Causes of miscarriage. Abortions in the past. Endocrine causes of miscarriage

01.05.2019

All 9 months, the expectant mother has to carefully monitor her condition, noting any changes, so that in case of complications, immediately consult a doctor. Unfortunately, it cannot always help: miscarriage is diagnosed in about 10-20% of cases.

Miscarriage in obstetrics and gynecology is called spontaneous abortion, which occurs before 37 weeks. Half of all such cases occur in the first trimester. Since it is the most dangerous, almost all medications, emotional and physical overload are prohibited, and sometimes bed rest is required. A spontaneous interruption that occurs before 22 weeks is called. At a later date -.

The classification of miscarriage is most often carried out by timing.

Up to 22 weeks - spontaneous abortion:

Up to 11 weeks and 6 days - early abortion.
From 12 weeks to 21 weeks and 6 days - late abortion.
From 12 weeks to any period, provided that the fetal body weight is less than 500 g - late abortion.

From 12 to 36 weeks and 6 days - premature birth:

From 22 weeks to 27 weeks and 6 days, with a fetal weight from 500 to 1000 grams - early premature birth.
From 28 weeks to 36 weeks and 6 days, with a fetal weight of more than 1000 grams - premature birth.

Also, miscarriage is divided into stages:

Threatened abortion- the stage at which the fetus grows and develops normally, but exists.
Started abortion- the ovum is already peeling off a little, but the pregnancy can still be saved.
Abortion in progress- the ovum is separated from the walls of the uterus and is located in its cavity or in the cervix, it is no longer possible to maintain a pregnancy.
Incomplete abortion- a part of the ovum remains in the uterine cavity, causing its inflammation and the development of infection.
Complete abortion- the ovum completely leaves the woman's body, only a doctor's supervision is required.
Failed abortion- the fetus dies inside the womb, but is not expelled for a long time.

Antiphospholipid syndrome

Antiphospholipid syndrome refers to an autoimmune disorder that leads to miscarriage. This disease is found in 27% of cases of spontaneous interruption.

Phospholipids are components of the cell walls of blood vessels, platelets, brain and lung tissues. In antiphospholipid syndrome, the immune system attacks membranes, causing damage to cells and tissues. As a result, thrombosis, thrombocytopenia, headaches, stroke, heart attack, hypertension and other diseases can develop.

Failure to carry an embryo at an early stage occurs due to a violation of the implantation of the ovum or its rejection. Vascular thrombosis of the placenta leads to intrauterine fetal death.

Other reasons

Other causes of miscarriage include:

injuries of a pregnant woman;
intense emotional experiences, stress;
diseases of internal organs (heart, blood vessels, kidneys, liver);
complications of pregnancy, such as acute fatty;
exposure to harmful substances during production, in areas with poor environmental conditions;
husband's diseases leading to ejaculate pathologies.

Symptoms

Symptoms of miscarriage include:

pulling pain in the lower abdomen;
sudden attacks of intense pain in the lower abdomen;
bleeding from the vagina;
pain in the lumbar region and sacrum;
dizziness and weakness;
nausea and vomiting;
temperature increase.

If such symptoms are found, you should immediately seek medical help: go to an appointment with a gynecologist out of turn or call an ambulance. If the risk of termination is confirmed, then in the future the woman will be consulted by a doctor on miscarriage.

Diagnostics

In case of miscarriage, the diagnosis is carried out before conception and after spontaneous interruption. The examination helps to find out the possible and existing causes of the complication.

It includes:

a clinical survey, which clarifies and clarifies complaints: when the symptoms began, what kind of nature they are, what could cause them, etc.;
collection of information about gynecological diseases, operations, abortions, pregnancies, etc. (obstetric and gynecological history);
collection of information about: how long does it take, when the menstrual period first began, when was the last time, etc.;
examination in order to study the characteristics of the physique, the degree of obesity, the state of the thyroid gland;
examination on a gynecological chair;
Ultrasound of the pelvic organs in each phase of the cycle;
blood test to detect TORCH infections:, and;
research to identify urogenital infectious diseases (sexually transmitted diseases);
study of hormones that affect the bearing of pregnancy (thyroid gland, ovaries, adrenal cortex);
study of the blood coagulation system (coagulogram);
genetic examination (set of chromosomes, their changes);
spermatogram;
a blood test to detect autoimmune diseases;
cytogenetic study of the remains of the ovum;
consultations of narrow specialists: endocrinologist, geneticist, psychotherapist, psychologist.

The choice of the necessary tests for miscarriage is carried out by the doctor individually. The survey data, obstetric and gynecological history, general health of the woman are taken into account.

Treatment

Treatment for miscarriage depends on the cause and stage. When the threat of interruption is identified, strict bed rest with an elevated position of the legs is required. Most often, a hospital stay is required. To prevent natural abortion, hormonal agents are prescribed (, etc.). They must be used strictly according to the medical scheme, exceeding the dosage can affect the child's sexual differentiation, and a sudden cessation of admission can provoke a miscarriage.

Depending on the causes of miscarriage, treatment may include taking sedatives and neurotropics, vitamins, anticoagulants, antibiotics, antiviral drugs, etc.

Helping the family in case of miscarriage is to create a calm, friendly atmosphere in the house, to prevent any physical and emotional overload of the expectant mother.

When intrauterine fetal death occurs without expulsion from the uterus, a procedure is performed to remove the ovum using a special suction. The woman is placed on a gynecological chair, local or general anesthesia is performed, the cervix is dilated and a vacuum tube is inserted. Negative pressure is created and the ovum is released.

In case of incomplete miscarriage, when the fetus is expelled, but parts of the fetal membrane remain, it is carried out. During this procedure, the uterus is cleansed using a curette - an instrument that resembles a spoon with a hole. All manipulations are performed under general anesthesia. In some cases, curettage can be replaced by vacuum aspiration, and in the second trimester, by the administration of oxytocin. This hormone causes uterine contractions similar to those occurring during natural childbirth.

The protocol for the treatment of miscarriage includes monitoring the woman's condition for 3-4 days after a spontaneous abortion. This is necessary in order to eliminate possible complications in time: bleeding, the development of infection, etc. When chills, fever, and lining of the tongue appear, antibiotics are prescribed.

Complications

With miscarriage, rejection and expulsion of the fetus from the uterine cavity occurs.

Miscarriage and premature birth can cause the following complications:

profuse bleeding, which can lead to a critical condition - weakness, decreased blood pressure, confusion and loss of consciousness, and in severe cases - to death;
infection of the abdominal cavity, peritonitis;
blood poisoning (sepsis).

Due to the risk of complications, inpatient observation is necessary for several days after spontaneous abortion. With timely medical assistance, it is possible to stop all symptoms and preserve the woman's reproductive health.

Prophylaxis

Prevention of miscarriage is based on maintaining the health of the woman and a comprehensive examination during planning. If the spontaneous interruption has already occurred, then you need to find out its cause. For this, there are several types of diagnostics: the study of genetic and chromosomal abnormalities, hormonal abnormalities, immunological and anatomical pathologies. All procedures can be performed in specialized centers for the prevention and treatment of miscarriage.

Once the cause of the miscarriage has been identified, treatment is necessary before the next pregnancy occurs. It can include taking medication, physical therapy, and in some cases, surgery.

If a woman has not yet encountered the problem of miscarriage, then prevention is to maintain health. It is necessary to strengthen the immune system by all means, observe sanitary and hygienic rules, avoid casual sexual intercourse, timely identify and treat diseases of internal organs. For preventive purposes, you need to visit a gynecologist every six months.

Miscarriage is the spontaneous termination of pregnancy up to 37 weeks. Depending on the term, it can be called a miscarriage or premature birth. There are many reasons for this complication: hormonal, anatomical, genetic, immunological, infectious.

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Miscarriage

1 Etiology and pathogenesis

Miscarriage is one of the most important problems of modern obstetrics. The frequency of this pathology in the total number of births is more than 15%.

The causes of spontaneous miscarriages are varied, often there is a combination of these reasons leading to this complication of pregnancy.

CLASSIFICATION (1975).

Maternal infectious diseases

complications associated with pregnancy

traumatic injury

isoserological incompatibility of the blood of the mother and the fetus

anomalies in the development of the female genital area

neuroendocrine pathology

various non-communicable diseases of the mother

chromosomal abnormalities

1. Infectious diseases of the mother. They occupy an important place among the structure of the causes of miscarriage. Chronic latent infections: chronic tonsillitis, chronic appendicitis, urinary tract infection. The mechanism of action of infection is different: many toxins penetrate the placental barrier, therefore, in general infectious diseases, bacteria and viruses and their toxins can become pathogenic factors. In acute febrile illnesses, hyperthermia can also lead to abortion. This termination of pregnancy can occur as a result of intrauterine damage to the fetus, the membranes and due to premature contractions of the uterus.

For example: influenza, malaria, syphilis, toxoplasmosis, chlamydia, mycoplasmosis, rubella. Their recognition is carried out on the basis of the clinic and various studies: bacterioscopy, bacteriological, biological, pathomorphological.

Infections directly affecting the genitals: uterus, ovaries, etc. after inflammatory processes of the internal genital organs, there may be changes in the position of the uterus, etc. local inflammatory processes account for up to 34% of the cause of miscarriage.

2. Toxicosis of the first and second half of pregnancy. Premature discharge of water, polyhydramnios, abnormal position of the placenta, abnormal position of the fetus, multiple pregnancy.

Polyhydramnios is a pathology of pregnancy, as a rule, it is infectious (infection of the membranes, placenta) is often combined with fetal deformity.

Premature discharge of water. If POV is observed in the early stages of pregnancy from 15 to 20 weeks, it is often associated with the so-called cervical insufficiency (isthmic-cervical insufficiency).

3. Traumatic injuries: trauma, both physical and mental. More often injuries of the uterus itself (as the main fetus). The main cause of these injuries is induced abortion. During abortion, the cervix is injured, abortion can be the cause of isthmic-cervical insufficiency: the neck is shortened and has a funnel-shaped shape, and the external and internal pharynx gapes - the cervix is actually open. Isthmic-cervical insufficiency can be of organic (structural or traumatic) origin:

for gynecological operations

after complicated childbirth (cervical rupture)

diathermocoagulation

malformations of the uterus (5-10%)

with an open cervix, the fetal bladder prolapses and can become infected, and then there is a combination of reasons. In addition to trauma to the cervix during abortions, trauma to the uterine cavity itself is also observed, and even after an abortion without complication, dystrophic changes in the myometrium can occur, and after traumatic abortions, the uterine cavity is overgrown. If the infection is complete, then the woman suffers from infertility.

Other types of surgical trauma: removal of benign tumors, surgery for an ectopic pregnancy (excision of the tubal angle).

4. Isoserological incompatibility for the Rh factor or for others. Corrosive is one reason for miscarriage, as a rule, combined with other reasons.

5. From 4 to 11%. Uterine abnormalities are difficult to diagnose and are placed after termination of pregnancy. Hysterography, hysterosalpingography.

Saddle uterus. In the process of embryogenesis, the uterus consists of 2 primordia, therefore, with anomalies, a bifurcation, as it were, occurs.

