Causes of miscarriage. Actual problems of miscarriage

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

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

Classification of miscarriage is most often carried out by timing.

Before 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 body weight of the fetus 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 body weight of 500 to 1000 g - early premature birth.
• From 28 weeks to 36 weeks and 6 days, with a fetal body weight of more than 1000 g - premature birth.

Also, miscarriage is divided into stages:

1. Threatened abortion- the stage at which the fetus grows and develops normally, but exists.
2. Started abortion- the fetal egg is already exfoliating a little, but the pregnancy can still be saved.
3. Abortion in progress- the fetal egg is separated from the walls of the uterus and is located in its cavity or in the neck, it is no longer possible to save the pregnancy.
4. incomplete abortion- part of the fetal egg remains in the uterine cavity, causing inflammation and infection.
5. Complete abortion- the fetal egg completely leaves the woman's body, only the supervision of a doctor is required.
6. Missed 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 membranes of blood vessels, platelets, brain and lung tissues. In antiphospholipid syndrome, the immune system attacks the membranes, causing damage to cells and tissues. As a result, thrombosis, thrombocytopenia, headaches, stroke, heart attack, hypertension and other diseases can develop.

Early miscarriage occurs due to a violation of the implantation of the fetal egg or its rejection. Thrombosis of the vessels of the placenta leads to intrauterine death of the fetus.

Other reasons

Other causes of miscarriage include:

• pregnancy injuries;
• 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;
• diseases of the husband, leading to pathologies of the ejaculate.

Symptoms

Symptoms of miscarriage include:

• pulling pains 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 rise.

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

Diagnostics

In case of miscarriage, 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, in which complaints are clarified and clarified: when the symptoms began, what their nature is, 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 last, when did menstruation first begin, when was the last time, etc.;
• examination to study the characteristics of the physique, 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;
• a blood test to detect TORCH infections:, and;
• a study to identify urogenital infectious diseases (sexually transmitted);
• study of hormones that affect 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 fetal egg;
• 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, the general health of the woman are taken into account.

Treatment

Treatment for miscarriage depends on its cause and stage. When the threat of interruption is detected, 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 may affect the sexual differentiation of the child, and a sudden cessation of admission can provoke a miscarriage.

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

The help of 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 death of the fetus occurs without expulsion from the uterus, the procedure for extracting the fetal egg using a special suction is carried out. 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 fetal egg comes out.

In case of incomplete miscarriage, when the fetus is expelled, but parts of the fetal membrane remain, it is carried out. During this procedure, with the help of a curette - an instrument resembling a spoon with a hole - the uterus is cleaned. 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 that occur 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, development of infection, etc. When chills, fever, and tongue coating appear, antibiotics are prescribed.

Complications

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

Miscarriage and premature birth can cause the following complications:

• profuse bleeding that can lead to a critical condition - weakness, low 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 the symptoms and preserve the reproductive health of a woman.

Prevention

Prevention of miscarriage is based on maintaining the health of the woman and a comprehensive examination during planning. If a 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 disorders, hormonal abnormalities, immunological and anatomical pathologies. All procedures can be carried out in specialized centers for the prevention and treatment of miscarriage.

When the cause of the miscarriage is determined, it is necessary to undergo treatment before the next pregnancy. This may include 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 immunity 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 a spontaneous termination of pregnancy before 37 weeks. Depending on the timing, it may be called a miscarriage or premature birth. There are many reasons for this complication: hormonal, anatomical, genetic, immunological, infectious.

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LECTURE 15

MISSIONPREGNANCY

Definition of post-term pregnancy.

Diagnostics.

obstetric tactics.

Indications for CS surgery in post-term pregnancy.

Miscarriage consider spontaneous interruption of it at various times from conception to 37 weeks, counting from the 1st day of the last menstruation.

habitual miscarriage(synonymous with "habitual loss of pregnancy") - spontaneous abortion in a row 2 or more times.

Prematurity - spontaneous abortion in terms of 28 to 37 weeks (less than 259 days).

Termination of pregnancy before 22 weeks is called spontaneous abortion (miscarriage), and from 22 to 36 weeks - premature birth.

The frequency of miscarriage is 10-30% (spontaneous miscarriages 10-20%) of all pregnancies and does not tend to decrease. The urgency of the problem of miscarriage lies in high perinatal losses.

perinatal period begins at 28 weeks of gestation, includes the period of childbirth and ends after 7 completed days of the newborn's life. The death of a fetus or newborn during these periods of pregnancy and the neonatal period constitutes perinatal mortality. According to WHO recommendations, perinatal mortality is taken into account from 22 weeks of pregnancy with a fetus weighing 500 g or more.

perinatal mortality is calculated by the number of cases of stillbirth and death of a newborn in the first 7 days of life. This indicator is calculated per 1000 births. In preterm birth, this figure is 10 times higher. This is the urgency of the problem of premature birth.

Premature babies die due to the deep immaturity of organs and systems, intrauterine infection, birth trauma, as premature babies are unstable to birth trauma. The lower the weight of the newborn, the more often premature babies die.

Newborns born weighing up to 2500 g are considered low birth weight, up to 1500 g - very low birth weight, up to 1000 g - extremely low birth weight. Most often, children of the last two groups die in the neonatal period.

Etiology of miscarriage It is diverse, and the cause of miscarriage can be various factors or even combinations of them.

I trimester be belts:

chromosomal abnormalities of the embryo;

insufficiency of the hormonal function of the ovaries of a pregnant woman;

hyperandrogenism in a pregnant woman;

hypoplasia of the uterus and / or anomalies in the development of the uterus;

diabetes;

hypo- and hyperthyroidism;

acute viral hepatitis;

glomerulonephritis.

Etiology of miscarriage in II trimester pregnancy:

placental insufficiency;

isthmic-cervical insufficiency (ICN);

antiphospholipid syndrome;

somatic pathology of the mother (hypertension, bronchial asthma, diseases of the urinary tract, diseases of the nervous system).

Etiology of miscarriage in III trimester pregnancy:

• anomalies in the location of the placenta;

premature detachment of a normally located placenta (PONRP);

polyhydramnios and / or multiple pregnancy;

incorrect position of the fetus;

rupture of membranes and chorioamnionitis.

Pregnancy can end at anyperiod due to the following reasons:

genital infection;

anomalies in the development of the uterus and uterine fibroids;

diabetes;

• occupational hazards;

  immunological disorders;

  any cause leading to fetal hypoxia.

The pathogenesis of miscarriage

I. Impact of damaging factors ® hormonal and immune disorders in the trophoblast (placenta) ® cytotoxic effect on the trophoblast ® placental abruption.

II. Activation of local factors (prostaglandins, cytokines, fibrinolysis system) ® increased excitability and contractile activity of the uterus.

On the 7-10th day after fertilization, the blastocyst nidates into the endometrium, due to the release of the dividing egg of chorionic gonadotropin (CG) by the primary chorion. The immersion process lasts 48 hours. CG maintains the function of the corpus luteum and puts it into a new mode of operation, like the corpus luteum of pregnancy (WTB).

The corpus luteum of pregnancy functions up to 16 weeks, releasing progesterone and estradiol, reducing the production of FSH and luteinizing hormone, and supports the functions of the trophoblast. After the formation of the trophoblast (placenta), it takes over (from 10 weeks of pregnancy) the function of the VTB and the entire endocrine function, controlling the homeostasis of the pregnant woman. The level of hormones in a woman's body rises sharply.

If the placenta is not formed intensively enough, such pregnancies have a complicated course, and, above all, in the early stages (up to 12 weeks). They are complicated by the threat of interruption. Consequently, one of the main mechanisms for the development of the threat of abortion is the insufficient development of the chorion.

In connection with the increase in hormone levels, intensive synthesis of pregnancy proteins begins. At the same time, the mother's immune system is inhibited (the production of antibodies to foreign proteins). As a result, the risk of infectious diseases increases, chronic infections become aggravated.

