Habitual miscarriage of pregnancy causes diagnosis treatment. Treatment of Miscarriage. Infectious causes of miscarriage

Miscarriage, regardless of the cause of the loss of the child, is a tragedy for the expectant mother. There are many reasons for the spontaneous interruption of the reproductive process. And they do not diminish over the years: both because of the poor ecology, and because of the stresses inherent in modern life, for which expectant mothers are often not ready.

An important role can be played by a woman's attitude to pursue a career, missing the time of greatest fertility, and when she “does herself”, having achieved some planned peaks in her life, diseases accumulate, making the normal course of pregnancy problematic. And in such a situation, alas, "strong women" often refuse the very opportunity to have a child.

In gynecology, miscarriage is considered a sudden termination of pregnancy before 259 days, or 37 weeks. A significant difference will be the time interval between miscarriage of a child up to 22 weeks, and up to 28 - 37 weeks. The first term is a miscarriage, the second is premature birth.

The intermediate period between 22 and 28 weeks in Russia and among foreign doctors is considered differently: in our country, miscarriage at such times is referred to as late abortion, if the result is a dead fetus, and if the fetus was born and survived within 7 days, it is already referred to to live-born children. In foreign medicine, miscarriage within 22-28 weeks is legally equated to childbirth without reservations.

Taking into account the same life situations or biomedical indications, a forced termination of pregnancy is possible. Made before 28 weeks, it is issued as an artificial abortion, after 28 weeks - premature artificial birth.

But it all depends on the timing of the process of bearing the fetus. Distinguish between early abortion, made before 12 weeks, and late, made in the period from 13 to 27 weeks. A separate item is "habitual miscarriage", when in the history of the disease there are more than two miscarriages or more than two early births in a row.

Causes of miscarriage

In the list of reasons for the loss when carrying even the desired child, there is a genetic reason as a leader. And this is given the fact that this happens from 3 to 6% of cases, and about half of them fall in the first trimester, and this indicates a programmed "unwillingness" of a woman's body to bear such a fetus due to natural selection.

Relentless medical statistics show that when examining about 7% of couples who wanted to become parents, but they did not succeed, chromosomal rearrangements of an abnormal nature were found. They did not in any way affect the health of both parents from the couple, but after the fertilization of the egg in a woman, the processes of chromosome pairing, and then their separation during meiosis, went “wildly”, in contrast to the correct natural program in genetically healthy couples. As a result, the formation of unbalanced rearrangements of chromosomes in the emerging embryo, as a result of which it became unviable, and the mother's body rejected it, interrupting the incipient pregnancy, or the fetus developed further, but carrying a genetic abnormality of varying severity.

Due to the complexity of the cause-and-effect relationships in the physiological mechanism of the problematic bearing of the fetus, as well as for the convenience of classification, indicating the reasons, it is better to compile the following list of them:

1. Spontaneous abortion (or miscarriage)
2. Non-developing pregnancy, or "miscarriage"
3. Habitual miscarriage
4. Premature birth

This material does not consider the separate items of criminal and septic abortion, as not related to the topic.

Spontaneous abortion

The collected factual material allows us to consider miscarriages occurring in 15-20% of all desired pregnancies, especially in the first trimester of pregnancy, as a manifestation of natural selection. That is, this mechanism is built into the human population in order to prevent the accumulation of qualitative irreversible consequences for the human gene pool. Preventive measures against this state of affairs may consist in the simultaneous examination for genetic failures in both the future father and the expectant mother.

The development of a fetus with chromosomal abnormalities has no effect on a woman's fertility.

Due to the confusion of reasons for spontaneous abortions, it is often not possible to identify the main one. In addition to genetics, social reasons often play an equally important role, such as an unfavorable working environment, where there may be high or low temperatures, vibration, extreme noise thresholds, and harmful chemical agents. This also includes the unstable emotional state of a woman during pregnancy, when she is not sure of the desirability of a child for herself or for a partner in marriage / cohabitation, domestic disorder, uncertainty about financial stability or the complete absence of such, housing problems.