Double reproductive apparatus: 2 vaginas, 2 cervixes, 2 uterus are usually underdeveloped. If pregnancy occurs, it ends in miscarriage. There may be several pregnancies in the anamnesis, the duration of which increases with each pregnancy. At the same time, the fruit receptacle develops.

Double uterus.

6. Neuroendocrine pathology.

Diabetes mellitus, if uncompensated in the early stages. Diabetes mellitus is often accompanied by polyhydramnios, a large fetus.

Hypo- and hyperthyroidism ovarian pathology: unsteady cycle, underdeveloped reproductive system, painful menstruation, hormonal deficiency in the form of a decrease in progesterone, gonadotropin, estrogen. With insufficient ovarian function: the mucous membrane is underdeveloped, the egg cell does not develop well in this mucosa, the placenta is underdeveloped, and functional cervical insufficiency develops.

Dysfunction of the adrenal cortex: the phenomenon of hyperandrogenism.

7. Estrogenital pathology not associated with inflammatory processes: coronary artery disease, anemia, various intoxication (benzene, nicotine).

8. Chromosomal abnormalities. In older parents, when using contraception, pregnancy is accidental. The use of antidiabetic drugs. Radiation effects, etc. diseases during pregnancy: rubella, flu, hepatitis.

2 The surveywomen suffering from miscarriage

The examination should be, if possible, outside of pregnancy, all types of pathology should be excluded, and several possible causes should be cured. First, infectious causes must be excluded, since it is impossible and impossible to treat infections during pregnancy. Secondly, to exclude genetic pathology.

Functional diagnostics to exclude neuroendocrine pathology.

Hysterosalpingography to exclude uterine malformations.

To exclude changes in the function of the adrenal glands - urine analysis for corticosteroids, hormonal tests.

PREPARATION FOR PREGNANCY.

Treatment of all infections of the woman and her spouse.

Hormone therapy. With hyperandrogenism of the adrenal glands, they are treated with prednisolone (1 tablet 4 times a day for 10 days, reduced to 1-2 tablets a day until the first half of pregnancy.

With the threat of termination of pregnancy, the possibilities are limited:

compulsory hospitalization

normalization of the neuropsychic state: conversations, psychotropic drugs.

Elimination of the cause of miscarriage

symptomatic therapy.

During pregnancy, you can prescribe penicillin, ampicillin in early pregnancy. For hormonal disorders, progesterone, vitamin E, estrogens, chorionic gonadotropin, sygetin with glucose, antispasmodics are prescribed: metacin, no-shpa, magnesium intramuscularly, in later periods - tocolytics - adrenomimetics.

In case of cervical insufficiency, a circular suture is applied to the cervix after 12 weeks with lavsan for up to 36 weeks. If a fistula forms in the cervix, labor can go through it.

3 Classicspontaneous miscarriage

Miscarriage - termination of pregnancy up to 28 weeks, after 28 weeks - premature birth, up to 1 kg - fetus, more than 1 kg - child.

From 5 to 14-16 weeks - early miscarriage, from 16 to 27 weeks - late miscarriage.

DEVELOPMENT CLASSIFICATION.

Threatened miscarriage. There is a threat. Characterized by unexpressed, pulling pains in the lower abdomen, tone may be increased, sometimes spotting. When viewed with the help of mirrors: cervix - no structural changes, that is, the cervix is preserved, the external pharynx is closed. See above for treatment.

An incipient miscarriage - detachment of the ovum, bloody discharge, constant pain in the lower abdomen, which can take on a cramping character, increased uterine tone, the presence of moderate bloody discharge. When viewed in mirrors, there are practically no structural changes in the neck: the neck is intact. The external pharynx is closed, there is always slight bloody discharge. Pregnancy can be saved. Treatment see above + hormones for hormonal deficiency.

Abortion is in progress. Practically all the ovum has already exfoliated - strong frequent contractions in the lower abdomen, the neck opens, frequent severe cramping pains, profuse spotting, profuse bleeding. The condition is serious, there may be post-hemorrhagic shock, anemia. With an internal study - the cervix is shortened, the canal is open - it allows 1-2 fingers to pass, the uterus corresponds to the gestational age, profuse bleeding. Pregnancy cannot be maintained. Stop bleeding, make up for blood loss. Stopping bleeding is carried out by scraping the uterine cavity. A contraindication is infection (the ovum is removed by abortion).

Incomplete abortion - reduction of pain in the lower abdomen, bleeding continues. The condition can be severe. You cannot save the pregnancy. The neck is shortened, 2 fingers pass, the size is less than the gestational age. The tactics are the same as in point 3.

Complete abortion: no complaints - no pain, no bloody discharge. History of abortion. There should be no bleeding, if there is, then this is an incomplete abortion. It is rare, the uterus is dense, the cervix is shortened, the canal is passable, which indicates that a miscarriage has occurred. Almost no help is needed. So often an abortion occurs with isthmic-cervical insufficiency. Hormonal examination no earlier than six months later.

Failed miscarriage (frozen pregnancy). A detachment occurred, but the ovum remained in the uterus. The fetus dies, the uterus stops growing.

earlier they expected an independent miscarriage until the development of the generic dominant, while the fetus was mummified. This is fraught with bleeding in the postpartum period. A frozen pregnancy often leads to blood coagulation pathology (DIC syndrome).

One-step curettage, stimulation with oxytocin. Afibrinogenemia, bleeding that is very difficult to stop, is common.

4 Bleeding in the puerperium and early labor

Previously, they died from these bleeding.

The normal afterbirth period lasts 2 hours (within 2 hours the afterbirth must be separated from the walls of the uterus). The placenta is normally located on the back wall of the uterus with a transition to the side (or bottom). The separation of the placenta occurs in the first 2-3 contractions after the birth of the fetus, although it can separate from the walls during the birth of the fetus.

In order for the placenta to separate, the contractility of the uterus must be high (that is, equal to that in 1 period).

The placenta is separated due to the fact that there is a discrepancy between the volume of the uterine cavity and the placental site. The separation most often occurs in the first 10-15 minutes after the birth of the fetus (in classical obstetrics, the placenta can be separated within 2 hours after delivery).

The mechanism of hemostasis in the uterus.

Retraction of the myometrium - the most important factor is the contractile ability of the uterus.

Hemocoagulation factor - the processes of thrombus formation of the vessels of the placental site (they do not apply to other organ systems). Provide thrombus formation processes:

plasma factors

blood cells

biologically active substances

Childbirth is always accompanied by blood loss, since there is a hematochorial type of structure of the placenta.

Tissue factors

Vascular factors.

Prof. Sustapak believes that part of the placenta, amniotic fluid and other elements of the ovum are also involved in the process of thrombus formation.

These assumptions are correct because violations when:

antenatal fetal death (stillbirth) If the fetus is born more than 10 days after death, DIC may develop. Therefore, in case of prenatal death, childbirth tends to end as quickly as possible.

Amniotic fluid embolism (mortality 80%) also leads to DIC.

Violations in any link of hemostasis can lead to bleeding in the successive and early postpartum period.

Normal blood loss is no more than 400 ml, all that is higher is pathology (no more than 0.5% of body weight).

The separation of the placenta occurs from the center (formation of a retroplacental hematoma) or from the edge, hence the clinical difference during the period:

if the placenta is separated from the center, the blood will be in the membranes and there will be no spotting before the birth of the placenta.

If it is separated from the edge, then when signs of separation of the placenta appear, bleeding appears.

Risk groups for the development of bleeding (in general).

I. If we proceed from the fact that muscle retraction is the main mechanism of hemostasis, then 3 risk groups can be distinguished:

violation of the contractility of the uterus before the onset of labor:

abnormalities of the uterus

tumors of the uterus (fibroids)

if there were inflammatory diseases of the uterus (endometritis, metroendometritis).

Dystrophic disorders.

Women who have overstretching of the myometrium:

large fruit

polyhydramnios

multiple pregnancy

Women with somatic and endocrine disorders.

II risk group.

Women who have impaired uterine contractility during childbirth.

Childbirth complicated by abnormalities of labor (excessive labor, weakness of labor).

With excessive use of antispasmodic drugs.

Women with traumatic injuries (uterus, cervix, vagina).

III risk group. These are women who have impaired attachment and separation of the placenta and anomalies in the location of the placenta:

placenta previa complete and incomplete

PNRP develops during childbirth

tight attachment of the placenta and true placental augmentation

retention of parts of the placenta in the uterine cavity

spasm of the internal pharynx with a detached placenta.

That is, the risk groups are women with extragenital pathology, with complications in the course of pregnancy, with complications in the course of childbirth.

Bleeding in the successive period.

It is caused by a violation of the processes of separation of the placenta and the release of the placenta.

There are 2 phases during the period:

separation of the placenta

allocation of placenta

Violation of the process of separation of the placenta:

in women with weakness of labor

with tight attachment and true increment

Dense attachment of the placenta is when the chorionic villi do not go beyond the compact layer of the decidua. It can be complete or incomplete, depending on the length.

True accretion - villi penetrate into the muscular membrane of the uterus up to serosa and sometimes cause rupture of the uterus. 1/10000 births occur. It can be complete and incomplete, depending on the length.

If there is a complete true increment and complete tight attachment, then there will never be bleeding, that is, when the entire placental site adjoins or grows into the muscle wall.

With true partial augmentation, part of the placenta is separated and bleeding occurs in the subsequent period.

Bleeding in the successive period can develop when parts of the placenta are delayed, when part of the placenta is separated and excreted, and a few lobules remain or a piece of the membrane remains and interferes with the contraction of the uterus.

Violation of the allocation of the placenta.

Violation at:

hypotonic uterus

internal throat spasm

Spasm can occur with improper use of contractile agents in the subsequent period.

The tactics of conducting the sequential period.

Principle: hands off the womb!

Before checking the contact signs, it is necessary to check the non-contact ones: they look at the umbilical cord remnant, which lengthens (positive Alfeld sign). The uterus deviates to the right, upward and flattens (Schroeder's sign), retraction of the umbilical cord with a deep breath (Dovzhenko's sign).

It is necessary to start separating the placenta as soon as signs of its separation appear.

Or physiologically (pushing)

external receptions (Abuladze, Genter, Krede-Lazarevich) - these methods can only separate the separated afterbirth.

If bleeding occurs in the subsequent period, then the first task of the obstetrician is to determine if there are signs of placental separation.

There are signs of separation of the placenta.	No signs of placental separation.
Immediately highlight the latter with external techniques assess blood loss enter or continue the administration of uterotonics put ice and weight on your stomach clarify the condition of the woman in labor and the amount of blood loss examine the afterbirth and the integrity of its tissues	Assess the general condition of the woman in labor and the amount of blood loss Give intravenous anesthesia and start or continue the administration of uterotonics after performing an external massage of the uterus before Proceed with the operation of manual separation of the placenta and allocation of the placenta.
If blood loss is normal, then you need to: monitor the condition of a woman introduce uterotonics for another 30-40 minutes.
If the blood loss is pathological, then you need to do: Clarify the woman's condition Reimburse blood loss: with blood loss of 400-500 ml - gelatinol + saline solution + intravenous oxytocin. If the blood loss is more than 500 ml, then hemodynamic disturbances occur, it is necessary to transfuse blood.