Mechanismthreat of interruption pregnancy at a later date is as follows: in each organ, only 30% of the vessels function, the rest are switched on only under load, these are reserve vessels. The uterus has a huge number of reserve vessels. Blood flow during pregnancy increases 17 times. If the blood flow is reduced by half (trophic deficiency), the child experiences hypoxia. In the urine of the fetus, incompletely oxidized products of hemoglobin metabolism - myoglobin appear. The latter, getting into the amniotic fluid of the fetus, is a powerful stimulator of prostaglandin synthesis. Labor activity at any stage of pregnancy is triggered by prostaglandins, they are produced by the decidual and aqueous membranes of the fetal egg. Any cause leading to fetal hypoxia can trigger the development of labor. During childbirth, uteroplacental blood flow decreases as a result of a powerful contraction of the uterine muscle, and myoglobin synthesis increases with an increase in labor activity.

It is impossible to stop the labor activity that has started. Pain during contractions due to ischemia of the uterine muscle. Therefore, the therapy of the threat of abortion should be aimed at mobilizing reserve vessels (bed rest, antispasmodics, drugs that relieve uterine contractions).

Terminology and classification

Termination of pregnancy in the period of the first 28 weeks is called an abortion or miscarriage, but if a child born at a gestational age of 22 to 28 weeks weighs from 500.0 to 999.0 grams and has lived more than 168 hours (7 days), then it is subject to registration in registry office as a newborn. In these cases, miscarriage is transferred to the category of early premature birth.

By the nature of the occurrence, abortion can be spontaneous and artificial. Artificial abortions, in turn, are divided into medical and criminal (produced outside the medical institution).

According to the terms of termination of pregnancy, abortions are divided into: early - up to 12 weeks and late - after 12 to 28 weeks.

According to the clinical course, there are:

Threatened abortion. The threat of interruption is indicated by: a history of miscarriages, a feeling of heaviness in the lower abdomen or slight pulling pains in the absence of bleeding, the size of the uterus corresponds to the gestational age, the external pharynx is closed. Ultrasound showed hypertonicity of the uterine muscles.

Initiated abortion. It is characterized by cramping pains in the lower abdomen and small spotting (associated with detachment of the fetal egg from the walls of the uterus). The size of the uterus corresponds to the gestational age. The cervix may be ajar.

The prognosis for carrying a pregnancy with an abortion that has begun is worse than with a threatening one, but pregnancy can be maintained.

Abortion is on the way. The fetal egg, exfoliated from the walls of the uterus, is pushed out through the dilated cervical canal, which is accompanied by significant bleeding. Preservation of pregnancy is impossible. The fertilized egg is removed with a curette as a matter of urgency.

incomplete abortion characterized by a delay in the uterine cavity of parts of the fetal egg, accompanied by bleeding, which can be moderate or profuse. The cervical canal is ajar, the size of the uterus is less than the expected gestational age.

Infected(feverish) abortion. In case of spontaneous abortion (beginning, beginning or incomplete), microflora can penetrate into the uterus and infect the membranes of the fetal egg (amnionitis, chorioamnionitis), the uterus itself (endometrium). Especially often, infection occurs during artificial termination of pregnancy outside a medical institution (criminal abortion).

An infected miscarriage can cause generalized septic complications. Depending on the degree of spread of infection, there are: uncomplicated febrile miscarriage (infection is localized in the uterus), complicated febrile miscarriage (the infection has gone beyond the uterus, but the process is limited to the pelvic area), septic miscarriage (the infection has become generalized).

delayed(missed) abortion. With a failed abortion, the death of the embryo occurs. At the same time, there may be no complaints and subjective sensations of "loss of pregnancy", there is no clinic of threatening or incipient miscarriage. In an ultrasound study: either the absence of an embryo (anembryony), or the visualization of an embryo with the absence of registration of its cardiac activity (embryo size, CTE - often less than the standard values ​​​​for the expected gestational age).

Medical tactics - instrumental removal of the fetal egg.

Examination of women with miscarriage

The success of the prevention and treatment of miscarriage depends on the ability, ability and perseverance of the doctor to identify the causes of miscarriage. Examination is advisable to conduct outside of pregnancy, at the planning stage and during pregnancy.

Examination before pregnancy planning:

Expert reviews:

obstetrician-gynecologist;

therapist;

immunologist;

andrologist - urologist;

psychotherapist;

genetics (with habitual miscarriage).

At this stage, it is necessary to carry out the following activities:

Careful collection of anamnesis with clarification of the nature of past diseases, especially during the formation of menstrual function; the presence of extragenital and genital diseases.

The study of menstrual function (menarche, cyclicity, duration, pain of menstruation).

The study of childbearing function - the time interval from the onset of sexual activity to the onset of pregnancy is specified. The nature of all previous pregnancies and childbirth is assessed. In case of termination of pregnancy in the past - features of the clinical course (bleeding, pain, contractions, fever).

General examination: pay attention to height and weight, body type, severity of secondary sexual characteristics, the presence and nature of obesity, hirsutism. An examination of the mammary glands is mandatory (a well-protruding erectile nipple indicates normal hormonal ovarian function).

Gynecological examination: assessment of the vaginal part of the cervix, the presence of ruptures, deformities. The nature of cervical mucus and its amount, taking into account the day of the menstrual cycle. Dimensions, shape, consistency, position and mobility of the uterus, the ratio of the length of the body of the uterus to the length of the cervix. The size of the ovaries, mobility, sensitivity, the presence of adhesions.

Hysterosalpingography is performed to exclude CCI and malformations of the uterus.

Ultrasound of the genitals should be performed on days 5-7, 9-14 and 21 of the menstrual cycle.

It is advisable to carry out tests of functional diagnostics: (colpocytology, basal temperature, pupil symptom, fern symptom), the study of blood hormones (depending on the phase of the menstrual cycle - FSH, LH, prolactin are determined on the 5th day of the cycle; on day 12, estradiol, FSH, LH; progesterone on day 21) and urinalysis for 17-ketosteroids in daily urine to rule out hyperandrogenism.

To exclude antiphospholipid syndrome, a hemostasiogram + antibodies to chorionic gonadotropin and lupus antigen are examined.

To exclude the infectious factor of miscarriage, a bacteriological examination of the contents of the cervical canal and vagina, a virological examination and examination for transplacental infections (toxoplasma, treponema, listeria, rubella, cytomegaly, herpes, measles), and an assessment of the immune status are carried out.

Examination during pregnancy:

Ultrasound at 10-12, 22, 32 weeks. One of the early signs of a threatened abortion is a local thickening of the myometrium on one of the walls of the uterus and an increase in the diameter of the internal os.

Hemostasiogram 1 time per month in case of autoimmune miscarriage.

Tank. sowing contents from the cervical canal in the 1st, 2nd, 3rd trimester.

Virological study in the 1st, 2nd, 3rd trimester.

Assessment of the state of the cervix from 12 to 24 weeks to exclude CI. For pregnant women at risk of developing ICI, vaginal examinations are performed once every 10 days from the end of the first trimester. Particular attention is paid to the softening and shortening of the neck, the gaping of the cervical canal. These changes are clinical manifestations of CI.

Fetal CTG.

Dopplerometry from 16 weeks of pregnancy.

Determination of the content of hormones of the fetoplacental complex.

placental hormones:

Progesterone. Biosynthesis is carried out from maternal blood cholesterol and is concentrated in the corpus luteum at the beginning of pregnancy, and from the 10th week of pregnancy it passes entirely into the placenta, where it is formed in the trophoblast syncytium. Progesterone is the basis for the synthesis of other steroid hormones: corgicosteroids, estrogens, androgens. The content of progesterone in the blood serum during pregnancy is characterized by a gradual increase and reaches a maximum at 37-38 weeks. The aging of the placenta is accompanied by a decrease in its concentration.

Chorionic gonadotropin (CG) appears in the body of a woman only during pregnancy. The diagnosis of pregnancy is based on its definition. Its synthesis in the placenta begins from the moment of implantation on the 8-10th day. Its level rises rapidly, reaching a maximum by 7 weeks of pregnancy, after which it rapidly decreases and remains at a low level throughout the remainder of the pregnancy. Disappears from the body in the first week after childbirth. Reduces the release of gonadotropins by the pituitary gland of the mother, stimulates the formation of progesterone by the corpus luteum. Early or late appearance of the peak of hCG indicates a violation of the function of the trophoblast and the corpus luteum - this is an early indicator of the threat of termination of pregnancy.

Placental lactogen (PL) produced throughout pregnancy. In the blood serum, it is determined from 5-6 weeks, the maximum level is at 36-37 weeks of pregnancy, then its content is kept at the same level until 39 weeks and falls from 40-41 weeks in accordance with the beginning aging of the placenta. It has lactotropic, somatotropic and luteotropic activity. After childbirth, it quickly disappears from the blood of a woman.