The second, approximately equal half of the reasons will be already medical and biological aspects such as fetal pathology or congenital malformations of the uterus. This also includes past infections, disorders of the endocrine system. Previous artificially induced abortions and IVF are often combined due to the similarity of the hormonal effects on the body.

The onset of the picture of spontaneous abortion often looks like either a spontaneous contraction of the uterine walls followed by a detachment of the ovum, or, conversely, its detachment precedes the onset of activity of the walls and muscles of the uterus. Although it happens that these two phenomena occur simultaneously. A miscarriage, depending on how it manifests itself, is considered as:

• threatening abortion,
• started abortion,
• abortion in progress,
• incomplete abortion,
• failed abortion,
• infected abortion
• habitual abortion.

Let's sort them out in order.

Threatening

There is a contractile hyperactivity of the uterine muscles; the fetal egg fits snugly against the uterine walls.

The clinical picture of such a miscarriage: the appearance of pulling pains in the lower abdomen, in the sacro-lumbar part of the back. There is a feeling of heaviness. The blood is not smeared, the mucous membranes of the vagina are normal, there is no discharge.

Examination of the vagina will show that the entrance to the uterus remains normal. When examining, the state of the cervix will be preserved, the external pharynx will not open by more than 10 mm, the internal pharynx will be closed, the general tone of the uterus will be increased. Uterine sizes correlate with the gestational age determined by the gynecologist.

Started

It will be evidenced by the beginning of the process of gradual separation of the embryo from the wall of the uterus. Against the background of uterine contractions, painful contractions begin, bloody spotting appears, pain is characteristic of localization in the lower abdomen and in the lumbar region. But an examination in a gynecological chair will give an unchanging picture: the cervical pharynx is closed (however, it may be slightly open), the size of the uterus corresponds to the period set when registering a pregnancy.

The test (b-XG) will always remain positive both with a threatening and with the onset of a spontaneous abortion. Both pathogenic processes will only be detected with great accuracy by ultrasound, showing the presence of the ovum in the uterus and the beginning of its detachment.

Treatment of such conditions, designed to preserve the pregnancy, is agreed with the patient. They use proven sedatives, vitamin E, antispasmodics for him, with the obligatory bed rest and exclusion of strong external stimuli from life. Sometimes, with such indications, you can use sparing methods of treatment.

If a threatening miscarriage is planned, and the gestational age is already later than 20 weeks, then b-adrenomimetics (beta-agonists) are indicated, initiating the production of dopamine and adrenaline, bringing smooth muscles to a normal state.

If there is an "incipient" abortion (miscarriage), its treatment is identical to the "threatening" abortion (miscarriage).

With hormonal disruptions, the same therapy is performed. If the tests showed hyperandrogenism (an excess of male sex hormones characteristic of Stein-Liventhal syndrome), corticosteroids can be used, controlling the values ​​of DHA-s in the blood and 17-KS in the urine. And if the corpus luteum deficiency is detected during the first trimester, gestagens are prescribed.

What is done in the event that the leakage of amniotic fluid is recorded? With such a development of the process, there is no point in maintaining pregnancy, it is impossible to stop the waste of water, this process is irreversible.

Abortion in progress

It is characterized by one hundred percent detachment of the fetal egg from the uterine walls and lowering it to its lower part when it reaches the cervical canal of the uterus and rests against it. External signs - pain in the lower abdomen, noticeable slight bleeding. The ovum reaches the dilated cervical canal, the lower pole of the fetus can protrude from this canal into the vagina.

Completion of such abortions:

1. Incomplete
2. Complete abortion.

At the first time after the loss of the ovum in the uterus, there are scraps of it in the form of membranes and parts of the placenta. This is revealed only with the help of ultrasound or with direct manual examination. If a pregnancy test is carried out at this time, it will be positive due to the presence of unreleased parts of the placenta, which continue to generate human chorionic gonadotropin (HCG), a specific planetary hormone that the placenta produces during pregnancy. (It is its presence that allows you to determine the onset of pregnancy by a test indicator with two strips).