Operation of manual separation of the placenta and allocation of the placenta.

The hand is inserted into the uterine cavity.

Professor Akininz proposed a method - a sterile sleeve is put on the hand and the fingers are closed when inserted into the vagina, the assistants pull the sleeve towards themselves and thus the infection is reduced.

The hand must get between the wall of the uterus and the membranes, so that then with sawing movements they reach the placental site, separate it from the wall and excrete the placenta.

Reassess blood loss. If the blood loss before the operation is 300-400, then during the operation it increases due to traumatic injuries.

Compensate for blood loss.

Continue intravenous administration of uterotonics.

With full true increment and full tight attachment, there is no bleeding (according to the classical laws, 2 hours are expected). In modern conditions, the rule is: to separate the placenta 30 minutes after the birth of the fetus, if there are no signs of placenta separation in the absence of bleeding. Carried out: the operation of manual separation of the placenta and the allocation of the placenta.

Further tactics depend on the result of the operation:

if the bleeding has stopped as a result of the operation, then it is necessary:

assess blood loss

If bleeding continues due to accretion, attachment of the placenta, etc. then this bleeding goes into the early postpartum period.

Prior to the operation of manual removal of the placenta, no data can be used to make a differential diagnosis of tight attachment or true placenta accreta. Differential diagnosis only during surgery.

With a tight attachment, the hand can separate the decidula from the underlying muscle tissue; in true increment, this is impossible. You can not be zealous, as very severe bleeding can develop.

With a true increment, the uterus must be removed - amputation, extirpation, depending on the location of the placenta, obstetric history, etc. this is the only way to stop the bleeding.

Bleeding in the early postpartum period.

Most often it is a continuation of complications in all stages of labor.

The main reason is the hypotonic state of the uterus.

Risk group.

Women with weakness in labor.

Childbirth with a large fetus.

Polyhydramnios.

Multiple pregnancies.

Pathogenesis. Violation of thrombus formation due to the exclusion of the muscle factor from the mechanisms of hemostasis.

Also, the causes of bleeding in the early postpartum period can be:

injuries of the uterus, cervix, vagina

blood diseases

Hypotonic bleeding options.

Bleeding immediately, profuse. In a few minutes, you can lose 1 liter of blood.

After taking measures to increase the contractility of the uterus: the uterus contracts, bleeding stops after a few minutes - a small portion of blood - the uterus contracts, etc. and so gradually, in small portions, blood loss increases and hemorrhagic shock occurs. With this option, the vigilance of the personnel is reduced and it is they that often lead to death, since there is no timely compensation for blood loss.

The main operation that is performed for bleeding in the early postpartum period is called MANUAL EXAMINATION OF THE UTERINE CAVITY.

Tasks of the ROPM operation:

to establish whether the lingering parts of the placenta remain in the uterine cavity, remove them.

Determine the contractile potential of the uterus.

Determine the integrity of the walls of the uterus - whether there is a rupture of the uterus (it is sometimes difficult to diagnose clinically).

To establish whether there is a malformation of the uterus or a tumor of the uterus (a fibromatous node is often the cause of bleeding).

The sequence of performing the operation of manual examination of the uterine cavity.

Determine the amount of blood loss and the general condition of the woman.

Treat hands and external genitals.

Give intravenous anesthesia and start (continue) the introduction of uterotonics.

Empty the uterine cavity from blood clots and retained parts of the placenta (if any).

Determine the tone of the uterus and the integrity of the walls of the uterus.

Examine the soft birth canal and suture lesions, if any.

Re-evaluate the woman's condition for blood loss, compensate for the blood loss.

SEQUENCE OF ACTIONS WHEN STOPPING HYPOTONIC BLEEDING.

Assess the general condition and volume of blood loss.

Intravenous anesthesia, start (continue) the introduction of uterotonics.

Proceed with the operation of manual examination of the uterine cavity.

Remove clots and retained parts of the placenta.

Determine the integrity of the uterus and its tone.

Examine the soft birth canal and suture the damage.

Against the background of the ongoing intravenous administration of oxytocin, 1 ml of methylergometrine can be injected intravenously at once and 1 ml of oxytocin can be injected into the cervix.

Introduction of tampons with ether into the posterior fornix.

Reassessment of blood loss, general condition.

Compensation for blood loss.

Obstetricians also allocate atonic bleeding (bleeding in the complete absence of contractile ability - Kuveler's uterus). They differ from hypotonic bleeding in that the uterus is completely absent and does not respond to the administration of uterotonics.

If hypotonic bleeding does not stop with ROPM, then further tactics are as follows:

put a suture on the posterior lip of the cervix with a thick catgut ligature - according to Lositskaya. The mechanism of hemostasis: reflex contraction of the uterus, since a huge number of interoreceptors are located in this lip.

The same mechanism occurs with the introduction of a tampon with ether.

Applying clamps to the cervix. Two fenestrated clamps are inserted into the vagina, one open branch is in the uterine cavity, and the other in the lateral fornix of the vagina. The uterine artery departs from the iliac in the area of the internal os, is divided into descending and ascending parts. These clamps clamp the uterine artery.

These methods sometimes stop bleeding and sometimes are preparation steps for surgery (as they reduce bleeding).

Massive blood loss is considered to be blood loss during childbirth of 1200 - 1500 ml. Such blood loss dictates the need for surgical treatment - removal of the uterus.

When starting the operation to remove the uterus, you can try another reflex method to stop bleeding:

ligation of blood vessels according to Tsitsishvili. The vessels passing in the round ligaments, the own ligament of the ovary and in the uterine section of the tube, and on the uterine arteries are ligated. The uterine artery runs along the rib of the uterus. If it does not help, then these clamps and vessels will be preparatory for removal.

Electrical stimulation of the uterus (now they are moving away from it). Electrodes are placed on the abdominal wall or directly on the uterus and a discharge is applied.

Acupuncture

Along with stopping bleeding, blood loss is compensated.

Prevention of bleeding.

It is possible and necessary to predict bleeding by risk groups:

extragenital pathology

complications of pregnancy

preeclampsia (chronic stage of DIC)

multiparous

large fruit, polyhydramnios, multiple pregnancy

weakness of labor during childbirth

This requires examination of the woman during pregnancy:

blood platelet test

blood coagulation potential

skilled management of childbirth

Prevention of bleeding in the successive and early postpartum period:

Administration of uterotonics depending on the risk group.

Minimum risk group: women with no somatic history. Bleeding can be because childbirth is a stressful situation, and the body's response can be different. Intramuscular administration of uterotonics after the birth of the placenta: oxytocin, pituitrin, gifhotocin 3-5 U (1 U = 0.2 ml), a group of higher risk. Intravenous drip of oxytocin, which begins in the second stage of labor and ends within 30-40 minutes after birth. Or according to the scheme: methylergometrine 1 mg in 20 ml of saline (5% glucose solution) intravenously at the time of the eruption of the head.

In the high-risk group, a combination of intravenous drip of oxytocin + simultaneous administration of methylergometrine.

Violation of hemostasis in childbirth is detected as follows:

test according to Lee-White (blood is taken from a vein into a test tube and the blood clotted).

It is possible to determine the coagulation potential on a glass slide using the Folia methods: 2-3 drops from a finger and it is determined after how many minutes the blood will coagulate.

The first stage of labor is 3-5 minutes.

The second stage of labor is 1-3 minutes.

The third period is 1-3 minutes.

NORM ON LEE-WHITE.

The first period is 6-7 minutes.

The third period is 5 minutes.

The early postpartum period is 4 minutes.

A woman at risk should be provided with blood substitutes and blood before entering childbirth.

Bibliography

For the preparation of this work were used materials from the site referat.med-lib.ru

Risk of primary miscarriage

Doctors note a certain pattern: the risk of spontaneous abortion after two failures increases by 24%, after three - 30%, after four - 40%.

With miscarriage, a complete or incomplete pregnancy occurs (the ovum detached from the wall of the uterus, but remained in its cavity and did not come out), a miscarriage in the period up to 22 weeks. At a later date, in the period 22-37 weeks, spontaneous termination of pregnancy is called premature birth, while an immature but viable baby is born. Its weight ranges from 500 to 2500 g. Premature, prematurely born children are immature. Their death is often noted. Developmental malformations are often recorded in surviving children. The concept of prematurity, in addition to the short term for the development of pregnancy, includes a low fetal body weight at birth, on average from 500 to 2500 g, as well as signs of physical immaturity in the fetus. Only by the combination of these three signs, a newborn can be considered premature.

With the development of miscarriage, certain risk factors are indicated.

Modern advances in medicine and new technologies, timeliness and quality of medical care make it possible to avoid serious complications and prevent premature termination of pregnancy.

A woman with a first trimester miscarriage should undergo a long examination even before the intended pregnancy and during pregnancy to identify the true cause of miscarriage. A very difficult situation develops with spontaneous miscarriage against the background of the normal course of pregnancy. In such cases, the woman and her doctor can do nothing to prevent such a course of events.

The most common factor in the development of premature termination of pregnancy is fetal chromosomal abnormalities. Chromosomes are microscopic elongated structures located in the internal structure of cells. Chromosomes contain genetic material that sets all the properties characteristic of each "person: eye color, hair, height, weight parameters, etc. In the structure of the human genetic code there are 23 pairs of chromosomes, in total 46, with one part inherited from organism, and the second - from the father. Two chromosomes in each set are called sex and determine the sex of a person (XX chromosomes determine the female sex, XY chromosomes - the male sex), while the other chromosomes carry the rest of the genetic information about the whole organism and are called somatic.

It was found that about 70% of all miscarriages in early pregnancy are due to abnormalities of somatic chromosomes in the fetus, while most of the chromosomal abnormalities of the developing fetus were due to the participation of a defective egg or sperm in the fertilization process. This is due to the biological process of division, when an egg and a sperm cell during their pre-maturation divide in order to form mature germ cells, in which the set of chromosomes is 23. In other cases, eggs or spermatozoa with an insufficient (22) or with an excess (24) set are formed. chromosomes. In such cases, the formed embryo will develop with a chromosomal abnormality, which leads to a miscarriage.

The most common chromosomal defect can be considered trisomy, while the embryo is formed when the germ cell merges with chromosome set 24, as a result of which the set of fetal chromosomes is not 46 (23 + 23), as it should be normal, but 47 (24 + 23) chromosomes ... Most trisomies involving somatic chromosomes lead to the development of a fetus with defects that are incompatible with life, which is why spontaneous miscarriage occurs in the early stages of pregnancy. In rare cases, a fetus with a similar developmental anomaly survives to a long time.

Down's disease (represented by trisomy 21 on chromosome) can be cited as an example of the most well-known developmental abnormality caused by trisomy.

A large role in the occurrence of chromosomal abnormalities is played by the woman's age. And recent studies show that the age of the father plays an equally important role, the risk of genetic abnormalities increases when the father is over 40 years old.
As a solution to this problem, married couples where at least one partner has been diagnosed with congenital genetic diseases is offered mandatory counseling with a geneticist. In certain cases, IVF (in vitro fertilization - in vitro fertilization) is proposed with a donor egg or sperm, which directly depends on which of the partners has revealed such chromosomal abnormalities.

