a risk of preterm labor was promptly made. Three
weeks later when the patient was discharged from
the hospital, repeated gynecological sonography was
performed and showed that the hypoechoic area had
enlarged to 6.0 cm × 2.4 cm. She received outpatient
follow-up at 19 wk of gestation, and the results revealed
WJCC|www.wjgnet.com
that hypoechoic area measured approximately 5.5 cm
× 1.5 cm × 4.7 cm. No intervention protocol was carried
out at that time. She was readmitted to our hospital at
32 wk of gestation on February 27, 2015 for a sudden
volume of vaginal bleeding without significant abdomi­
nal pain. Considering that she had a previous history
of central placenta previa (very likely with hematoma)
and intermittent bleeding, and was in her third trimester
when massive hemorrhage might occur at any time,
a comprehensive examination including gynecological
sonography, blood/urine testing, blood coagulation test,
electrocardiogram, and fetal heart rate monitoring
were performed. As shown in Figure 1, ultrasound exa­
mination revealed a heterogeneous echo measuring
4.2 cm × 3.5 cm. Blood tests are detailed in Table 1.
Notably, her serum AFP level was extremely elevated
at 1032 ng/mL. One day later, doctors performed a
cae­sarean surgery. After the baby was delivered,
doctors examined the placenta and found an abnormal
area with black appearance between the placenta and
the uterine myometrium. It was then confirmed to be
necrosis tissue by histopathological examination (Figure
2), and its location was approximate to the hypoechoic
area indicated in the pre-operation ultrasound examina­
tion. Before she was discharged from the hospital, we
performed another blood test and the result showed
that her serum AFP level had returned to baseline. As
for the baby, its weight was 1550 g. Apgar was 9 at
the first minute and was 10 at the tenth minute. It was
soon admitted to the NICU for further treatment. We
also followed up with the patient and her baby until
this article was written. Her serum AFP level remained
normal. Her baby had asthma since ten months and
suffered from herpangina at one year old. The baby also
had mild anemia (99 g/L hemoglobin).
DISCUSSION
We reported a case of central placenta previa acco­
mpanied by intermittent bleeding. Follow-up gynecolo­
gical sonography showed a gradual enlarging and subse­
quently stable hypoechoic area between the placenta
and the uterine wall. Prenatal testing of peripheral blood
revealed elevated levels of C-reactive protein (CRP) and
neutrophils, and a severely increased serum AFP level
without a history of hepatitis, miscarriage, or abortion.
Later during a caesarean surgery, necrosis of the placenta
was confirmed.
The placenta is the exclusive source of oxygen and
nutrients for the fetus. Diffusion to and from the ma­
ternal circulatory system is essential for maintaining
these life-sustaining functions of the placenta. The basic
mechanism of placental abruption is vascular damage
caused by a spasm or sclerosis of small spiral arteries
followed by hematoma formation between the placenta
and the bottom of the decidua and finally placental
[4]
separation from the uterus . One report suggests that
maternal viral infection, such as HBV and HIV infection,
may increase the necrotic rate of placental trophoblastic
676 November 6, 2018|Volume 6|Issue 13|
 Yu MY et al . Elevated serum AFP and placental necrosis

Table 1 Prenatal clinical laboratory data of the patient

Name Items Result Reference range

Blood routine examination WBC 13.79 × 109/L 3.50-9.50 × 109/L
LY 0.84 × 109/L 1.10-3.20 × 109/L
MO 0.43 × 109/L 0.10-0.60 × 109/L
NE 12.50 × 109/L 1.80-6.30 × 109/L
EO 0.00 × 109/L 0.02-0.52 × 109/L
BA 0.02 × 109/L 0.00-0.06 × 109/L
RBC 2.98 × 1012/L 3.80-5.10 × 1012/L
HGB 90 g/L 115-150 g/L
PLT 212 × 109/L 125-350 × 109/L
CRP 12.00 mg/L 0-8 mg/L
Coagulation function tests PT 11.80 s 11 ± 3 s
INR 0.98 -
APTT 19.10 s 24.5 ± 10 s
FIB 2.44 g/L 2.0-4.0 g/L
TT 15.90 s 18 ± 3 s
D-D 1.08 mg/L < 0.55 mg/L
Biochemistry examination HbA1c 4.90% 4.0-6.4 %
ALT 15.7 U/L 7-40 U/L
AST 20.3 U/L 13-35 U/L
Thyroid function tests FT3 2.94 pmol/L 3.10-6.80 pmol/L
TSH 1.09 mIU/L 0.27-4.20 mIU/L
FT4 14.23 pmol/L 12.00-22.00 pmol/L
Tumor markers AFP 1032.00 ng/mL < 20.0 ng/mL
CEA 0.43 ng/mL < 4.7 ng/mL
CA125 168.20 U/mL < 35.0 U/mL
CA199 26.47 U/mL < 27.0 U/mL
NSE 17.05 ng/mL < 16.3 ng/mL