The examination at this stage reveals the opening of the cervical canal of the cervix to a diameter of about 12 mm. Inside the canal, there may be remnants of the ovum, palpable as a soft substrate. Uterine sizes are reduced in comparison with those that should be at a predetermined duration of pregnancy. Blood is present as smearing discharge of varying intensity.

Treatment

Forced abortion, instrumental scraping of the mucous membranes of the uterus and the mandatory removal of the ovum or its remnants.

If there is bleeding of low intensity, it is advisable to use vacuum aspiration. 5 to 10 units are administered intravenously to stimulate uterine contractions and stop bleeding, and also take measures to compensate and restore blood loss using intravenous plasma and crystalloids. After the operation, antibiotics are used to prevent infection. If the patient has Rh-negative blood, anti-Rh-gamma globulin must be injected.

With a complete abortion, a complete forced release of the ovum from the uterus is done. This is possible only in the case of a fully formed placenta at 12-13 weeks of pregnancy. Only after the onset of this period can we talk about the release of the uterus from the remnants of the traces of a failed pregnancy. Although it is imperative to check the condition of the walls of the organ that has not yet departed from the attempt to take out the child with a small curette! After 14-15 weeks of gestation, if you are convinced of the integrity of the placenta, uterine curettage can be omitted.

Miscarriage

Or a pregnancy that has stopped in development. This stalled phase is equated to a failed abortion, when the fetus or embryo died without outside intervention.

In a dead state, it can rest in the uterus for more than a month, mummifying itself, and without causing contractions of the uterus, as it does not react to a dead fetus as to a foreign body.

Doubtful signs of pregnancy as clinical disappear, the uterus is smaller than it should be with the existing period of delay in menstruation. Ultrasound does not detect fetal heartbeat; abundant spotting bloody discharge from the vagina is possible.

If the ovum in the uterus is delayed for a long time, the blood group is urgently determined, always with the Rh factor, and measures are taken to fully stop the possibility of abundant blood loss. If the gestation period is still up to 14 weeks, it is better, in view of the general trauma of the cleaning process, to apply vacuum aspiration, as the most gentle method. Later, in the second trimester, more radical methods of interruption are used: the introduction of laminaria into the birth canal, with the simultaneous introduction into a vein or intra-amnial application of oxytocin and dinapost (prostaglandin F2a). Intravaginal application of prostaglandin gel is also practiced.

Miscarriage treatment

It is advisable to start treatment with a deep diagnosis, using the data of the "family tree" of the family members of the pregnant woman and her partner.

The risks of miscarriage increase as this phenomenon recurs: if after the first miscarriage the risk of a second miscarriage is about 12%, then with a second one it rises to 25. And after the second, if no rehabilitation measures have been taken, the risk of losing a child will be 50 percent or more.

Diagnostics

Treatment is impossible without high-quality diagnostics, and the more complete it is, the more there will be a guarantee of the correct anamnesis and the effectiveness of the drugs used in the treatment.

The stages of the survey include:

1. General inspection;
2. gynecological examination;
3. special diagnostic methods, which, in turn, include:

• or hysteroscopy;
• If necessary, laparoscopic diagnostics
• Magnetic resonance imaging
• Scheduling changes in basal temperature
• Complex of laboratory diagnostic measures (microbiological and immunological research); genetic research.

If there was a history of miscarriage, genetics tests are prescribed for both spouses. This is also done in cases of the birth of still babies for reasons that could not be determined; or the alternative methods used have been shown to be ineffective; if one of the spouses (or both) is over 35 years old. Such an examination of the couple is carried out at the medical center in two visits.

1. Identification of accidents or patterns of miscarriages, infertility, developmental disorders in accordance with family pedigree.
2. Determination of the complete chromosomal set of cells of both parents (determination of the karyotype). The goal is to identify inversions, trisomy, mosaicism and other chromosomal inversions.