Causes of primary miscarriage

There can be many reasons for the occurrence of such violations. The process of conceiving and bearing a baby is complex and fragile, it involves a large number of interrelated factors, one of which is endocrine (hormonal). The female body maintains a certain hormonal background so that the baby can develop correctly at every stage of its intrauterine development. If, for some reason, the body of the expectant mother begins to produce hormones incorrectly, then hormonal imbalances threaten to terminate the pregnancy.

Never take hormones on your own. Taking them can seriously impair reproductive function.

The following congenital or acquired uterine lesions may threaten the course of pregnancy.

Anatomical malformations of the uterus - doubling of the uterus, saddle uterus, two-horned uterus, one-horned uterus, partial or complete uterine septum in the cavity - are congenital. Most often, they prevent the ovum from successfully implanting (for example, the egg "sits" on the septum, which is unable to perform the functions of the inner layer of the uterus), which is why a miscarriage occurs.
Chronic endometritis - inflammation of the mucous layer of the uterus - the endometrium. As you remember from the section that provides information on the anatomy and physiology of women, the endometrium has an important reproductive function, but only as long as it is "healthy". Prolonged inflammation changes the nature of the mucous layer and disrupts its functionality. It will not be easy for the ovum to attach and grow and develop normally on such an endometrium, which can lead to the loss of pregnancy.
Polyps and endometrial hyperplasia - proliferation of the mucous membrane of the uterine cavity - the endometrium. This pathology can also interfere with embryo implantation.
Intrauterine synechiae are adhesions between the walls in the uterine cavity, which prevent the fertilized egg from moving, implanting and developing. Synechiae most often occur as a result of mechanical trauma to the uterine cavity or inflammatory diseases.
Uterine fibroids are benign tumor processes that occur in the muscular layer of the uterus - myometrium. Fibroids can cause miscarriage if the ovum is implanted next to the myoma node, which has violated the tissue of the inner cavity of the uterus, "takes over" the blood flow and can grow towards the ovum.
Isthmico-cervical insufficiency. It is considered the most common cause of perinatal losses in the second trimester of pregnancy (13-20%). The cervix is shortened with subsequent dilatation, which leads to the loss of pregnancy. Usually isthmic-cervical insufficiency occurs in women whose cervix has been damaged earlier (abortion, rupture in childbirth, etc.), has a congenital malformation or cannot cope with increased stress during pregnancy (large fetus, polyhydramnios, multiple pregnancies, etc.). NS.).

Some women have a congenital predisposition to thrombosis (blood clots, blood clots in the vessels), which makes it difficult to implant the ovum and interferes with normal blood flow between the placenta, baby and mother.

The expectant mother often does not even know about her pathology before pregnancy, since her hemostasis system coped well with its functions before pregnancy, that is, without the "double" load that appears with the task of carrying a baby.

There are other causes of miscarriage that need to be diagnosed for timely prevention and treatment. Correction methods will depend on the identified cause.

The reason for the habitual miscarriage can also be normal chromosomes, which do not give development problems in both partners, but carry a latent carriage of chromosomal abnormalities, which affect fetal abnormalities. In such a situation, both parents must perform a karyotype test of their blood in order to detect such chromosomal abnormalities (carriage of non-manifest chromosomal abnormalities). With this examination, based on the results of karyotyping, a probable assessment of the course of subsequent pregnancy is determined, and the examination cannot give a 100% guarantee of possible anomalies.

Chromosomal abnormalities are manifold, they can also cause missed pregnancies. In this case, only the fetal membranes are formed, while the fetus itself may not be. It is noted that the ovum is either formed initially, or it stopped its further development in the early stages. For this, in the early stages, the cessation of the characteristic symptoms of pregnancy is characteristic, at the same time, dark brown discharge from the vagina often appears. An ultrasound scan allows to reliably determine the absence of the ovum.

Miscarriage in the second trimester of pregnancy is mainly associated with abnormalities in the structure of the uterus (such as an irregular shape of the uterus, an extra uterine horn, its saddle shape, the presence of a septum, or a weakening of the retention capacity of the cervix, the disclosure of which leads to premature birth). In this case, infection of the mother (inflammatory diseases of the appendages and uterus) or chromosomal abnormalities of the fetus can become possible causes of miscarriage at a later date. According to statistics, chromosomal abnormalities are the cause of miscarriage in the second trimester of pregnancy in 20% of cases.

Symptoms and signs of primary miscarriage

Bleeding is a characteristic symptom of miscarriage. Bloody vaginal discharge with spontaneous miscarriage usually begins suddenly. In some cases, a miscarriage is preceded by a pulling pain in the lower abdomen, which resembles pain before menstruation. Along with the release of blood from the genital tract, with the onset of spontaneous miscarriage, the following symptoms are often observed: general weakness, malaise, fever, decrease in nausea that was present before, emotional tension.

But not all cases of bleeding in early pregnancy end in spontaneous miscarriage. In case of discharge of blood from the vagina, a woman should consult a doctor. Only a doctor will be able to conduct a proper examination, determine the condition of the fetus, find out if the cervix is dilated and choose the right treatment aimed at maintaining the pregnancy.

If spotting from the genital tract is detected in the hospital, a vaginal examination is performed first. If the first miscarriage occurred in the first trimester of pregnancy, then the study is carried out shallowly. In the event of a miscarriage in the second trimester or two or more spontaneous abortions in the first trimester of pregnancy, a complete examination becomes necessary.

In this case, the course of a full examination includes a certain set of examinations:

blood tests for chromosomal abnormalities in both parents (clarification of the karyotype) and determination of hormonal and immunological changes in the mother's blood;
conducting a test for chromosomal abnormalities of aborted tissues (it is possible to determine when these tissues are available - either the woman herself saved them, or they were removed after curettage of the uterus in a hospital);
ultrasound examination of the uterus and hysteroscopy (examination of the uterine cavity using a video camera, which is inserted through the cervix and displays a picture on the screen);
hysterosalpingography (x-ray examination of the uterus;
biopsy of the endometrium (inner layer) of the uterus. This manipulation involves taking a small piece of the uterine lining, after which a hormonal examination of the tissue is performed.

Treatment and prevention of primary miscarriage

If pregnancy is threatened by endocrine disorders in a woman, then after laboratory tests, the doctor prescribes hormonal therapy. In order to prevent unwanted hormone surges, medications can be prescribed even before pregnancy, with subsequent dosage and drug adjustments already during pregnancy. In the case of hormone therapy, the condition of the expectant mother is always monitored and the appropriate laboratory tests (analyzes) are performed.

If miscarriage is due to uterine factors, then the appropriate treatment is carried out several months before the conception of the baby, since it requires surgical intervention. During the operation, synechiae are dissected, polyps of the uterine cavity are eliminated, fibroids that interfere with the course of pregnancy are removed. Medication before pregnancy treats infections that contribute to the development of endometritis. Cervical insufficiency during pregnancy is corrected surgically. Most often, the doctor prescribes suturing of the cervix (for a period of 13-27 weeks) when its insufficiency occurs - the cervix begins to shorten, become softer, the internal or external pharynx opens. Stitches are removed at 37 weeks of gestation. A woman with a sutured cervix is shown a gentle physical regimen, no psychological stress, since even on the sutured cervix, amniotic fluid may leak.

In addition to suturing the cervix, a less traumatic intervention is used - putting on the neck of the Meyer ring (obstetric pessary), which also protects the cervix from further disclosure.

The doctor will suggest the most appropriate method for each specific situation.

Do not forget that not only ultrasound data are important, but also information obtained during a vaginal examination, since the neck can be not only shortened, but also softened.

For the prevention and treatment of problems associated with the hemostasis system of the expectant mother, the doctor will prescribe laboratory blood tests (mutations in the hemostasis system, coagulogram, D-dimer, etc.). Based on the published examination results, medication (tablets, injections) can be applied to improve blood flow. Expectant mothers with impaired venous blood flow are recommended to wear medical compression hosiery.

There can be many reasons for miscarriage. We did not mention severe extragenital pathologies (diseases not related to the genital area), in which it is difficult to bear a child. It is possible that for a particular woman, not one reason is "working" for her condition, but several factors at once, which, overlapping each other, give such a pathology.

It is very important that a woman with miscarriage (three or more losses in history) is examined and medication trained BEFORE the forthcoming pregnancy in order to avoid this complication.

Treatment of such a pathology is extremely difficult and requires a strictly individual approach.

Most women do not need treatment as such immediately after a spontaneous miscarriage in the early stages. The uterus is gradually and completely self-cleaning, as it does during menstruation. However, in some cases of incomplete miscarriage (partially the remnants of the ovum remain in the uterine cavity) and when the cervix is bent, it becomes necessary to scrap the uterine cavity. Such manipulation is also required with intense and non-stopping bleeding, as well as in cases of a threat of the development of an infectious process, or if, according to ultrasound data, remnants of the membranes are found in the uterus.

Anomalies in the structure of the uterus are one of the main causes of habitual miscarriage (the cause is in 10-15% of cases of repeated miscarriage in both the first and second trimesters of pregnancy). Such structural anomalies include: an irregular shape of the uterus, the presence of a septum in the uterine cavity, benign neoplasms that deform the uterine cavity (fibroids, fibromas, fibroids) or scars from previous surgical interventions (cesarean section, removal of fibromatous nodes). As a result of such violations, problems arise for the growth and development of the fetus. The solution in such cases is the elimination of possible structural abnormalities and very close monitoring during pregnancy.

An equally important role in the habitual miscarriage is played by a certain weakness of the muscular ring of the cervix, while the most typical term for termination of pregnancy for this reason is 16-18 weeks of pregnancy. Initially, the weakness of the muscle ring of the cervix can be congenital, and can also result from medical interventions - traumatic injuries of the muscle ring of the cervix (as a result of abortion, cleansing, rupture of the cervix during childbirth) or a certain kind of hormonal disorders (in particular, an increase in the level of male sex hormones). The problem can be solved by placing a special suture around the cervix at the beginning of the subsequent pregnancy. The procedure is called "cervical sequestration".

A significant cause of recurrent miscarriage is hormonal imbalance. Thus, the studies conducted have revealed that a low level of progesterone is extremely important in maintaining pregnancy in the early stages. It is the lack of this hormone that is the cause of early termination of pregnancy in 40% of cases. The modern pharmaceutical market has significantly replenished with drugs similar to the hormone progesterone. These are called progestins. The molecules of such synthetic substances are very similar to progesterone, but they also have a number of differences due to modification. Such drugs are used in hormone replacement therapy in cases of insufficiency of the corpus luteum, although each of them has a certain range of disadvantages and side effects. Currently, one can name only one drug that is completely identical to natural progesterone - utrozhestan. The drug is very easy to use - it can be taken orally and inserted into the vagina. Moreover, the vaginal route of administration has a large number of advantages, since, being absorbed into the vagina, progesterone immediately enters the uterine bloodstream, therefore, the secretion of progesterone by the corpus luteum is simulated. To maintain the luteal phase, micronized progesterone is prescribed in a dose of 2-3 capsules per day. If, against the background of the use of urozhestan, pregnancy develops safely, then its reception continues, and the dose is increased to 10 capsules (as determined by the gynecologist). With the course of pregnancy, the dosage of the drug is gradually reduced. The drug is reasonably used up to the 20th week of pregnancy.