WBC: White blood cell; LY: Lymphocyte; MO: Monocyte; NE: Neutrophilic; ECO: Eosinophil; BA: Basophil; RBC: Red blood cell; HGB: Hemoglobin;
PLT: Platelet; CRP: C-reactive protein; PT: Prothrombin time; INR: International normalized ratio; APTT: Activated partial thromboplastin time; FIB:
Fibrinogen; TT: Thrombin time; D-D: D-dimer; HbA1c: Glycated hemoglobin; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; FT3: Free
triiodothyronine; TSH: Thyroid stimulating hormone; FT4: Free thyroxine; AFP: α-fetoprotein; CEA: Carcinoembryonic antigen; CA125: Carbohydrate
antigen 125; CA199: Carbohydrate antigen 199; NSE: Neuron-specific enolase.

tocytes and the yolk sac. It enters maternal circulation

CX
HS
Figure 1 Ultrasound examination on February 27, 2015 showed a heter­
ogeneous echo measuring 4.2 cm × 3.5 cm.
[5]
cells . If the separated area is small, bleeding quickly
stops. Most patients have no clinical symptoms or are
unaware of the bleeding. Only clots that remain on the
maternal surface of the placenta are often discovered
on a postpartum examination. However, if the separa­
ted area is large enough to cause coagulation failure,
a hematoma will form in the posterior aspect of the
placenta and progressively expand followed by tissue
necrosis, as was the case in our study.
Maternal serum AFP is synthesized from fetal hepa­
through the placenta. The placenta serves as a barrier.
But when placental necrosis happens, the separation
of placenta and uterus leads to barrier leak, which will
increase the amount of AFP delivered from the fetus to
the mother. Studies have demonstrated that maternal
serum AFP is clinically elevated in cases of a morbidly
adherent placenta, and it is a secondary indicator of
[6-8]
placenta previa . However, until now there have been
no reports emphasizing its relationship with the degree
of placental damage (such as hematoma necrosis). This
is the first report of a rare case of extreme AFP level in
placental necrosis. Although color Doppler flow imaging
(CDFI) widely used in gynecological sonography can
distinguish a blood flow inside a hematoma or the uterine
[9]
myometrium , it only evaluates ongoing lesions, not
already established lesions.
An insufficient placental blood supply may lead to
ischemia-reperfusion damage and fetal growth res­
[10]
triction . Therefore, intervention should be promptly
performed when the size of placental necrosis reaches
a tipping point that is very likely to induce irreversible
injuries to the fetus and the mother. The combination
of quantitative ultrasound imaging and maternal-fetal
interface biochemical markers (such as AFP in our case)
is a valuable assessing tool for this situation.

WJCC|www.wjgnet.com 677 November 6, 2018|Volume 6|Issue 13|

 Yu MY et al . Elevated serum AFP and placental necrosis

Experiences and lessons

The combination of quantitative ultrasound imaging and AFP is valuable in
assessing maternal-fetal interface lesion during pregnancy.