Another goal of genetic counseling is to identify possible genetic incompatibilities in which leukocyte antigens are assessed.

So the treatment will depend on the identified causes of miscarriage identified during the examination.

Drugs

When an inferior luteal phase is found, it is possible to recommend the appointment of antispasmodics ("Drotaverin", "No-Shpa" and the like), herbal sedatives, in the form of a tincture of valerian root; Magne B-6; hormonal drugs in the form of chorionic gonadotropin and "Duphaston".

In a situation where a strong reaction to progesterone is detected, glucocorticoids and the same "" are shown, immunoglobulin injections cannot be dispensed with, and immunotherapy with the introduction of lymphocytes from the blood of her spouse into the blood of a pregnant woman will be especially useful.

Prevention of plantar insufficiency, as well as its treatment, is done with the help of the drugs "Piracetam", "Actovegin", "Infezol".

Outpouring of amniotic fluid and detected infections are the reason for the use of antibiotics, antifungal and tocolytic drugs.

With the existing threat of miscarriage, complete rest is shown by excluding stress factors from life, with indications - treatment with magnesium sulfates, terbutaline, hexoprenaline, salbutamol. And also fenoterol, non-steroidal drugs ("Indomethacin"); blocking calcium channels ("Nifedipine") and sex hormones, such as "Capronate oxyprogosterone".

Plasmapheresis

For allergies, local intolerance to some drugs, as well as with gestosis of pregnancy, an increase in symptoms of chronic course, disseminated intravascular coagulation syndrome and to prevent inflammatory lesions of the lungs (distress syndrome) occurring with edema, up to 3 sessions of plasmapheresis are performed. That is, in one session, from the entire volume of blood that circulates in the body, from 600 to 1000 ml of plasma is withdrawn and replaced with protein and rheological solutions. This allows you to cleanse the blood of toxins and antigens, improve its capillary circulation, reduce its coagulability (if it is increased), and, as a result, reduce the dosage of drugs if the female body does not tolerate them well.

Surgery

Surgical methods of treatment include excision of the uterine septa, synechiae within the uterus and fibroid nodes, which is best done during hysteroscopy.

Surgical intervention for this type of miscarriage depends on the experience of the surgeon, and is 70-80% effective. True, the operation may be unsuccessful if the patient's pregnancy and childbirth were normal before. This means that miscarriage was associated with other factors acquired in the last years or even months before the current pregnancy. To improve the growth of the uterine lining, which is necessary for normal conception, it is recommended to take combined oral contraceptives for at least three months, during which time the endometrium is restored.

From non-drug means of influence, magnetotherapy and electrophoresis with zinc sulfate are shown.

After examining the luteal phase and identifying its insufficiency, it is necessary to eliminate its cause. In the presence of NLF with simultaneous hyperprolactinemia, an MRI of the brain or an X-ray of the skull for examining the state of the pituitary gland is shown. His adenoma is possible, which will require surgical intervention.

If the pituitary gland is normal, bromocriptine therapy is prescribed, with its cancellation in case of pregnancy.

Medical therapeutic intervention is carried out in one of the following ways:

1. Ovulation is stimulated with clomiphene, from 5 to 9 days of the cycle, doing this procedure for three lunar months in a row.
2. Progesterone is replaced by "", "Duphaston" in order to maintain full secretory changes in the endometrium while maintaining full ovulation. If, after such treatment, it was possible to achieve the onset of pregnancy, progesterone therapy is still continued.

Habitual miscarriage

This term describes a recurrent abortion, which happened two or more times one after another, without a break for successful, and taking into account the previously held miscarriages and antenatal deaths of the fetus. So, when there is a history of spontaneous fetal loss, the risks of its repeated miscarriages will be in direct proportion to the number of previous ones.