Severe hormonal disturbance can be a consequence of polycystic ovaries, resulting in multiple cystic formations in the body of the ovaries. The reasons for repeated failure in such cases are not well understood. Habitual miscarriage is often the result of immune disorders in the body of the mother and fetus. This is due to the specific feature of the body to produce antibodies to fight off penetrating infections. However, the body can also synthesize antibodies against the body's own cells (autoantibodies), which can attack the body's own tissues, causing health problems and premature termination of pregnancy. These autoimmune disorders are the cause in 3-15% of cases of habitual pregnancy failure. In such a situation, first of all, it is necessary to measure the available level of antibodies with the help of special blood tests. Treatment involves the use of low doses of aspirin and blood thinners (heparin), which leads to the possibility of carrying a healthy baby.

Modern medicine draws attention to a new genetic abnormality - factor V Leiden mutation, which affects blood clotting. This genetic trait can also play an important role in recurrent miscarriage. Treatment of this kind of disorders is currently not fully developed.

A special place among the causes of habitual pregnancy failure is occupied by asymptomatic infectious processes in the genitals. It is possible to prevent premature termination of pregnancy by routine examination of partners for infections, including women, before a planned pregnancy. The main pathogens causing recurrent miscarriage are mycoplasmas and ureaplasmas. For the treatment of such infections, antibiotics are used: ofloxin, vibromycin, doxycycline. Treatment must be performed by both partners. A control examination for the presence of these pathogens is performed one month after the end of antibiotic therapy. A combination of local and general treatment is essential in this case. Locally, it is better to use broad-spectrum drugs that act on several pathogens at the same time.

In the event that the reasons for repeated pregnancy failure even after a comprehensive examination cannot be found, the spouses should not lose hope. It was statistically established that in 65% of cases after pregnancy, the spouses have a successful subsequent pregnancy. To do this, it is important to strictly follow the instructions of doctors, namely to take a proper break between pregnancies. For full physiological recovery after a spontaneous miscarriage, it takes from several weeks to a month, depending on at what time the pregnancy was terminated. For example, certain pregnancy hormones remain in the blood for one or two months after a spontaneous miscarriage, and in most cases menstruation begins 4-6 weeks after the termination of the pregnancy. But psycho-emotional recovery often takes much longer.

It should be remembered that the observation of a pregnant woman with habitual miscarriage should be carried out weekly, and if necessary, more often, for which hospitalization is carried out in a hospital. After establishing the fact of pregnancy, an ultrasound examination should be performed to confirm the uterine form, and then every two weeks until the period at which the previous pregnancy was terminated. If, according to the ultrasound, the fetal cardiac activity is not recorded, then it is recommended to take fetal tissues for karyotyping.

Once fetal cardiac activity is detected, additional blood tests are unnecessary. However, in later stages of pregnancy, in addition to ultrasound, an assessment of the level of α-fetoprotein is desirable. An increase in its level may indicate malformations of the neural tube, and low values - chromosomal abnormalities. An increase in the concentration of α-fetoprotein for no obvious reason at 16-18 weeks of gestation may indicate the risk of spontaneous abortion in the second and third trimesters.

Assessment of the karyotype of the fetus is of great importance. This study should be carried out not only for all pregnant women over 35, but also for women with recurrent miscarriage, which is associated with an increased likelihood of fetal malformations during subsequent pregnancy.

When treating recurrent miscarriage of an unclear cause, IVF can be considered one of the alternatives. This method allows you to perform a study of germ cells for chromosomal abnormalities even before in vitro fertilization. The combination of the application of this technique with the use of a donor egg yields positive results in the onset of the desired full-fledged pregnancy. According to statistics, full-fledged pregnancy in women with recurrent miscarriage after this procedure occurred in 86% of cases, and the frequency of miscarriages decreases to 11%.

In addition to the described various methods of treating recurrent miscarriage, it should be noted that non-specific, background therapy, the purpose of which is to remove the increased tone of the muscular wall of the uterus. It is the increased tone of the uterus of various natures that is the main cause of premature miscarriages. Treatment involves the use of no-shpa, suppositories with papaverine or belladonna (injected into the rectum), intravenous drip of magnesia.

Miscarriage- spontaneous termination of pregnancy up to 37 full weeks, counting from the first day of the last menstruation. Miscarriage, ending in the death of the fetus at various stages of pregnancy, is a complex obstetric and gynecological problem and often has serious psychological consequences for the entire family. According to the WHO definition, miscarriage is considered "expulsion or removal from the mother's body of an embryo or fetus weighing 500 g or less", which approximately corresponds to a gestation period of 20-22 weeks and the fetus is still considered unviable.

The frequency of miscarriages is 15-20% of the total number of all clinically diagnosed pregnancies. However, only according to clinical data, in the early stages of pregnancy, a spontaneous miscarriage may not be diagnosed. Its frequency increases to 30-60%, when, before the onset of the next menstruation, such highly sensitive methods as determining the level of β-hCG in the blood serum are used to confirm pregnancy. Most often, the diagnosis of "chemical" pregnancy by the level of β-hCG is established in a group of patients with infertility after stimulation of ovulation with hormonal drugs.

From 40 to 80% of miscarriages occur in the first trimester of pregnancy, and almost every second woman does not even assume that she had a pregnancy. With an increase in the duration of pregnancy (in the II and III trimesters), the frequency of miscarriages decreases.

Miscarriage occurs more often in patients with bleeding from the genital tract from early pregnancy (12.4-13.6%) compared with patients without bleeding (4.2-6.1%). For women with idiopathic or "unexplained" miscarriage, the most dangerous abortion rates are 6-8 weeks. It is during this period that 78% of miscarriages occur, and most of them are before the onset of cardiac activity, that is, the embryo dies, not the embryo. At 8 weeks of pregnancy, in the presence of a fetal heartbeat, the probability of miscarriages is 2%, pregnancy persists in 98% of patients. At the same time, during a pregnancy of 10 weeks and a normal fetal heartbeat, the frequency of miscarriages is only 0.6%, and the probability of maintaining the pregnancy is 99.4%.

The outcome of pregnancy depends on the age of the patient: if a 20-year-old patient with two miscarriages in history has a 92% chance of a favorable outcome of a subsequent pregnancy, then in a 45-year-old woman with a similar number of miscarriages it is 60%.

An increase in the risk of miscarriage rates has been described, depending on the number of previous miscarriages. So, with one miscarriage, the threat of subsequent termination of pregnancy is 15%, with two - 25%, with three - 45% and with four - 54%. Similarly, the risk of developing secondary infertility increases, which in general for the group is about 35%.

In cases where a woman has three consecutive miscarriages in gestation up to 20 weeks, a diagnosis of recurrent miscarriage is established. According to statistics, this pathology is 1 in 300 pregnancies. Termination of pregnancy and subsequent curettage of the uterus is the cause of the development of severe inflammatory diseases of the genitals, adhesions, pathology of the uterus and tubes, complex neuroendocrine disorders, recurrent miscarriage and infertility.

What provokes miscarriage

Miscarriage, as a rule, is the result of not one, but several reasons that act simultaneously or sequentially. In clinical practice, it can be difficult to establish a specific factor that led to spontaneous abortion, since this is prevented by tissue maceration after fetal death, which complicates chromosomal and morphological research. A detailed analysis of the reasons that were probably the cause of miscarriage, and the most accurate diagnosis is possible to establish only during examination after a spontaneous miscarriage. In most foreign clinics, examination and treatment for miscarriage begins only after three miscarriages. Domestic scientists believe that finding out the causes of miscarriage should begin after the first termination of pregnancy.

The main reasons for miscarriage are considered:
- genetic factors;
- sexually transmitted infections (STIs);
- endocrine disorders;
- immune factors;
- congenital and acquired pathology of the uterus;
- other factors.

In almost 45-50% of women, it is not possible to establish the cause of spontaneous miscarriage, and they constitute the group of "unexplained" miscarriage.

Characteristics of the most significant risk factors

- Genetic disorders
Genetic disorders leading to spontaneous miscarriage are well studied and account for about 5% in the structure of the causes of this pathology. From 40 to 60% of miscarriages occurring in the first trimester of pregnancy are caused by abnormalities in the chromosomes of the embryo. Early termination of pregnancy can be the result of natural selection, which leads to the death of the pathologically developing embryo and / or fetus.

Chromosomal pathology with recurrent miscarriage is more common and clinically more significant than in patients with a single miscarriage. The causes of spontaneous miscarriage and recurrent miscarriage may be identical, however, concomitant pathology of the reproductive system in married couples with recurrent miscarriage occurs much more often than in women with one miscarriage.

Chromosomal aberrations play a special role in patients with spontaneous miscarriages.

Autosomal trisomy as the most common type of chromosomal pathology is responsible for more than half of the pathological karyotypes. Autosomal trisomies result from the absence of chromosome divergence during the first mitotic division of the oocyte, and the frequency of this phenomenon increases with the age of the mother.

Mother's age does not matter for other chromosomal abnormalities that cause spontaneous miscarriages.

Monosomy X causes embryo aplasia. Triploidy and tetraploidy occur with moderate frequency. A structural chromosome abnormality is a translocation transmitted by one of the parents. Among other violations of the karyotype, there are various forms of mosaicism, double trisomies and other pathologies.

Sporadic spontaneous miscarriages during short term pregnancies reflect the universal biological mechanism of natural selection that ensures the birth of healthy offspring. More than 95% of mutations are eliminated in utero. Human chromosomal pathology depends not only on the intensity of the mutation process, but also on the efficiency of selection. With age, selection weakens and therefore developmental anomalies are more common.

Chromosomal abnormalities are detected only when the karyotype is determined. It is not easy to establish the significance of defects in one gene in the development of spontaneous abortions, since not all medical institutions have the technical ability to detect this pathology. Sex-linked hereditary diseases can lead to spontaneous miscarriage only during pregnancy with a male fetus.

- Inflammatory diseases
The inflammatory genesis of miscarriage is due to the peculiarities of the penetration of microorganisms through the placenta to the fetus from the mother's blood. The presence of microorganisms in the mother may be asymptomatic or accompanied by characteristic signs of an inflammatory disease. Often, the pathogen, passing through the placenta, causes the development of placentitis with certain histopathological changes. Thus, bacteria (gram-negative and gram-positive cocci, listeria, treponema and mycobacteria), protozoa (toxoplasma, plasmodia) and viruses can enter the fetus.

The hematogenous and contact routes of infection, prevailing in the first trimester of pregnancy, subsequently give way to the ascending spread of infections. An ascending infection from the lower parts of the reproductive organs infects the amniotic membranes, whether their integrity is compromised or not. The fetus becomes infected with contaminated amniotic fluid or infectious agents that spread through the amniotic membranes and further along the umbilical cord to the fetus.