Fetal hormones:

Estriol (E). It is synthesized by the placenta-fetus complex from maternal cholesterol metabolites. With the normal development of pregnancy, estriol production increases in accordance with the increase in its duration. A rapid decrease in the concentration of estriol in the blood serum by more than 40% of the norm is the earliest diagnostic sign of fetal development disorders. This gives the doctor time to carry out therapeutic measures.

Alpha-fetoprotein (AFP) - it is a glycoprotein, a fetal protein, that makes up about 30% of fetal plasma proteins. It has a high protein binding capacity for steroid hormones, mainly maternal estrogen. Synthesis of AFP in the fetus begins at 5 weeks of gestation in the yolk sac, liver, and gastrointestinal tract. It enters the blood of pregnant women through the placenta. The content of AFP in the blood of a pregnant woman begins to increase from 10 weeks of pregnancy, the maximum is determined at 32-34 weeks, after which its content decreases. A high concentration of AFP in the mother's blood serum is observed in: malformations of the brain, gastrointestinal tract, intrauterine fetal death, chromosomal diseases, multiple pregnancy. Low concentration - with fetal hypotrophy, non-developing pregnancy, Down syndrome.

9. Functional diagnostic tests are used to diagnose abortion in the first trimester.

Cytology of vaginal smears indicates the saturation of the body with estrogens. Karyopyknotic index - the ratio of cells with pyknotic nuclei to the total number of surface cells. KPI in the first trimester - no more than 10%; in the II trimester - 5%, in the III trimester - 3%. With the threat of abortion, the KPI increases to 20 - 50%.

Basal temperature with an uncomplicated course of pregnancy, it is 37.2 - 37.4 ° C. With the threat of termination of pregnancy, a decrease in basal temperature to 37 ° C indicates a lack of progesterone.

pupil symptom. In uncomplicated pregnancy, the content of mucus in the cervical canal is minimal.

With the threat of termination of pregnancy, a pronounced "symptom of the pupil" appears.

Treatment of miscarriage

Treatment of patients with miscarriage should be pathogenetically substantiated and widely combined with symptomatic therapy. A prerequisite for conducting conservation therapy should be the consent of the mother, the exclusion of fetal malformations and extragenital pathology, which is a contraindication for carrying a pregnancy.

Contraindications for pregnancy:

diabetes insulin-dependent mellitus with ketoacidosis;

diabetes mellitus + tuberculosis;

hypertension II, III;

heart defects with circulatory disorders;

epilepsy with personality degradation;

severe blood diseases.

Treatment of threatened miscarriage inItrimester:

Bed rest.

Sedatives (motherwort, trioxazine, nozepam, seduxen, diphenhydramine), psychotherapy.

Antispasmodics (papaverine, no-shpa).

hormone therapy.

Prevention of FPI

metabolic therapy.

hormone therapy.In the absence of a corpus luteumin the ovary which can be confirmed by the data of hormonal examination and echography, gestagens should be prescribed (replacing the lack of endogenous progesterone).

a) duphaston: threatening abortion - 40 mg at once, then 10 mg every 8 hours until the symptoms disappear; habitual abortion - 10 mg twice a day until 20 weeks of pregnancy.

b) utrogestan: threatening abortion or in order to prevent habitual abortions that occur against the background of progesterone deficiency: 2-4 capsules daily in two divided doses up to 12 weeks of pregnancy (vaginally).

If there is a corpus luteum in the ovary - chorionic gonadotropin (stimulation of the synthesis of endogenous progesterone by the corpus luteum and trophoblast, direct stimulating effect of hCG on the process of implantation of the ovum)

a) Pregnyl: Initial dose - 10,000 IU - once (no later than 8 weeks of pregnancy), then 5,000 IU twice a week until 14 weeks of pregnancy.

Treatment of threatened miscarriageIIandIIItrimesters:

Bed rest and psycho-emotional rest.

Appointment of b-agonists (tocolytics), which cause relaxation of the smooth muscles of the uterus (partusisten, ginipral, ritodrine). Treatment begins with an intravenous drip of 0.5 mg of partusisten diluted in 400 ml of NaCI 0.9%, starting with 6-8 drops per minute, but not more than 20 drops. The dose is increased until the cessation of contractile activity of the uterus. Before the end of the infusion, oral administration of the drug is started at 0.5 mg every 6-8 hours.

Calcium channel blockers: verapamil 0.04 3 times a day; isoptin 0.04 3 times a day.

Hormonal support: 17-OPC (hydroxyprogesterone capronate) 125 mg once a week until 28 weeks of pregnancy.

Magnesia therapy: magnesium sulfate 25% 10 ml per 200 ml NaCI 0.9% for 5-7 days; MagneV 6 2 tablets 2 times a day for 10-15 days; electrophoresis with 2% magnesium on the uterus 10 procedures.

Inhibitors of prostaglandin synthesis: indomethacin in tablets or suppositories, the total dose per course is not more than 1000 mg, the duration of the course is 5-9 days.

Prevention of fetal hypoxia.

Prevention of placental insufficiency.

With the threat of preterm birth at 28-33 weeks, prevention of respiratory distress syndrome in newborns is carried out by prescribing pregnant women glucocorticoid drugs (dexamethasone) 8-12 mg per course or lazolvan, ambroxol, ambrobene 800-1000 mg per day for 5 days in / in drip.

Antispasmodics.

Sedative drugs.

With hyperandrogenism termination of pregnancy is due to the antiestrogenic action of androgens. Treatment for threatened interruption is with corticosteroids. It is based on the suppression of ACTH secretion, which leads, according to the feedback principle, to a decrease in the biosynthesis of androgens by the adrenal glands. Treatment is prescribed with a persistent increase in 17-KS with dexamethasone in an individually selected dose until the normalization of 17-KS values. Hormonal treatment should be discontinued at 32-33 weeks of gestation so as not to suppress fetal adrenal function.

With antiphospholipid syndrome therapy is carried out with prednisolone 5 mg / day. VA control - in two weeks. If VA is detected again, the dose of prednisolone is doubled. If the result is negative, the dose should be considered adequate. A repeated study of VA, after selecting an adequate dose, is carried out once a month throughout pregnancy for a possible dose adjustment of the drug. Plasmapheresis should be included in the complex of therapy.

In case of miscarriage against the background of immunoconflict bere changes according to erythrocyte antigens (the formation of erythrocyte antigens begins from 5 weeks of pregnancy) to all women with O (I) blood group with A (II) or B (III) blood group of the husband, as well as with Rh-negative blood belonging to the pregnant woman, check the blood for group and Rh antibodies. Treatment is with allogeneic lymphocytes.

Isthmic-cervical insufficiency (ICN). ICI is characterized by the inferiority of the circular muscles in the area of ​​​​the internal uterine os, which contributes to the development of insufficiency of the isthmus and cervix. The frequency of ICI is 7-13%. There are organic and functional ICI.

Organic ICI develops as a result of traumatic injuries of the isthmic cervical region during induced abortion, childbirth with a large fetus, surgical delivery (obstetric forceps).

Functional ICI is due to hormonal deficiency, usually develops during pregnancy and is observed more often than organic.

Diagnosis of ICI:

There are no complaints, the uterus is in a normal tone.

When examining in the mirrors: a gaping external pharynx with flaccid edges, prolapse of the fetal bladder.

3. During vaginal examination: shortening of the cervix, the cervical canal passes a finger beyond the area of ​​​​the internal pharynx.

4. Ultrasound of the internal os: the length of the cervix is ​​less than 2 cm - an absolute ultrasound sign of CCI and an indication for suturing the cervix.

The optimal time for suturing the cervix is ​​14-16 weeks, up to a maximum of 22-24 weeks. The suture is removed at 37 weeks, or at any time when labor occurs.

Management of early preterm labor depends on the severity of the clinical picture of this complication, the integrity of the amniotic fluid, the duration of pregnancy.

Management of preterm labor with whole fetusbubble:

Pregnancy term 22 - 27 weeks (fetal weight 500-1000g): you should try to remove labor activity by prescribing b-adrenergic agonists in the absence of contraindications to pregnancy. In the presence of ICI - suture the neck. Conduct courses of metabolic therapy. If possible, identify the cause of miscarriage and correct therapy based on the survey data obtained.