REFERENCES
1 Silver RM. Abnormal Placentation: Placenta Previa, Vasa Previa,
and Placenta Accreta. Obstet Gynecol 2015; 126: 654-668 [PMID:
26244528 DOI: 10.1097/AOG.0000000000001005]
2 Jung EJ, Cho HJ, Byun JM, Jeong DH, Lee KB, Sung MS, Kim
KT, Kim YN. Placental pathologic changes and perinatal outcomes
in placenta previa. Placenta 2018; 63: 15-20 [PMID: 29486851
DOI: 10.1016/j.placenta.2017.12.016]
3 Krantz DA, Hallahan TW, Sherwin JE. Screening for open neural
tube defects. Clin Lab Med 2010; 30: 721-725 [PMID: 20638584
Figure 2 Hematoxylin and eosin staining showed placental necrosis DOI: 10.1016/j.cll.2010.04.010]
(magnification × 100). 4 Stepan H, Geipel A, Schwarz F, Krämer T, Wessel N, Faber
R. Circulatory soluble endoglin and its predictive value for pre­
eclampsia in second-trimester pregnancies with abnormal uterine
perfusion. Am J Obstet Gynecol 2008; 198: 175.e1-175.e6 [PMID:
ARTICLEHIGHLIGHTS
ARTICLE HIGHLIGHTS 18226617 DOI: 10.1016/j.ajog.2007.08.052]
Case characteristics 5 Liu Y, Zhang J, Zhang R, Li S, Kuang J, Chen M, Liu X.
A 23-year-old female patient at 32 wk of gestation was admitted for vaginal [Relationship between the immunohistopathological changes of
bleeding. hepatitis B virus carrier mothers’ placentas and fetal hepatitis B
virus infection]. Zhonghua Fuchanke Zazhi 2002; 37: 278-280
[PMID: 12133400]
Clinical diagnosis 6 Lyell DJ, Faucett AM, Baer RJ, Blumenfeld YJ, Druzin ML, El-
Central placenta previa with repeated intermittent vaginal bleeding. Sayed YY, Shaw GM, Currier RJ, Jelliffe-Pawlowski LL. Maternal
serum markers, characteristics and morbidly adherent placenta
in women with previa. J Perinatol 2015; 35: 570-574 [PMID:
Laboratory diagnosis
25927270 DOI: 10.1038/jp.2015.40]
Laboratory investigations showed moderately elevated neutrophils and
7 Kelly RB, Nyberg DA, Mack LA, Fitzsimmons J, Uhrich S.
C-reactive protein as well as extremely elevated α-fetoprotein (AFP) (1032 ng/
Sonography of placental abnormalities and oligohydramnios in
mL).
women with elevated alpha-fetoprotein levels: comparison with
control subjects. AJR Am J Roentgenol 1989; 153: 815-819 [PMID:
Imaging diagnosis 2476009 DOI: 10.2214/ajr.153.4.815]
Ultrasonography revealed a heterogeneous and gradually enlarging hypoechoic 8 Gagnon A, Wilson RD; Society of Obstetricians and Gynaeco­
area (reached 4.2 cm × 3.5 cm before labor) between the amniotic sac and the logists of Canada Genetics Committee. Obstetrical complications
uterine myometrium. associated with abnormal maternal serum markers analytes. J
Obstet Gynaecol Can 2008; 30: 918-932 [PMID: 19038077 DOI:
10.1016/S1701-2163(16)32973-5]
Pathological diagnosis 9 Cali G, Forlani F, Foti F, Minneci G, Manzoli L, Flacco ME, Buca
After caesarean, histological examination of placenta demonstrated the D, Liberati M, Scambia G, D’Antonio F. Diagnostic accuracy of
hypoechoic area was necrotic tissue. first-trimester ultrasound in detecting abnormally invasive placenta
in high-risk women with placenta previa. Ultrasound Obstet
Treatment Gynecol 2018; 52: 258-264 [PMID: 29532529 DOI: 10.1002/
uog.19045]
A caesarean surgery with placental exploration was performed.
10 Thaete LG, Qu XW, Neerhof MG, Hirsch E, Jilling T. Fetal
Growth Restriction Induced by Transient Uterine Ischemia-Re­
Related reports perfusion: Differential Responses in Different Mouse Strains.
This is the first report of a rare case of placental necrosis with extremely Reprod Sci 2018; 25: 1083-1092 [PMID: 28946817 DOI: 10.1177/
elevated serum AFP. 1933719117732160]

P- Reviewer: Khajehei M, Zhang X S- Editor: Ji FF

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