Some inflammatory diseases of the mother during pregnancy are characterized by special clinical manifestations or more severe consequences. Acute infections, accompanied by severe intoxication and hyperthermia, can stimulate the activity of the uterus and thereby lead to termination of pregnancy. In most cases, it is difficult to establish a direct causal relationship between abortion and a specific pathogenic agent. If any microorganism can be isolated from the tissues of a deceased embryo / fetus, it is almost impossible to determine when the contamination occurred: before or after its death in the uterine cavity.

In general, it is possible that bacteria and viruses can enter the uterine cavity during pregnancy and cause spontaneous miscarriage, but only a few of them directly affect the fetus. It is more likely that the fetus is infected through the placenta, which leads to chorionamnionitis, release of prostaglandins and increased uterine contractile activity.

There is a relationship between bacterial invasion and the synthesis of cytokines by cells of the amnion, chorion, decidua and fetal tissues. The reproduction of microorganisms in the amniotic fluid leads to an increase in the level of lipopolysaccharides, which activate the synthesis of cytokines: TNF, IL-1, -6, -8, etc. pregnancy.

One of the possible ways of penetration of infection into the embryo / fetus is chorionic biopsy, amniocentesis, fetoscopy, cordocentesis, intrauterine blood transfusion, especially if these manipulations are carried out transcervically.

In clinical practice, the differential diagnosis between primary and secondary inflammatory process of the genitals is of great importance, which is carried out according to the data of pathomorphological examination after a spontaneous miscarriage occurred. The diagnosis of primary inflammation is established in the absence of other pathological processes that can cause a violation of uterine pregnancy.

Combined inflammation can be talked about in the case of the simultaneous presence of several etiological factors, the severity of which does not allow distinguishing the sequence of their pathogenic effects. Secondary inflammation is characterized by vascular-cellular reactions against the background of long-term manifestations of the preceding etiological factors.

The effect of infection on the fetus depends on the state of its body and the gestational age. Given the absence of a formed placental barrier in the first trimester, any types of hematogenous and ascending infection are dangerous. At this time, the most common complications of pregnancy are intrauterine infection, fetal abnormalities and spontaneous miscarriage.

The severity of the lesion and the prevalence of the pathological process in the embryo / fetus depend on its ability to an immune response, on the type, virulence and number of penetrated microorganisms, the duration of the mother's illness, the state of her protective and adaptive mechanisms and other factors.

A distinctive feature of the etiological structure of infectious diseases is currently various associations of microorganisms - viral-bacterial, viral-viral and bacterial-bacterial, which is due to the peculiarities of the immune response, in which complete elimination of the pathogen from the body is impossible.

The main source of the gravidar inflammatory process that develops in the first trimester of pregnancy is most often the foci of infection located in the vagina and cervix. The presence of nonspecific inflammatory diseases of the vagina and cervix (acute or chronic endocervicitis, structural and functional inferiority of the cervix) is one of the presumed factors of a similar inflammatory process in the endometrium. This inflammatory process exacerbates the likelihood of infection of the fetal bladder and thereby serves as an indirect cause of early termination of pregnancy.

The state of the vaginal microflora, as a risk factor, has not been given due attention for a long time, but today there is no doubt that opportunistic bacteria prevail among the microbes entering the uterine cavity from the lower reproductive organs, and the imbalance of the vaginal environment is considered as the main reason for the complicated course of pregnancy and fetal IUI. The spectrum of pathogens includes numerous pathogens, such as group A streptococci, opportunistic anaerobes, which are relatively often detected in the vagina.

The action of various infectious agents, as well as unfavorable factors of a different nature (any form of bleeding during pregnancy, the threat of spontaneous abortion, active sex life, etc.) lead to the loss of mechanisms for controlling the immune response and disorders in the local immunity system, which is of great importance in preventing various diseases. Violation of the microbiocenosis of the genital tract is accompanied by an imbalance in the local immune status, expressed in a decrease in the level of IgG and an increase in the amount of IgA.

Infectious processes in the vagina and cervix belong to a group of diseases, the consequences of which during pregnancy can be largely prevented by screening for infections, timely detection of imbalances in various types of microorganisms and appropriate treatment.

The most common violation of the vaginal microflora, the frequency of which in pregnant women is 10-20%, is dysbiosis, characterized by a sharp decrease in the representatives of obligate microflora and its replacement by a mixed flora consisting of anaerobic opportunistic bacteria (Bacteroidesspp., Mobiluncusspp., Peptostreptococcusspp., Peptostreptococcusspp. NS.). The quantitative and qualitative composition of the microflora of the vagina and cervix of the uterus changes both by increasing the intensity of colonization of microorganisms and by increasing the frequency of their excretion.

Immunological weekly sufficiency weakens the compensatory-protective mechanisms of the body as a whole, which largely determines the individual characteristics of the course and outcome of the disease. Thus, a vicious circle is created: the activation of opportunistic vaginal flora and prolonged exposure to an infectious agent contribute to the development of immune disorders, which in turn further aggravate dysbiotic disorders in the vagina, supporting the inflammatory process and significantly increasing the risk of IUI.

For the correct diagnosis of vaginal dysbiosis, along with the clinical signs of the disease, an important role belongs to laboratory research methods and, above all, to microbiological examination of not only the luminal, but also the parietal microflora of the vagina, which avoids mistakes.

Studies of smears help to navigate the possible pathology and determine the need, sequence and volume of additional studies (PCR, ELISA, etc.)

Therapeutic measures in the first trimester of pregnancy are limited due to the danger of using certain medications during embryogenesis. Nevertheless, with pronounced dysbiotic disorders of the vagina, a complicated course of pregnancy (the threat of abortion, an abortion that has begun, etc.), as well as structural and functional inferiority of the cervix, it is recommended to use correctors and interferon inductors: KIP-feron (vaginal suppositories) 1 candle 2 times per day for 10 days; viferon (vaginal suppositories) 1 suppository 1 time per day for 10 days. With a high risk of infection, intravenous drip of human immunoglobulin in a dose of 25 ml every other day 3 times and / or octagam 2.5 mg intravenously every 2 days 2-3 times is shown.

The drugs of choice for dysbiotic disorders of the vagina in the II trimester are vaginal suppositories and vaginal tablets (terzhinan, betadine, Klion-D, flagil, etc.). At the second stage of treatment, the normal vaginal microbiocenosis is restored with biological products (acilac, lactobacterin), as well as the activation of local immunity factors using immunomodulators (vaginal or rectal suppositories Viferon, KIP-feron, etc.).

Treatment of candidiasis is carried out from the first trimester of pregnancy with pimafucin orally (1 tablet 2 times a day for 10 days) and / or vaginally (1 suppository for 10 days).

- Endocrine factors
The endocrine factors of miscarriage, which are detected in 17-23% of cases, include:
- defective luteal phase;
- violation of androgen secretion (hyperandrogenism);
- diseases of the thyroid gland;
- diabetes.

Defective luteal phase as a cause of endocrine infertility and miscarriage in women was first described in 1949 by G. Jones et al. For a full-fledged secretory transformation and preparation of the endometrium for implantation of a fertilized egg, a sufficient concentration of estrogens, progesterone and the maintenance of their normal ratio during the menstrual cycle and especially in the second phase of the cycle are required.

The results of hormonal examination indicate the presence of an inadequate luteal phase of the cycle in 40% of women with recurrent miscarriage and in 28% with infertility and a regular rhythm of menstruation.

During clinical and endocrinological examination of patients with incomplete luteal phase, it was shown that this pathology occurs as a result of disorders at various levels of the hypothalamic-pituitary-ovarian and adrenal systems and manifests itself in the form of:
- a decrease in the amplitude and changes in the pulsating rhythm of the secretion of gonadotropic releasing hormone (luliberin);
- increasing the level of prolactin;
- a decrease in the ovulatory peak of LH and / or the FSH / LH ratio during the cycle and during ovulation.

Disruption of the mechanisms of regulation of the menstrual cycle at the level of the hypothalamic-pituitary region is the main reason:
- impaired growth and full maturation of follicles;
- defective ovulation;
- the formation of a pathological corpus luteum.

As a result of the described violations, a corpus luteum is formed, which in each subsequent cycle secretes a reduced amount of progesterone. Hormonal ovarian failure is also manifested by a decrease in estrogen levels during the menstrual cycle and a change in the ratio between estrogen and progesterone, especially in the luteal phase.

A possible cause of impaired follicular maturation is pathological conditions of the ovaries caused by a chronic inflammatory process of the genitals, surgical interventions on the ovaries, which leads to a decrease in their functional activity, especially in women over 35-36 years old.

Ultimately, against the background of hypoestrogenism and hypoprogesteronemia, an inferior phase of endometrial secretion develops, which prevents the implantation of a fertilized egg and the normal development of pregnancy.

Thus, a dysfunction of the corpus luteum, secreting a sufficient amount of progesterone for a week, is the cause of spontaneous miscarriage in the early stages, and the defective function of the trophoblast is at a later stage of the first trimester of pregnancy.

With an inferior luteal phase, natural progesterones are prescribed for several months (dyufaston 200 mg, oral morning 200 mg or intravaginally 300 mg per day) from the 16th to the 25th day of the menstrual cycle. In the early stages of pregnancy, depending on the presence of symptoms of threatened abortion and the level of progesterone, it is possible to prescribe duphaston and uterine in similar doses up to 10-12 weeks of pregnancy.

Hyperandrogenism is a pathological condition caused by an increased level of adrenal and ovarian androgens, which is the cause of spontaneous miscarriage in 20-40% of women. The clinic distinguishes between three types of hyperandrogenism:
- adrenal;
- ovarian;
- mixed.

Regardless of the type of hyperandrogenism, termination of pregnancy occurs in the early stages and proceeds as anembryonic or non-developing pregnancy. In 40% of patients during pregnancy, functional ICI or low placenta previa occurs. In the II and III trimesters, pregnancy termination occurs at a critical time. With each subsequent miscarriage, the nature of hormonal disorders becomes more severe and in 25-30% of cases, secondary infertility is added to the problem of miscarriage.

During pregnancy, patients with hyperandrogenism experience three critical periods when the level of androgens in the mother's body increases due to androgens synthesized by the fetus. So, at 12-13 weeks, the adrenal glands of the fetus begin to function; at 23-24 weeks, the testes of the male fetus begin to produce androgens, and at 27-28 weeks, ACTH by the anterior pituitary gland of the fetus begins to be secreted.

In case of hyperandrogenism detected before pregnancy, preparatory therapy with dexamethasone 1/2 tablet (0.25 mg) is carried out 1 time per day in the evening before bedtime, continuously until pregnancy. The dose of the drug varies depending on the level of adrenal androgens (DHEA / DHEA-sulfate), which are determined once a month (on the 5-7th day of the cycle).

Determination of testosterone against the background of ongoing therapy is impractical, since dexamethasone does not have any suppressive effect on it. The duration of therapy before the onset of pregnancy is 6-12 months, and if during this time the pregnancy has not occurred, you should think about the occurrence of secondary infertility. During pregnancy, the dose and duration of taking the drug are determined by the characteristics of the clinical course of pregnancy, the presence of symptoms of the threat of interruption and ICI, as well as the dynamics of the DHEA / DHEA sulfate level. The timing of discontinuation of dexamethasone ranges from 16 to 36 weeks and is determined individually for each patient.