Pregnancy 28- 33 weeks (fetal weight 1000-1800 g): the therapy is the same, except for suturing the cervix. Against the background of the prevention of fetal RDS, control the degree of maturity of his lungs. The outcome for the fetus is more favorable than in the previous group.

Pregnancy 34- 37 weeks (fetal weight 1900-2500 g or more): due to the fact that the lungs of the fetus are almost mature, prolongation of pregnancy is not required.

Management of preterm labor in antenatal effusionti amniotic fluid:

Tactics depends on the presence of infection and the duration of pregnancy.

Expectant management is preferable, since with the lengthening of the anhydrous period, there is an accelerated maturation of the fetal lung surfactant and, accordingly, a decrease in the incidence of hyaline membrane disease in the newborn.

Refusal of expectant tactics and labor induction are carried out in the following cases:

if there are signs of infection: temperature above 37.5 °, tachycardia (pulse 100 and more beats / min), leukocytosis with a shift to the left in the blood test, more than 20 leukocytes in the analysis of the vaginal smear in the field of view. In such situations, against the background of antibiotic therapy, labor induction should be started.

High risk of infection (diabetes mellitus, pyelonephritis, respiratory infection and other diseases in the mother).

Miscarriage This is the main problem of today's society. The essence of the existing problem lies in the spontaneous termination of pregnancy from the time of fertilization to 37 weeks. WHO explains the existing term as the rejection or extraction of an embryo or fetus with a total weight of 500 grams or less from the mother's body.

According to generally accepted rules, a miscarriage that occurs before twenty-eight weeks is considered a spontaneous miscarriage or abortion. While when it occurs after twenty-eight weeks, this process is called premature birth. The public faces a serious family-psychological problem of families that have experienced such grief. And this is also a problem that occupies a leading place in medical topics, about solving the issue of early diagnosis and prevention of this pathology, but there is also a problem of socio-economic significance for the country as a whole.

Pathology is twice as likely to be diagnosed in women, with overt discharge, starting from the early stages, of a hemorrhagic nature (12%) than in patients with no such (4%). The most dangerous in all this is the unreasonable interruption in the first trimester, namely, from the sixth to the eighth week. It is at this time interval that about 80% of miscarriages occur. Most of them occur before the appearance of a heartbeat, that is, the embryo dies. At the same time, a woman may not be aware of a previous and already interrupted pregnancy. Later than the eighth week, the probability of the occurrence of a pathological process, with a heartbeat that has already appeared, is only 2%. And with a period of ten weeks and a satisfactory heartbeat, the threat reaches barely 0.7%.

Often, in the early stages, pathology is associated with developmental abnormalities, the mechanism of the so-called biological natural selection is activated. And it has been proven that the embryos had a chromosomal defect in 82% of cases.

The causes of miscarriage cannot always be accurately determined, because. they are of somewhat mixed origin. The age indicator is also important, so if a girl of twenty had a history of two miscarriages, then a favorable outcome of a subsequent pregnancy will be 92%, and in a similar situation at 45 years old - 60%.

Risk of miscarriage

The risk of this pathological condition can be classified into several subcategories, but the main shaping factor is the number of previous miscarriages. With the initial occurrence, the probability of a subsequent one increases by 16%, with the second case in a row, the indicator increases to 28%, with three in a row it reaches 44%, with all subsequent ones over 55%. Similarly, on the basis of this pathology, secondary infertility develops, the frequency of damage reaches 35%. So, not timely started treatment entails an increase in the occurrence of a subsequent threat of miscarriage up to 52%.

Divide the risk into the following subcategories:

- Pathological changes in the organism of the future mother: heart and vascular diseases, asthmatic phenomena, kidney disease, diabetic manifestations.

- Low social factor: alcohol abuse, tobacco and drug addiction, difficult physical working conditions, constant stress, poor living conditions, food factor and poor environmental background.

- The factor of the presence of complications: oligohydramnios or polyhydramnios, premature detachment or, severe toxicosis, transverse presentation of the child or buttocks, the presence of intrauterine or intrauterine infections.

habitual miscarriage

Every day, the diagnosis becomes more common - habitual miscarriage, which is characterized by the repetition of spontaneous miscarriage over 3 times in a row. In world practice, out of 300 women, one will have this diagnosis. Often, a specialist in miscarriage, already with the second interruption in a row, exposes this pathology as a diagnosis. The process of interruption itself is repeated at approximately the same time, which introduces a woman into a state of melancholy, life begins with a sense of her own guilt. In the future, in such a situation, and the untimely help of a professional psychologist, all subsequent attempts to endure will also not be crowned with success.

Do not equate habitual miscarriage with an accidental miscarriage. The second option occurs under the influence of temporary negatively damaging factors, which as a result leads to the initial non-viability of the embryo. This phenomenon is rather sporadic and is not considered as a threat of recurrence and subsequent impact on the ability to become pregnant and, subsequently, bear a child.

The causes of recurrent miscarriage are multifactorial. These include:

- Violations of the internal secretion system: an increase in the production of the hormone prolactin, pathology of the luteal phase.

- Viruses persisting in the body:,. Pathogenic and conditionally pathogenic flora: gono- and streptococci gr. B, myco- and ureoplasma, chlamydia. And also, among them, various variations of the viral and bacteriological nature.

- Congenital pathologies of the uterus: bicornuate, saddle-shaped, adhesions, additional partitions, scars of any origin, cervical isthmus failure and multiple myomatosis. In this case, surgery is performed.

- Deviation of karyotyping.

- The presence of antibodies that interfere with the gestation process: antisperm, antibodies to chorionotropic hormone, pathology of human leukocyte antigens.

— Genomic mutations of various origins.

As a result, the reasons provided impede the normal physiological development of the placenta and contribute to damage to the embryos, which entails, first of all, the inability to bear the child normally.

Already with the diagnosis, and, in turn, the desire to give birth, a woman needs to plan and undergo examinations in advance. There are a number of specific methods, these include:

- Determination of the quantitative component of the hormones responsible for reproduction - estradiol, progesterone, androgens, prolactin, DHEAS, testosterone, 17-OP, measurement of basal temperature, hCG level. Bacpose is carried out on the flora from the cervical canal, the definition of virological factors and diseases of the sexual venereological sphere.

— Autoimmune analysis for antibodies (AT): phospholipid antibodies, antisperm antibodies, karyotype of a married couple, human leukocyte AG.

– To exclude concomitant pathology, ultrasound from 12 weeks, Doppler ultrasound from 28 weeks of fetal-placental blood flow, cardiotocography from 33 weeks, hysteroscopy, salpingography.

It is reasonable to undergo an anti-relapse and rehabilitation course of treatment before pregnancy in order to eliminate the etiopathogenetic factor. Summing up, we can say that the diagnosis of recurrent miscarriage is not a sentence, but it requires careful research and timely treatment for complete elimination, which is entirely feasible.

Causes of miscarriage

The reasons are extremely varied. Significant difficulties are the presence of an etiopathogenetic factor, but the pathology is due, rather, to the combination of several etiologies at once.

Factors are divided into those coming from the pregnant woman, the compatibility of the fetus and the female body, and the impact of the surrounding climate. The most significant are the following:

- Genetic disorders, that is, changes in chromosomes. By location, they can be intrachromosomal or interchromosomal, and quantitatively: monosomy (absence of a chromosome), trisomy (additional chromosome), polyploidy (increase in the set by a complete haploid).

In a karyotypic study of a married couple, if no anomalies are found, the probability of failure in subsequent cases of pregnancy is negligible - up to 1%. But, when one of the couple is identified, the risk increases significantly. In the event of such a case, it is recommended to consult a genetic profile and perinatal diagnosis. Often they have a family hereditary character, the presence in the family of relatives with congenital developmental defects.

Changes in gene structures are the most common and studied, accounting for about 5% in the structure of the etiopathogenesis of the given anomaly. It is known that more than half of the cases of miscarriage occurring specifically in the first trimester are due to abnormal chromosomes of the embryo. And, as mentioned earlier, it is interpreted by the scientific community as a result of natural selection, which leads to the death of a damaged, pathologically developing, and initially non-viable embryo. That is, the genetic and etiological factor depends on the intensity of the mutation and effective selection.