The reasons for miscarriage mainly appear in the form of changes in the chromosome set. Among the defects, it happens when one chromosome is "lost", or, conversely, trisomy (when an additional one appears). Both of these anomalies are a consequence of errors in meiosis under the influence of anthropogenic factors (improper or excessive intake of drugs, ionizing radiation, exposure to chemicals, etc.) polyploidy, which means an increase in the complete chromosome set of 23 chromosomes, is also referred to as genetic anomalies, or, otherwise, complete haploid set.

Diagnostics

Data is being collected on not only parents, but also all close relatives, both on the paternal and maternal side. During the diagnosis, diseases are detected that are inherited in both families, the presence of relatives with congenital genetic defects and anomalies; the presence of children with developmental defects in spouses (in the case of previous marriages or in an existing one, but about which the doctors were not notified). Whether infertility was noted along the lines of both spouses (and in what generation), whether miscarriage of unknown etiology occurred.

Shown is invasive perinatal diagnostics in the form of cordocentesis (fetal cord blood sampling), amniocentesis (amniotic fluid sampling, or, otherwise, amniotic fluid) and chorionic biopsy (samples of fetal membrane particles). But, of course, invasive diagnostics can only be trusted by highly qualified specialists trained in the most modern perinatal centers. In some cases, when the risk of having a child with serious genetic disorders is close to 100%, termination of pregnancy may be offered.

When changes are found in the karyotype of the spouses, a genetic consultation is required! He will assess the possibility of the risk of a sick child, give recommendations for the use of donor germ cells.

Anatomical causes of miscarriage

Initial (congenital) malformations or formation of the uterus, namely:

1. Doubling of the uterus
2. Two-horned or one-horned uterus
3. Saddle uterus
4. With full or partial uterine septum

Defects of this organ, manifested under the influence of those different factors (diseases, excessive physical exertion at work or in strength sports):

1. Submucosal myomatic formations
2. Intrauterine synechia
3. Endometrial polyp

Painless and asymptomatic dilatation of the cervical canal, provoking premature labor in the second trimester of pregnancy.

Habitual miscarriage caused by reasons lying in the peculiarities of the patient's anatomy, in general statistics, reaches 12-16% in absolute terms.

The saddle uterus in the list of these reasons is in the position of 15%, in 11% there is a double uterus, in 4% - with one horn, and 22% - cloisonné. The “palm tree” belongs to the two-horned one, when it happens up to 37% of miscarriages. In a two-legged uterus, the main reason for miscarriage is most often in delayed fetal development, as well as in simultaneous placental insufficiency caused by a peculiar form of the inner lining of the uterus. That is why, already in the early stages, as soon as the women's consultation diagnosed pregnancy, and her 14th week went, bed rest, a complete absence of exertion and the reception of a sedative natural origin (motherwort, valerian), hemostatics, antispasmodics and gestagens are shown.

Uterine abnormalities as causes of miscarriage occur either in case of unsuccessful implantation of an already fertilized egg next to the myoma missed during examination, or there was poor blood supply to the uterine mucosa. The reasons could be endocrine disorders and endometritis in the chronic phase.

Isthmic-cervical insufficiency is always considered as a separate cause.

Hormonal imbalance

Miscarriage caused by endocrine problems occurs in 8 to 20% of cases. The main reason for the overwhelming majority is the insufficiency of the luteal phase - a common pathology in which the functions of the corpus luteum are impaired. With her, the corpus luteum does not adequately produce progesterone, which is necessary for the normal course of pregnancy. This deficiency is responsible for about 50% of miscarriages and may be influenced by the following conditions:

• In the first period of the cycle, the synthesis of FSH (follicular-stimulating hormone) and LH (luteinizing) is knocked down.
• Violation of the timing of the surge in LH.
• Incomplete and inhibited follicular maturation. It is caused by hyperprolactemenia, an excess of androgenic hormones and hypothyroidism.
  Studying the history of the disease, first of all, they take into account the timing of the onset of menstruation, the regularity of the cycle and the increase in body weight, moreover, sharp, if it took place. And also in the case when there was a diagnosis of infertility or spontaneous abortions took place. To increase the reliability of the diagnosis, it is advisable to measure the basal temperature in advance, for at least three cycles, to draw up a dynamic picture in the form of a graph. During a medical examination, all physical parameters are assessed, such as height, weight, hirsutism (excessive body and facial hair growth in the male pattern), the severity of secondary sexual characteristics, mammary glands in order to exclude or confirm (that is, the discharge of milk or colostrum from the breast, not associated with pregnancy or the presence of infants).