The most frequent complications of pregnancies caused by endocrine causes of miscarriage, especially against the background of hyperandrogenism, are the threat of early termination, functional ICI, low placentation, and the threat of hypertension and gestosis in the II and III trimesters of pregnancy.

In patients with thyroid diseases of the type of hypo-, hyperthyroidism, autoimmune thyroiditis, etc., it is recommended that the identified disorders be eliminated before the onset of the next pregnancy, as well as the selection of the dose of thyroid homones and clinical laboratory control during the entire pregnancy.

Pregnancy in women with diabetes mellitus is recommended after examination by an endocrinologist and correction of the underlying disease. During pregnancy, the patient is under the supervision of both an endocrinologist and a gynecologist, and the tactics of pregnancy management and the nature of delivery are decided depending on the patient's health status.

- Immune factors
Immune factors of miscarriage are the most common causes of miscarriage and their frequency, according to different authors, is 40-50%. Recognition of a foreign agent and the development of an immune response in a woman's body are regulated by HLA antigens, which are divided into two classes.

The genes encoding these antigens are located on chromosome 6. I class of HLA antigens is represented by antigens A, B, C, which are necessary for recognition of transformed cells by cytotoxic T-lymphocytes. HLA class II antigens (DR, DP, DQ) provide interaction between macrophages and T-lymphocytes in the course of the immune response. Carriage of some HLA antigens is believed to be associated with a predisposition to certain diseases.

When studying the role of the immunological factor in the clinic of miscarriage, two groups of disorders were identified: in the humoral and cellular links of immunity.

Violations in the humoral link of immunity are associated with antiphospholipid syndrome.

The second, no less complex mechanism of miscarriage is due to violations in the cellular link of immunity, which is manifested by the response of the mother's body to the paternal antigens of the embryo.

In this group of patients, the relationship between hormonal and immune factors is most clearly defined.

It is believed that among these mechanisms, progesterone plays a significant role, which is involved in the normalization of the immune response in the early stages of pregnancy. Under the influence of progesterone, lymphocytes are activated and begin to produce a protein, the so-called progesterone-induced blocking factor (PIBF), which has an anti-abortive effect in a woman's body and helps to maintain pregnancy.

What are the immunological mechanisms that cause early termination of pregnancy? To this end, one should recall the features of the formation of an embryo after fertilization of an egg with a sperm. A sperm cell, formed from an embryonic cell and passing through a number of developmental stages, contains half of the total set of chromosomes (23 chromosomes). A similar set of 23 chromosomes contains the ovum produced by ovulation. Accordingly, a fertilized egg already contains a set of 46 genetically programmed chromosomes.

In peripheral blood lymphocytes, progesterone receptors are normally present. In the absence of pregnancy, the number of lymphocytes containing progesterone receptors is negligible. However, the number of these cells increases with the onset of pregnancy and increases in proportion to its duration. Probably, such an increase in the number of progesterone receptors can be caused by the embryo, which acts as an alloantigen that stimulates blood lymphocytes. With spontaneous miscarriage, the number of cells containing progesterone receptors decreases sharply and practically does not differ from indicators outside of pregnancy.

It is believed that unexplained forms of miscarriage can be caused by disorders in the cellular and humoral links of immunity. Much attention is paid to cell-mediated immune mechanisms as possible etiological factors of spontaneous abortion; in particular, we are talking about T-helper cells (TX1, TX2) and the cytokines secreted by them. In the body, these cells are activated in turn.

The TX2 response helps maintain a normal pregnancy, while the TX1 response is antagonistic to pregnancy and can cause abortion.

Despite the fact that at present the mechanism for the development of spontaneous miscarriage is not completely understood, it is believed that natural killers activated by lymphokines and activated decidual macrophages can play an important role in them.

Returning to the mechanism of the effect of progesterone on the activity of lymphocytes, it should be noted that the number of progesterone receptors increases with allogeneic or mitogenic stimulation of lymphocytes.

It has been found that after a blood transfusion or transplant, the number of cells containing progesterone receptors is comparable to that of pregnancy. This indicates that in vivo alloantigenic stimulation leads to an increase in progesterone receptors in lymphocytes. It is believed that the increase in the number of progesterone receptors during pregnancy may be associated with the presence of the embryo, which acts as an alloantigenic stimulant.

In a pregnant woman, under the influence of antigens of the embryo, against the background of activation of lymphocytes and the appearance of progesterone receptors in them, a mediator protein begins to be produced. This factor is produced by CD56 + cells located on the fetoplacental surface of the membrane.

The immunological effect of PIBP concerns both cellular and humoral immune mechanisms. PIBP at the cellular level affects the synthesis of cytokines in T-helper lymphocytes. With a normal pregnancy, there is a shift towards an increase in TX2 and their production of cytokines, while a decrease in TX1. This mechanism contributes to the maintenance of pregnancy.

In the presence of PIBP, activated lymphocytes produce 8 times more cytokine TX2 (IL-2) than in its absence. An increase in the production of TX2 cytokines entails an increase in the production of immunoglobulins and affects humoral immunity.

With the introduction of PIBP to animals, the emergence of a new subgroup of immunoglobulins, asymmetric antibodies, was noted. These antibodies are able to bind to antigens, compete with antibodies of the same specificity, and act as "blocking" antibodies. Thus, they protect the embryo and prevent it from being destroyed by the mother's immune system. In pregnant women, a direct relationship is determined between the expression of PIBP and the number of asymmetric molecules - IgG. In the absence of pregnancy, the PIBP level and the number of asymmetric antibodies are low.

PIBP appears in the blood of women from early pregnancy. Its concentration increases, reaching a maximum by 40 weeks of gestation. The content of PIBP drops sharply after childbirth. PIBP is determined by the enzyme immunoassay. During miscarriage and outside pregnancy, low levels of PIBP are determined.

As a result of studies devoted to the study of the mechanism of action of PIBP, it was shown that this substance:
- influences the balance of cytokines, as a result of which the production of TX1 cytokines decreases and the level of TX2 cytokines increases;
- reduces the activity of natural killer cells and ensures a normal pregnancy outcome.

The blockade of progesterone receptors leads to a decrease in the production of PIBP, which results in an increase in the production of TX1 cytokines, an increase in natural killer cells and the onset of spontaneous abortion.

In experiments in vitro and in vivo, it was found that stimulation of progesterone receptors with endogenous progesterone or its derivatives (dydrogesterone, duphaston) induces the production of PIBP and protects the embryo in the mother's body.

At present, three main pathways have been described along which the embryo is rejected by the mother's body.

Allogeneic reaction. Symmetric (cytotoxic) antibodies bind to embryonic antigens (FAB-structures) and then the complement system is activated by the Fc-structure of the antigen. As a result, cytotoxicity, phagocytic cellular reactions develop and, as a result, the destruction of the embryo.

The mechanism of destruction of the embryo, caused by TX1. This mechanism is mediated by cytokines: TNF α, IFN γ and IL-2, -12, -18. In all cases of an abortogenic response of the maternal immune system, the lymphocytic response of TX1 prevails over the lymphocytic protective response of the mother's body caused by TX2.

Increased activity of natural killer cells. These cells are converted into LAK cells under the influence of IL-2 and TNF α, which are released by TX1.

Taking into account the data concerning the mechanisms of embryo rejection, it was concluded that in order to maintain its viability in the body, the opposite processes must be provided. Thus, immunomodulation aimed at protecting the embryo also includes three protection pathways.

Asymmetric antibodies are introduced that do not match the structure of the antigens of the fetus and do not bind to it completely, as a result of which the complement cascade does not start.

The effects of TX2 activation predominate, protective cytokines are released and TX1 activity is suppressed.

There is no release of TNF α and IL-2, and killer cells are not transformed into embryonic LAK cells.

The key to such a restructuring of the immune response in the direction of protecting the embryo is the stimulation of the production of PIBP, which provides the processes described above.

A number of studies have shown that progesterone significantly blocks and suppresses the activation and proliferation of cytotoxic TX1, the activity of killer cells, as well as the production of γ-IFN, IL-2, TNF α, and therefore this hormone is considered as a natural immunosuppressant. Since progesterone inhibits the production of TX1 cytokines and stimulates the production of TX2 cytokines, it is proposed to use progesterone or its analogs in women with recurrent miscarriage of unknown etiology, when a shift towards the prevalence of TX1 cytokines is observed in the body.

It has been shown that stimulation of progesterone receptors with endogenous progesterone or dydrogesterone (dyufastone) stimulates the production of PIBP, which in turn affects the balance of cytokines, reducing the production of TX1 cytokines and the number of natural killer cells.

According to the literature, an important role in preventing spontaneous miscarriages and maintaining early pregnancy is played by the effect on progesterone receptors. In this regard, progesterone is prescribed to prepare for pregnancy and prevent spontaneous miscarriages. It is noted that the immunomodulatory effect of hormones is important for maintaining the normal function of the endometrium, stabilizing its functional state and relaxing effect on the muscles of the uterus. It is believed that the protective effect of progesterone, in particular the stabilization and decrease in endometrial tone, is a consequence of a decrease in the production of prostaglandins by endometrial cells, as well as blocking the release of cytokines and other inflammatory mediators.

- Organic pathology of the genital organs
Organic pathology of the genitals during miscarriage is of two types: congenital and acquired.

Congenital pathology (malformations):
- malformations of derivatives of Müllerian ducts;
- ICN;
- anomalies of divergence and branching of the uterine arteries.

Acquired pathology:
- ICN;
- Asherman's syndrome;
- uterine fibroids;
- endometriosis.

The mechanism of termination of pregnancy with malformations of the uterus is associated with a violation of the processes of implantation of the ovum, inadequate secretory transformations of the endometrium due to reduced vascularization, close spatial relationships of the internal genital organs, functional features of the myometrium, increased excitability of the infantile uterus. The threat of termination is observed at all stages of pregnancy.

With an intrauterine septum, the risk of spontaneous abortion is 60%. Miscarriages are more likely to occur in the second trimester. If the embryo is implanted in the area of the septum, abortion occurs in the first trimester, which is explained by the inferiority of the endometrium in this area and the violation of the placentation process.

Abnormalities in the discharge and branching of the uterine arteries lead to impaired blood supply to the implanted embryo and placenta, and as a result, to spontaneous miscarriage.

Intrauterine synechiae are the cause of abortion in 60-80% of women, which depends on the location of the synechiae and the degree of their severity.

The pathogenesis of habitual spontaneous abortion in the presence of uterine fibroids is associated with absolute or relative progesterone sufficiency, increased bioelectrical activity of the myometrium and increased enzymatic activity of the uterine contractile complex, as well as malnutrition in the myomatous nodes.

The pathogenesis of habitual spontaneous abortion in genital endometriosis is not fully understood and is possibly associated with immune disorders, and in adenomyosis - with the pathological state of the endo- and myometrium.

The diagnosis of malformations and other pathological conditions of the uterus and cervical canal is established on the basis of anamnesis data, gynecological examination, results of hysterosalpingography, ultrasound scanning, hysteroscopy and laparoscopy. Currently, most of the organic pathology that causes habitual spontaneous abortion is treated with hysteroscopic operations. During hysteroscopy, you can remove the submucous myomatous node, destroy the intra-uterine synechia, remove the intrauterine septum. With intrauterine synechiae and uterine septum, transcervical metroplasty is also performed under ultrasound control.