Chromosomal aberrations deserve special attention. So autosomal trisomy, the most common subspecies of abnormalities on the part of chromosomes, provokes more than half of all pathological karyotypes. Its essence lies in the non-disjunction of oocyte chromosomes in mitosis, which is directly related to an increase in the age index. In all other aberrations, age does not matter.

- Thrombophilic causes: lack of protein C or S, mutational changes in the prothrombin gene, hyperhomocysteinemia, antithrombin III deficiency. It is difficult to determine only if the family history and the presence of deviations in it are known in advance (thromboembolism, thrombosis, miscarriage, stillbirth, IUGR, early).

- Inflammatory diseases, with various types of association of viruses and bacteria and colonization of the inner wall of the uterus, an inconsistent immune response with the inability to eliminate a foreign agent from the body.

The role of infections has not been fully proven, since having initially provoked a miscarriage, it is not a fact that history will repeat itself a second time, the probability is negligible. The reason is rather single and is highly discussed in the scientific world. In addition, a single proven agent that provokes recurrent miscarriages has not been identified; the viral population prevails in the flora of the endometrium.

According to the data studied, persistent infections can independently trigger immunopathological processes, causing malfunctions in the whole organism. CMV, herpes, Coxsackie, enteroviruses are found in patients with abortions more often than in those with a normal course.

Colonization occurs when the immune system and the complement system, phagocytic forces, are unable to completely overcome the infection. In all likelihood, it is this condition that prevents the formation of local immunosuppression in the preimplantation period, during the formation of a protection barrier and the prevention of the expulsion of a partly alien fetus.

Often, placentitis develops along the way, with thinning of the walls and leads to the vulnerability of the fetus from penetration. The blood and airborne mechanism is observed only in the first trimester, from the second the ascending path becomes dominant. Infection goes through the amniotic fluid or foreign agents, along the amniotic membranes, getting to the umbilical cord. Chorioamnionitis develops due to exposure to prostaglandins with increased uterine contractions. Also during a diagnostic biopsy.

The state of the vaginal flora plays an important role, as it is the entrance gate for infection to enter the uterine cavity, and is the leading cause of intrauterine infection.

- Endocrine causes account for 9-23%. But! The very influence of hormonal disruptions is not so thoroughly mastered. The varieties include: violations of the luteal phase, failures in the release of androgens, thyroid disease, insulin-dependent diabetes.

Insufficiency of the luteal phase is due to a decrease in the pregnancy hormone - progesterone. Its level takes an important part in the attachment of the fetal egg to the uterine wall and its further retention. Without a sufficient level, abortion occurs and the subsequent development of infertility.

An excess of androgens is associated with increased testosterone production. adrenal is a genetically hereditary anomaly. At the same time, the ovarian comes from. Their combination, that is, mixed genesis, can be detected when the hypothalamic-pituitary function fails. In addition, antidepressants and oral contraceptives can provoke hyperprolactinemia.

Of the disorders of the thyroid gland, the most dangerous are thyroiditis, in which it is impossible to normally support the development of the fetus due to a lack of hormones and iodine deficiency.

- Immunological factors account for about 80% of all scientifically uncertain cases of repeated loss of a child. They are divided into two subcategories:

In autoimmune - the response of aggression is directed to its own tissue antigens, in the blood there are antibodies to thyroid peroxidase, thyroglobulin, phospholipids. Under the prevailing conditions, the fetus dies from damaged maternal tissues. The leading culprit in the death of the fetus is.

With alloimmune, there are antigens of the histocompatibility complex common with the partner, which are foreign to the mother's body, the response is disturbed and it will be directed against the fetal antigens.

That is, groups of immune breakdowns are revealed: in the humoral, associated with APS and cellular, the response of the maternal organism to the embryonic antigens of the father.

- Organic defects of the genital area:

Acquired (isthmic-cervical insufficiency, or,).

Congenital (uterine septa, saddle, one- or two-horned, anomalies of the uterine arteries).

The deviations described above lead to the impossibility of introducing an abnormal uterine wall of the fetal egg in order for full development to occur.

With intrauterine septa, the risk of miscarriage is 60%, with adhesions - 58-80%, depending on the location. When the branching of the arteries is incorrect, the normal blood supply is disrupted.

With myomatous changes, the activity of the myometrium is increased, the fermentation of the contractile complex, caused by malnutrition of the nodes, is enhanced.

ICI is caused by damage to the cervix during abortion, childbirth. It is characterized by softening and gaping of the cervix, as a result, the fetal bladder prolapses and the membranes enter the cervical canal, it is opened. This phenomenon is observed towards the end of the bearing of a pregnant child, but it may appear slightly earlier.

The threat and timing are due to specific causes for each period, there are “gestationally vulnerable phases of miscarriage”, namely:

5-6 weeks these are represented by genetic causes.

7-10 weeks: violations of the hormonal sector and disorders of the relationship between the endocrine and autoimmune systems.

10-15 weeks: immunological causes.

15-16 weeks: CI and infectious etiology.

22-27 weeks: ICI, malformations, discharge of water, multiple pregnancies with the addition of infection.

28-37 weeks: infection, discharge of water, fetal distress syndrome, stress not related to the gynecological area, autoimmune attacks, conditions in which the uterus is overdistended, uterine malformations.

Symptoms of miscarriage

The symptom complex does not clearly manifest itself, which makes it difficult to diagnose the disease, the process of finding the root cause, establishing the correct diagnosis and finding the best ways to resolve the problem, as such, becomes more difficult.

The symptom complex includes the following manifestations:

- The fundamental and most significant manifestation is intermittent increasing bleeding or bloody drips outside of menstruation, without significant reasons.

- Spasmodic pain, poorly relieved by medications.

- Pain that spreads downwards to the pubic region, and also radiates to the lumbar zone, inconsistent, changing at times, intensifying and subsiding, regardless of activity, stress and treatment.

- It is possible, rather as a sporadic case, a slight rise in the patient's body temperature against this background, being causeless, in the absence of infectious symptoms or other genesis.

- Alternate weakness, possibly nausea to vomiting.

As can be judged from the above, the symptomatic manifestations are not so extensive and disguised as many other diseases that even the patient herself, with the pathology that has arisen, will not suspect an abortion, but rather will associate it with the onset of menstruation or mild poisoning, neuralgia.

Diagnosis of miscarriage

It is desirable to carry out diagnostic measures before the conception of a child, and then be examined at each stage of gestation.

First of all, the life history of each applicant is carefully studied, the doctor notes: the number of previous pregnancies, their course, the presence of monitoring, the term of interruption, the use of drugs, attempts to save and specifically applicable drugs, the available tests and their interpretation, abortus pathology.

Genealogical diagnostics is the collection of information to determine causal and hereditary deviations. They study the family genealogical tree of a woman and a man, the presence of hereditary diseases in the family, deviations in the development of the couple's parents or their relatives. It turns out whether the woman was born full-term and whether she has brothers and sisters, whether they are healthy or not. The frequency of morbidity, the presence of chronic diseases, and the social standard of living are determined. Conduct a survey regarding the nature of menstruation, what was the beginning, their abundance and duration. Were there diseases of an inflammatory nature and was therapy used, were operations performed in the gynecological field. And most importantly, the definition of childbearing reproductive ability from the beginning of intimate life to the very onset of pregnancy, the methods of protection used earlier. All these factors together determine further tactics, taking preventive preventive measures and developing a protocol for managing a pregnant woman.

Clinical examination is a general examination of the skin and mucous membranes, determination of body type, body mass index, whether there are secondary sexual characteristics, how pronounced, examination for the appearance of stretch marks, listening to cardiac activity, studying liver parameters, measuring blood pressure, identifying signs of disorders metabolism, examine the chest for. The examination also includes an assessment of the psychological and emotional sphere - nervousness or apathetic signs in the patient, stress resistance, autonomic and neurotic disorders. They look at absolutely everything systematically.

They also determine the gynecological status: the state of the ovaries, ovulation processes according to the basal temperature and the menstruation calendar that the woman leads. Determination of hair growth according to the female type, neck size. Detection of existing warts, defects, hypoplasia, tumors, scars on the cervix. With this type of diagnosis is carried out:

– Bakposev, general and Nechiporenko urinalysis, biochemistry and general blood test, examination for STIs and TORCH-complex.

- Hysterosalpingography to exclude anatomical malformations of the uterus and cervical isthmus incompetence.

– Ultrasound assessment of internal organs and endometrium. Sonohysterosalpingography with the introduction of a physiological 0.9% sodium chloride solution into the uterine cavity.

- MRI and laparoscopy, if it is impossible to verify the diagnosis.

- Measurement of basal temperature with drawing its graph to assess the luteal phase.

— Infection screening. Includes microscopy of smears from the urethra, cervix and vagina, examination for virus carriers, blood for Ig M, Ig G to CMV, PCR - for carriage of HH, CMV, STIs, determination of immunity status, examination of the cervix for pathogenic bacteria and lactobacilli and their number, determination of the sensitivity of lymphocytes to interferon inducers, the study of the concentration content of the neck for cytokines, a biopsy with endometrial histology, a bacterial study and PCR to confirm the presence of an infectious factor.

- Studying the hormonal background, the progesterone function is primarily determined for women with regular menstruation. Conducting a small test using Dexamethasone and its further use with the calculation of individual doses is carried out when failures of adrenal etiology are detected, the issue of corrective therapeutic doses of drugs for an incompetent luteal stage and the definition of hormone imbalance is resolved. For auxiliary purposes, groups of hormones of the adrenal glands, thyroid gland, ovaries, and hypothalamus are studied.

- Immunological study, which determines the presence of immunoglobulins in the blood, the titer of autoantibodies to phospholipids, somatotropin, glycoproteins, chorionic gonadotropin, prothrombin, progesterone and thyroid hormones. The study of interferons is carried out with the determination of the personal sensitivity of lymphocytes to interferon inducers, endometrial biopsy is performed, and the quantitative content of pro-inflammatory cytokines is determined.

- Hemostasiogram, represents an analysis of the quantity and qualitative determination, the functioning of the whole blood coagulation system. Thromboelastography is performed with blood plasma, which reflects the very dynamics of coagulation, the quality of the indicators, and whether the cells cope with the task. The study of coagulogram and platelet adhesion. Finding features and D-dimer. The study of gene polymorphism, the decrease in trophoblastic globulin is being investigated as a primary indicator of the risk of an abnormal placenta.

- Genetic studies, mandatory for age-related couples, recurrence of miscarriages, stillbirths, lack of treatment effect. Includes genealogy as described earlier and cytogenetic study - karyotyping to detect chromosomal abnormalities, analysis of abortus and karyotyping of neonatal death.

- With a difference in blood types of partners, an analysis for immune antibodies is performed, with a Rh conflict - the presence of Rh antibodies.

- Lupus antigen, antichoriotropin to determine the aggression of autoimmune origin.

- Examination of a man consists of passing a spermogram (expanded), a survey about related diseases, the presence of somatic diseases, diseases of the immune system.

In addition, weekly diagnostic measures are classified:

15-20 weeks: examination in the gynecological chair and ultrasound to exclude cervical isthmus incompetence, taking smears to determine the microflora, testing alphafetoprotein, beta-chorionotopin.

20-24 weeks: glucose tolerance test, vaginal ultrasound and, if indicated, manual assessment of the genital tract, swabs for pro-inflammatory cytokines and fibronectin, Doppler blood flow assessment.

28-32 weeks: ultrasound, prevention of Rh sensitization, study of fetal activity, control of contractile processes of the uterus, hemostasogram.

34-37 weeks: cardiotocography, blood tests for sugar, protein, urinalysis and bacterial culture, repeat hemostasiogram, examination of vaginal smears, tests for hepatitis, immunodeficiency virus and Wasserman reaction.

The frequency of examinations should be carried out every week, more often if necessary, with possible observation in the hospital.

Treatment of miscarriage

If the miscarriage is complete and the uterine cavity is clean, no special treatment is usually required. But, when the uterus is not completely cleared, a curettage procedure is performed, which consists in carefully opening the uterus and extracting the fetal remains or placenta. An alternative method is to take specific medications that cause the contents of the uterus to be rejected, but it is applicable only in a normal state of health, since after that it requires the expenditure of vital forces to restore the body.

To date, there is no approved protocol for the treatment of miscarriage, they vary. Since none of the protocols is supported by scientific research and does not meet the criteria for the effectiveness of treatment, the therapy is carried out taking into account the personal characteristics of the woman who applied, but not according to a unified standard.

Of the routine methods of treating miscarriage, as a reinforcement to the main methods, use:

- Vitamin therapy. Especially Tocopherol (fat-soluble vitamin E, vitamin of life) at 15 mg twice a day, it has been proven that in combination with the use of hormones, the therapeutic effect is higher. Electrophoresis with B1 is used - this stimulates the sympathetic central nervous system, thereby lowering the contractility of the muscles of the uterus.

– Neurotropic therapy normalizes already existing functional disorders of the nervous system, sodium bromide is used in droppers or per os, as well as Caffeia for neuromuscular blockades.

Therapeutic measures are carried out after a thorough examination and identification of the leading factor in the development of pathology, since treatment is directly distributed according to etiology:

- Treatment, with an infectious genesis, depends on the microorganism that provokes the disease. They try to use sparing methods with the complete elimination of the pathogenic agent, these include immunoglobulin therapy, antibiotic therapy with the determination of individual sensitivity for quick and effective resolution of the disease, interferon therapy - KIP-feron suppositories, Viferon suppositories, Betadin, Klion-D, intravenous human immunoglobulin or Octagam. Tocolytic therapy is applicable, which removes the excessive contractile message - Ginipral, Partusisten. With fungal etiology in suppositories or orally Pimafucin. After examining the vaginal normobiocenosis, the normal concentration of lactobacilli. If necessary, biological preparations are used - Acilak and Lactobacterin. If the indicators are normal, you can plan a pregnancy.

– The treatment of genetic abnormalities in partners with a congenital disease consists in conducting a genetic consultation and subsequent treatment with the method, with a donor egg or sperm, depending on who the deviation was determined. An alternative is artificial insemination with own cells, but with preimplantation genetic diagnosis.

- Anatomical pathology is corrected only surgically. For example, hysteroscopic access to remove intrauterine septa and the concomitant administration of hormonal drugs to stimulate the growth of endometrial tissues. With cervical-isthmus incompetence, a circular suture is applied to the cervix until 14-20 weeks. But, this manipulation is contraindicated in case of labor and opening of the external pharynx over 4.5 centimeters. They are supposed to be removed by 37 weeks or much earlier for urgent delivery.

- For the treatment of luteal phase deficiency, progesterone is preferably used. The greatest effectiveness of gestagens is Duphaston or Utrozhestan. The combination of Duphaston with Clostilbegit has a positive effect, which improves the maturation of the follicle, supporting the first phase and the formation of a full-fledged corpus luteum. When choosing any method, treatment with progesterone preparations should last up to 16 weeks. In case of sensitization to progesterone, immunoglobulins and immunotherapy with the introduction of spouse's lymphocytes are administered.

If an MRI study excludes the pathology of the Turkish saddle - pituitary adenoma, then Bromkriptin or Parlodelay therapy is performed. With concomitant pathology of the thyroid gland, Levothyroxine sodium is added, and continued after the onset of pregnancy.

It is also applicable to use antispasmodics - Papaverine, No-shpa, herbal sedatives - Valerian infusions, Magne B6 preparation.

- In the treatment of antiphospholipid syndrome, which leads to thrombosis of the placenta, antiaggregation drugs are used - Heparin subcutaneously and Aspirin. They are especially effective when taking vitamin D and calcium at the same time, since there are not isolated cases of development. Limited, due to strong side effects, the use of corticosteroids - Dexamethasone or Metipred in individual doses, and its use in conjunction with low molecular weight heparin subcutaneously is desirable. The schemes provided are very dangerous for the woman and the fetus, but the AF syndrome itself causes a significant blow to the body. Another method is plasmapheresis, but it is also limited due to the individually significant effect. Plasmapheresis in a course of three sessions consists in removing 600-1000 ml of BCC per session and replacing it with rheological solutions, thus eliminating toxins, partially antigens, improving microcirculation, and reducing increased clotting.

- For the normalization and prevention of placental insufficiency, Actovegin, Piracetam, Infezol are used, mainly intravenously. If there is a threat, strict rest is needed, taking according to the scheme magnesium sulfate and hexoprenaline sulfate, fenoterol, NPP - Indomethacin, Nifedipine, Oxyprogesterone Capronate. To relax the uterus, non-drug means are used - electrorelaxation and acupuncture.