Isthymic-cervical sufficiency is more often a consequence of frequent and gross intrauterine interventions and traumatic injuries of the cervix during abortion and childbirth. The incidence of ICI ranges from 7.2 to 13.5%, and the relative risk of developing this pathology increases with an increase in the number of induced miscarriages.

Pregnancy in the case of ICI usually proceeds without symptoms of threatened termination. The pregnant woman has no complaints; palpation reveals a normal tone of the uterus. With a vaginal examination, the shortening and softening of the cervix is determined, the cervical canal freely passes the finger beyond the area of the internal pharynx. When viewed in the mirrors, a gaping external cervical os with flaccid edges is visible, prolapse of the fetal bladder is possible. With an increase in intrauterine pressure, the membranes protrude into the dilated cervical canal, become infected and open. In the presence of ICI, termination of pregnancy occurs, as a rule, in the II and III trimesters and begins with the discharge of amniotic fluid.

Currently, there is a tendency to an increase in the frequency of functional ICI, which occurs in endocrine disorders (defective luteal phase, hyperandrogenism).

Diagnosis of ICI, in addition to anamnestic data and examination data, includes a special examination: outside pregnancy - hysterosalpingography and echographic examination, and during pregnancy - transvaginal scanning.

Surgical treatment of ICI is carried out in the following cases:
- when detecting ICI of organic genesis outside of pregnancy;
- in the presence of signs of a progressive week of cervical insufficiency (change - consistency, the appearance of flabbiness, shortening of the cervix);
- with a gradual increase in the "gaping" of the external and opening of the internal pharynx;
- if there is a history of spontaneous miscarriages or premature birth in the II and III trimesters of pregnancy.

Methods for surgical removal of ICI (cervical suture) are described in detail in the manuals for operative obstetrics. The question of suturing the cervix with a prolapsing fetal bladder, low placenta and multiple pregnancy should be decided individually in each specific clinical situation.

Contraindications for the imposition of a circular suture on the cervix are:
- signs of a threat of interruption;
- diseases for which pregnancy is contraindicated;
- cicatricial deformity of the cervix, its deep ruptures, a sharp shortening of the cervix;
- presence of pato

Symptoms of Miscarriage

Symptoms of miscarriage include:
- Increasing bleeding
- Spasms
- Pain in the lower abdomen
- Elevated temperature
- Weakness
- Vomit
- Back pain

If you find these symptoms in yourself, immediately contact your obstetrician-gynecologist.

Diagnosis of Miscarriage

Miscarriage is a multifactorial disease in which most patients have a combination of several causes at the same time. In this regard, the examination of patients in this group should be comprehensive and include all modern clinical, instrumental and laboratory methods. When examining these patients, it is required not only to establish the cause (s) of spontaneous miscarriage, but also to assess the state of the reproductive system in order to prevent subsequent miscarriages.

Examination before pregnancy
Anamnesis includes clarification of the presence of hereditary, oncological somatic diseases, neuroendocrine pathology. The gynecological history reveals the presence of inflammatory diseases of the genitals, viral infection, methods of therapy, especially menstrual and reproductive functions (abortion, childbirth, spontaneous miscarriages, including complicated ones), other gynecological diseases and surgical interventions.

Clinical examination consists of examination, assessment of the condition of the skin, the degree of obesity according to the body mass index, the state of the thyroid gland. According to the hirsut number, the degree of hirsutism is determined, the condition of the internal organs is assessed, as well as the gynecological status. The functional state of the ovaries, the presence or absence of ovulation are analyzed according to the data of rectal temperature and menstrual calendar.

Laboratory and instrumental methods studies are as follows.
- Hysterosalpingography - performed on the 17th-23rd day of the menstrual cycle and eliminates uterine malformations, intrauterine synechiae, ICI.

Ultrasound - while assessing the state of the ovaries, the presence of cysts of uterine fibroids, adenomyosis. Clarify the state of the endometrium: chronic endometritis, polyps, endometrial hyperplasia.

Infection screening. Includes microscopic examination of smears from the urethra, cervical canal and vagina, PCR diagnostics, bacteriological examination of the contents of the cervical canal, examination for virus carriers (see section 8.3.2).

Hormonal research. It is carried out on the 5-7th day of the menstrual cycle with regular menstruation and on any day in patients with oligo- and amenorrhea. The content of prolactin, LH, FSH, testosterone, cortisol, DHEA-sulfate, 17-hydroxyprogesterone is determined. Progesterone is determined only in women with a regular menstrual cycle: on the 5-7th day in the I phase of the cycle and on the 6-7th day of the rise in rectal temperature in the II phase of the cycle. In patients with adrenal hyperandrogenism, a small test with dexamethasone is performed to determine an adequate therapeutic dose.

In order to clarify the autoimmune genesis of miscarriage, the presence of lupus antigen, anti-hCG, anticardiolipin antibodies are determined, and the features of the hemostasis system are analyzed.

Examination of the spouse includes finding out the hereditary history, the presence of somatic, especially neuroendocrine diseases, analysis of the expanded spermogram, clarification of the immune and inflammatory factors.

If there is a suspicion of the presence of intrauterine pathology and / or pathology of the endometrium, separate diagnostic curettage is performed under the control of hysteroscopy.

If there is a suspicion of genital endometriosis, tubal pathology and adhesions in the small pelvis, with uterine myoma and scleropolycystic ovaries, operative laparoscopy is indicated.

After the examination, a set of therapeutic measures is planned, depending on the identified factors of miscarriage.

Examination during pregnancy
Monitoring during pregnancy begins immediately after the onset of pregnancy and includes the following research methods:
- ultrasound scanning;
- periodic determination of hCG in the blood;
- determination of DHEA / DHEA-sulfate;
- if necessary, consultation with a psychologist and psychotherapist.

Treatment of Miscarriage

If the miscarriage is complete and the uterus is clear, then usually no special treatment is required. Sometimes the uterus is not completely cleansed, then the procedure for scraping the uterine cavity is performed. During this procedure, the uterus is opened and the remains of the fetus or placenta in it are carefully removed. An alternative to curettage is certain medications that will cause your body to reject the contents of the uterus. This method can be ideal for those who want to avoid surgery and who are in stable health.

Forecast
Prediction of the course of subsequent pregnancies in women with a history of spontaneous miscarriages, depending on the outcome of the previous one.

It has been shown that the most promising in this regard are women with organic pathology of the uterus, endocrine and immune factors.

In conclusion, it should be noted that a thorough and complete examination of women before pregnancy, especially after spontaneous miscarriages, the most accurate diagnosis of the causes of miscarriage, timely and pathogenetically substantiated therapy, dynamic monitoring during pregnancy can significantly reduce the risk of the threat of termination of pregnancy and loss of a child.

Prevention of Miscarriage

Prophylaxis consists in a thorough examination of women in order to identify the causes of miscarriage and conduct rehabilitation therapy to prepare for subsequent pregnancy. Examination in the antenatal clinic includes a consultation with a therapist to identify extragenital diseases in which pregnancy is contraindicated; metrosalpingography and / or hysteroscopy to exclude uterine malformations, intrauterine synechiae, isthmic-cervical insufficiency; functional diagnostic tests to assess hormonal balance; bacteriological examination of the contents of the cervical canal, examination for toxoplasmosis, cytomegalovirus, etc., determination of the blood group and Rh factor. An obligatory component of the examination of a woman with a history of miscarriage is an assessment of her husband's health, including a study of his sperm. If at the first stage of the examination, the reasons for miscarriage are not identified, the woman is sent to specialized offices of the antenatal clinic or polyclinic, where hormonal, medico-genetic research is carried out. If the reasons for miscarriage still remain unclear, an examination is necessary in specialized institutions or in hospitals, where a deeper study of the endocrine system, the immune system and other special studies is carried out.

31.07.2018

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Ministry of Health of the Republic of Belarus
Belarusian Medical Academy of Postgraduate Education
Miscarriage

(etiology, pathogenesis, diagnosis, clinical picture, treatment)
Educational - methodical manual

Approved by

At the Council of the Faculty of Surgical

Dean of the Faculty of Surgery, Associate Professor

V.L. Silyava

UDC 618.39 (075.8)

Associate Professor of the Department of Obstetrics and Gynecology of BELMAPO, Candidate of Medical Sciences L.V. Vavilov.
Reviewers:

Chief obstetrician-gynecologist of the Ministry of Health of the Republic of Belarus, Doctor of Medical Sciences, Professor O. A. Peresada

Head of the Department of Obstetrics and Gynecology of Vitebsk State Medical University, Doctor of Medicine, Professor S.N. Zanko.

Miscarriage (etiology, pathogenesis, diagnosis, clinical picture, treatment): Textbook. - method. manual. / C. L. Yakutovskaya, V. L. Silyava, L. V. Vavilova. - Minsk: BELMAPO, 2004 - p.

The educational - methodical manual covers the etiology of the pathogenesis of miscarriage, methods of diagnosis and treatment.

The tactics of preparation for pregnancy and management of pregnancy in patients with this pathology are presented.

Designed for obstetricians - gynecologists.

UDC 618.39 (075.8)

BBK 57.16 i 7

Table of contents

Introduction	4
1. Etiology of miscarriage	4
1.1. Genetic causes of miscarriage	5
1.2. Endocrine causes of miscarriage	6
1.3. Infectious causes of miscarriage	10
1.4. Immunological causes of miscarriage	11
1.5. Thrombophilic complications and their role in miscarriage	13
1.6. Uterine causes of miscarriage	14
1.7. Extragenital diseases as a cause of NB	16
1.8. Paternal causes of miscarriage	16
1.9. Socio-biological factors of miscarriage	16
2. Tactics of pregnancy management in patients with miscarriage	17
2.1. Diagnostic tests to assess the course of pregnancy	17
3. Therapeutic and prophylactic measures in the management of pregnancy in patients with miscarriage	18
3.1. Threatened abortion	18
3.2. Started abortion	19
3.3. Abortion in progress	20
4. Treatment of the threat of termination of pregnancy.	21
4.1 Therapy during pregnancy, in women with NLF	22
4.2. Pregnancy management tactics in women with various forms of hyperandrogenism	22
4.3. Pregnancy management tactics in women with infectious genesis of miscarriage	24
4.4 Management of women with ICI during pregnancy	27
4.5. Management of pregnancy in women with APS	29
4.6. Pregnancy management with sensitization to hCG	31
5. Preparing for pregnancy in patients with miscarriage	32
5.1. Management of patients with luteal phase insufficiency outside of pregnancy	32
5.2. Tactics of preparing women with hyperandrogenism for pregnancy	33
5.3. Tactics of preparation for pregnancy in patients with miscarriage of infectious genesis.	37
5.4. Treatment of ICI outside of pregnancy	38
5.5. Tactics of preparation for pregnancy in patients with APS.	39
5.6. Preparing for pregnancy in patients with sensitization to hCG	41
6. Literature	42

Introduction