- In case of hyperandrogenism, treatment should begin with weight correction, normalization of carbohydrate and fat metabolism. In preparation for conception, conduct Dexamethasone therapy under control.

Resolving the issue of miscarriage is not a problem. The main thing is to carry out targeted diagnostics in time, a thorough examination before pregnancy, pathogenetically substantiated and methodically constructed treatment, and dynamic monitoring throughout pregnancy.

Prevention of miscarriage

Prevention consists in an initially serious attitude towards the female health of the patient herself and the competence of the doctor who leads her. Prevention of miscarriage is carried out for the most thorough identification of the causes and timely appointment of rehabilitation therapy.

There are fundamental principles for the prevention of miscarriage:

– Determination of the initial risk group and their dispensary management by a gynecologist.

– Initially, a survey when planning a pregnancy for both partners and their preventive preparation. Determination of compatibility by Rh group, human leukocyte antigen and similar diagnostic methods.

- With a manual assessment, the diagnosis of cervical isthmus insufficiency, using an intravaginal probe with ultrasound up to, and with twins up to 26 weeks.

— Prevention and adequate therapy of extragenital pathologies and exclusion of the impact of strong stress factors.

- Timely treatment of thrombophilic diseases from early pregnancy.

- Elimination and prevention of placental insufficiency.

- Sanitation of chronic foci of infection.

- With a known pathological hormonal background, the selection of treatment and timely preventive correction. So with a known infectious background, immunoglobulin therapy.

- If harmful consequences are identified and cannot be avoided, careful provision of information to a woman and the search for alternative individually selected methods of conceiving and giving birth to a child.

- The expectant mother herself should also be involved in preventive measures: exclude addictions, lead a healthy lifestyle, exclude uncontrolled sexual intercourse and adequate contraception in such cases, rejection of artificial abortions.

Miscarriage is a serious problem that happens to be faced by about 15-25% of couples expecting a baby. Why are some pregnancies doomed to such a sad outcome, and is it possible to deal with this problem, our article will tell.

They talk about miscarriage when, in the period from the moment of conception to 37 weeks, all the hopes of the expectant mother collapse due to spontaneous miscarriage. It acquires the status of a “familiar” phenomenon when misfortune befalls a pregnant woman 2-3 or more times in a row. Statistics say that habitual miscarriage competes with infertility for the right to be called the most common problem of procreation.

Classification of cases of miscarriage

Depending on the term of termination of pregnancy, there are:

1. Spontaneous abortions. If the miscarriage occurred before 11 weeks, the abortion is considered early. If the misfortune happened between 11 and 21 weeks of gestation, the abortion is late. The interrupt occurs regardless of whether the child is alive or dead.
2. premature birth. Pregnancy is terminated at 22 - 27 weeks, when the child's body weight fluctuates in the range of 0.5 - 1 kg.

There are several stages of abortion, based on which the following types of this condition are distinguished:

• threatened abortion;
• abortion in progress;
• incomplete abortion;
• complete abortion.

In addition, speaking of abortion in general, they mean that it can be failed and infected.

Causes of miscarriage

A great many factors have been found to cause this pathology. Stimulates miscarriage is often not one, but several reasons. Let's list them all.

Reasons depending on the future mother:

• endocrine diseases (for example, pathologies related to the health of the ovaries or adrenal glands);
• anatomical features of the female body (for example, an infantile uterus or serious anomalies in its development);
• pathological incompatibility of a woman and a child. We are talking about the phenomenon when, on immunological or genetic grounds, the mother organism rejects the embryo/fetus as a potential threat.

Complications that occur during pregnancy:

• preeclampsia, which entails various disorders of cerebral circulation;
• placenta previa or its premature detachment;
• violation of the integrity of the membranes earlier than expected;
• polyhydramnios;
• the presence in the uterus of 2 or more embryos;
• pathological location of the fetus.

Factors not related to gestation:

• acute and chronic infectious diseases;
• pathology of the heart and blood vessels;
• disorders of the functionality of the genitourinary system;
• thrombophilic diseases;
• diseases of the abdominal organs.

Adverse environmental impact:

• bad ecology;
• harmfulness in production related to the profession of a woman;
• physical or mental trauma of the expectant mother;
• bad habits.

It should also be noted that the causes of 27.5 - 63.5% of cases of miscarriage remain unexplained. Pregnant women and the physicians leading them find themselves in such a difficult situation so often that the phenomenon has even been identified as idiopathic (not to be explained) abortion. Drug treatment in these cases is ineffective, and the psychological support of a woman comes to the fore, helping her to endure the pain of loss.

The mechanism of development of pathology

At the basis of self-interruption of intrauterine development of the fetus, a pathological destruction of the connection between cortical and cortico-subcortical factors is hidden, which occurs under the influence of many prerequisites. The prerequisites mean the most complex reflex relationships between mother and child, as well as factors that can affect the nuances and strength of the reflex.

Today, 4 options for the development of pathology have been identified:

1. Termination of pregnancy is possible on the basis of pathological changes in the immune and hormonal balance of the fetoplacental complex. In this case, miscarriage occurs in the early stages (up to 12 weeks).
2. Gestation is interrupted due to active uterine contractions: the fetus is rejected as if labor had begun. This happens mainly closer to the 3rd trimester of the “interesting” position, when the uterus has already undergone morphological and functional metamorphoses.
3. The death and rejection of the fetus occurs under the influence of mutations or genetic disorders.
4. Miscarriage occurs on the basis of isthmic-cervical insufficiency (pathology of the isthmus and cervix) in the middle and at the end of gestation.

Scientists have combined all types of childbearing losses into fetal loss syndrome. The general concept means:

1. One or more miscarriages in a row during a pregnancy of 10 weeks or more.
2. The birth of a dead child in the history of the disease.
3. Neonatal (infant) death.
4. 3 or more self-abortions during the pre-embryonic or early embryonic stage.

Diagnosis of pathology

Due to the fact that miscarriage is considered the result of a combination of the interaction of a number of unfavorable causes, the examination of affected patients is complex. It involves clinical, instrumental and laboratory diagnostic methods, during which the doctor must not only detect the "weak link" during pregnancy, but also examine the state of the patient's reproductive system in order to prevent a recurrence of the misfortune.

Features of the examination before conception

Analyzing the medical history of a woman who has experienced habitual miscarriage, the specialist will pay attention to the hereditary factor, oncological diseases and neuroendocrine disorders. It also remains to be determined whether the patient suffered from genital inflammatory diseases and viral infections in the past, whether she underwent surgery during childbirth, intentional or spontaneous abortions.

Clinical examination is represented by the following procedures:

• examination of a woman by a gynecologist;
• assessment of the patient's skin condition;
• determination of the amount of excess weight according to BMI;
• assessment of the state of the "thyroid gland";
• determination of the frequency of ovulation and the functional viability of the ovaries based on data from rectal temperature and the monthly calendar.

In laboratory and instrumental diagnostics, the following methods are used:

1. Hysterosalpingography. The procedure is relevant in the period from 17 to 23 days of the monthly cycle. With its help, you can examine the body of a woman for the presence of defects and anomalies in the development of internal genital organs, intrauterine synechia, etc.
2. ultrasound. During the procedure, the ovaries are examined, the uterus is checked for the presence of cysts, adenomyosis and polyps.
3. infectious screening. The method involves the examination under a microscope of biological material taken from the urethra, vagina and uterus.
4. Hormonal analysis. Allows you to clarify the level of prolactin, testosterone, cortisol, luteinizing, follicle-stimulating hormones and other important active substances in the patient's blood.

The potential father also undergoes an examination, during which his detailed spermogram is analyzed, the presence of immune and inflammatory factors and specific somatic diseases is clarified.

Features of the examination after conception

If there is a risk of miscarriage in a patient who is in position, she is observed with particular care. The conduct of such a pregnancy is necessarily accompanied by the following research methods:

• regular blood sampling to determine the level of hCG;
• a blood test for DHEA / DHEA sulfate (this is the main steroid hormone in a woman's body, with the participation of which the glands of the endocrine system produce another 27 hormones);
• periodic consultations with a psychologist.

Symptoms and treatment of miscarriage

The allocation of some blood from the vagina and painful discomfort in the lower abdomen are considered to be the main signs of spontaneous abortion. However, it should be borne in mind that each stage of miscarriage has its own specific manifestations, which means that it requires a special approach to treatment.

Threatened abortion

A woman in position is disturbed by pulling pains in the lower abdomen and in the lower back. If alarming symptoms are noted in the middle of pregnancy, the pain, as a rule, resembles contractions. There is a slight discharge of blood. The uterus develops well, its volume corresponds to the gestational age, but there is hypertonicity.

The ultrasound procedure reveals such symptoms of a threatened abortion as an indistinct contour of the fetal egg or detachment of the chorion / placenta in a certain area.

Before prescribing maintenance therapy to a pregnant woman with a threat of miscarriage, the doctor will certainly pay attention to the presence of such concomitant factors as:

• cases of self-abortion in the past;
• age over 34;
• bradycardia;
• the absence of a heartbeat in an embryo with KTR;
• slow growth or its absence in the fetal egg within 10 days;
• an empty fetal egg measuring 15 mm for a gestation period of 7 weeks and 21 mm for a period of 8 weeks;
• the size of the embryo is significantly inferior to the size of the fetal egg;
• reduced levels of hCG;
• low levels of progesterone.

Despite all the warning signs of a threatened abortion, targeted treatment helps keep the pregnancy going. Supportive therapy in this case is complex: drugs are prescribed at a minimum in scanty doses, mainly focusing on safe procedures in the form of electroanalgesia, acupuncture, electrorelaxation of the uterus and phytoaromatherapy.

Abortion on the go

At this stage of miscarriage, the embryo exfoliates from the uterine endometrium and leaves the uterus through the dilated cervical canal. The pregnant woman feels cramping pain in the abdomen, she has profuse bleeding. Vaginal examination reveals an open cervix with parts of the fetal egg in it. At 12 weeks' gestation, an ultrasound shows a complete detachment of the egg or partial detachment of the placenta.

The tactics of further actions are chosen taking into account the duration of pregnancy. So, for a gestation period of up to 16 weeks, the uterus is scraped as a matter of urgency, followed by a laboratory analysis of the torn tissue. With a period of 16 weeks, spontaneous complete rejection of biological material is expected, and only then vacuum cleaning or curettage of the uterus is carried out.

In case of severe bleeding, which can threaten the life of the patient, they act promptly: the embryo is removed from the uterus without waiting for its rejection, and hemodynamics are stabilized. If an immediate operation to curettage the uterus for some reason is not possible, with severe bleeding, the pregnancy is terminated abdominally.

incomplete abortion

The embryo leaves the uterus, but some of its parts remain there. Outwardly, this is manifested by pain of a cramping nature and the release of blood from the vagina, and these symptoms can be of varying degrees of intensity. On examination, the sick doctor determines that the cervix is ​​​​shortened, and the pharynx is open. There is no uterine tone - the organ is soft and does not correspond to the gestation period. On ultrasound in the cavity of the muscular organ, unclear outlines of heterogeneous tissues are found.

In case of incomplete abortion, the uterine cavity is cleaned, removing rejected tissues from there, followed by a laboratory study. They resort to a surgical or medical method of ridding the uterus of parts of the embryo.

The choice in favor of surgery is made in the case of:

• intense bleeding;
• the uterine cavity is open by more than 50 mm;
• body temperature is about 38 0 С.

With a satisfactory condition of the patient and a gestational age of 70 days from the first day of the last menstruation, preference is given to the medical method of cleaning. In case of incomplete abortion, large doses of prostaglandin (from 800 to 1200 mg) are used. Most often they stop at the drug Misoprostol. After 4-6 hours after intravaginal administration, the uterus begins to contract and completely expels the fetal egg. The main advantage of this method is the low percentage of cases of pelvic infection.

Complete abortion

Under the influence of strong uterine contractions, the fetal egg is rejected by the uterine cavity. External signs are either completely absent or expressed by scanty bleeding and pulling pains in the lower abdomen. Vaginal examination reveals a firm uterus with an open external os. If the patient's condition is satisfactory, then an instrumental examination of the walls of the uterine cavity is not performed.

Missed abortion

In this case, the embryo stops developing, but does not leave the uterus. The patient at this time may increase body temperature and appear ichorus. Subjective sensations of an “interesting” position disappear. Ultrasound shows that the size of the embryo lags behind the gestation period. In addition, there are no heartbeats and movements of the embryo. If the diagnosis of a failed abortion is confirmed, an urgent operation is necessary to remove the embryonic or fetal material by surgical or medical means.

Forecast and measures to prevent recurrent miscarriage

The prognosis for the development of pregnancy in the future in a patient whose medical history contains a mark on self-abortion depends on how the previous pregnancy ended. The most favorable prognosis is in women whose pregnancy was terminated due to organic uterine pathology, endocrine or immune factors.

With all the complexity and unpredictability of the phenomenon of habitual miscarriage, you can try to avoid it. After a detailed study of the patient's history, the doctor prescribes a comprehensive treatment, consisting of the use of medications and the implementation of the recommendations of a specialist. An approximate therapeutic complex for the treatment of recurrent miscarriage looks like this:

1. Bed rest and strict diet.
2. The use of sedatives (Sanosan, Diazepam, Phenazepam, herbal tinctures).
3. The use of hormonal drugs. Treatment is effective from the 5th week of gestation until the 28th week inclusive. The most popular drugs are progesterone, gonadotropin, Duphaston and Ethinylestradiol.
4. Use of antibiotics to prevent infection.
5. Tocolytic treatment aimed at suppressing the contractile activity of the uterus.
6. Work to improve the metabolism of the fetoplacental complex, for which the patient is prescribed multivitamin complexes, preparations of ascorbic acid and tocopherol acetate.
7. Operative surgical intervention (in case of urgent need) - a circular suture is applied to the uterus until the 38th week of gestation.

Prevention of miscarriage

Unfortunately, nature cannot be outwitted, and with all the desire of expectant mothers and their attending physicians, cases of habitual miscarriage still occur. The search for methods of getting rid of this pathology continues to this day and indicates that the methods of treatment already found cannot be called 100% effective. However, you can’t give up - a woman must use all the opportunities and chances to become a mother. Therefore, planning pregnancy after the previous one ended in spontaneous abortion is of no small importance.

The patient should consult a doctor for a thorough examination of the state of the body for the presence of diseases in which the course of pregnancy can be complicated, tests to analyze the hormonal background and bacteriological examination of the microflora of the internal genital organs, determine the blood type and Rh factor. In addition, the future father must also undergo a thorough examination.

With an unclear etiology of the causes of miscarriage, a woman can be sent to a specialized hospital for a rigorous analysis of the state of her endocrine and immune systems.

How to deal with the problem. Video

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

(etiology, pathogenesis, diagnosis, clinic, treatment)
Educational - methodical manual

Approved

At the Council of the Faculty of Surgery

Dean of the Faculty of Surgery, Associate Professor

V.L. Silava

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, Vitebsk State Medical University, Doctor of Medical Sciences, Professor S.N. Zanko.

Miscarriage (etiology, pathogenesis, diagnosis, clinic, treatment): Proc. - method. allowance./C. L. Yakutovskaya, V.L. Silyava, L.V. Vavilova. - Minsk: BELMAPO, 2004 - p.

The teaching aid covers the etiology of the pathogenesis of miscarriage, methods of diagnosis and treatment.

The tactics of preparing for pregnancy and managing pregnancy in patients with this pathology are presented.

Designed for obstetrician-gynecologists.

UDC 618.39 (075.8)

LBC 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. Management of pregnancy in patients with miscarriage	17
2.1. Diagnostic tests to assess the course of pregnancy	17
3. Therapeutic and preventive 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 threatened miscarriage.	21
4.1 Therapy during pregnancy, in women with NLF	22
4.2. Tactics of pregnancy management in women with various forms of hyperandrogenism	22
4.3. Tactics of pregnancy management in women with infectious genesis of miscarriage	24
4.4 Management of women with CI during pregnancy	27
4.5. Management of pregnancy in women with APS	29
4.6. Management of pregnancy with sensitization to hCG	31
5. Preparation for pregnancy of patients with miscarriage	32
5.1. Tactics of managing 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 CCI outside of pregnancy	38
5.5. Tactics of preparation for pregnancy in patients with APS.	39
5.6. Preparation for pregnancy of patients with sensitization to hCG	41
6. Literature	42

Introduction