Ovarian hyperandrogenism

They are mainly hereditary, and women with disorders in the production of hormones of the adrenal cortex suffer from it.

The only difference is that with adrenogenital syndrome there is no change in the ovaries, and when the diagnosis of "ovarian hyperandrogenism" is made, their polycystic disease with an abnormal structural disorder is observed.

Treatment in the first case with glucocorticoids (dexamethasone), and with a history of polycystic disease, clomiphene is used to stimulate ovulation. With a severe course of hyperandrogenism, surgery with a wedge-shaped excision of the ovaries is recommended, or laser treatment is performed.

Prophylaxis

It consists in putting in order the way of life, abandoning habits that are harmful to health, eliminating abortions, creating a calm atmosphere in the family. With notes about abortions in the medical history, miscarriages, premature births, the patient is included in the high-risk group with a diagnosis of recurrent miscarriage. It is advisable for both spouses to undergo tests.

According to statistics, miscarriage is recorded in 10-25% of pregnant women.

The cause of miscarriage can be various diseases that are difficult to cure or become chronic. Moreover, these diseases do not belong to the genital area. An important feature of this kind of pathology is the unpredictability of the process, since for each particular pregnancy it is difficult to determine the true reason for the termination of pregnancy. Indeed, at the same time, many different factors affect the body of a pregnant woman, which can act covertly or explicitly. The outcome of pregnancy in the case of her habitual miscarriage is largely determined by the therapy. With three or more spontaneous miscarriages during pregnancy up to 20 weeks of pregnancy, the obstetrician-gynecologist diagnoses recurrent miscarriage. This pathology occurs in 1% of all pregnant women.

After the fertilized egg has "settled" in the uterine cavity, the complex process of its engraftment begins there - implantation. The future baby first develops from the ovum, then becomes an embryo, then it is called the fetus, which grows and develops during pregnancy. Unfortunately, at any stage of carrying a child, a woman may face such a pathology of pregnancy as miscarriage.

Miscarriage is the termination of pregnancy from the moment of conception to the 37th week.

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 female sex, XY chromosomes - male), while 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 is proposed (in vitro fertilization - in vitro fertilization) 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 disturbed 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:

1. blood tests for chromosomal abnormalities in both parents (clarification of the karyotype) and determination of hormonal and immunological changes in the mother's blood;
2. 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);
3. 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);
4. hysterosalpingography (x-ray examination of the uterus;
5. 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.

The 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: 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.

Habitual miscarriage is a miscarriage that occurs in a woman 2 or more times in a row. And, unfortunately, this problem is as common as infertility. Many women remain childless because of illiterate doctors who cannot find the causes of recurrent miscarriage, while there is a standard of examination for both spouses who are faced with this problem. In this article, we will take a quick look at the causes of recurrent miscarriage and the algorithm for the medical examination.

Why can't you bear the child?

1. Miscarriage is possible due to chromosomal abnormalities of the embryo. And the more often they happen, the older the expectant mother is. In women over 35, the risk of fetal chromosomal abnormalities increases at times from year to year. Sometimes chromosomal abnormalities in the embryo arise "through" the peculiarities of the karyotype of one of the spouses. In this case, a geneticist can help.

2. The action of teratogens. Alcoholic beverages, drugs, and also some drugs have a teratogenic effect. If any of these substances are taken, for example, during 2-4 weeks of pregnancy, this almost certainly means a heart defect in the embryo. But more often the pregnancy is simply terminated.

3. Autoimmune factors. Antiphospholipid antibodies are detected in approximately every 7th woman who has experienced a miscarriage (s). With antiphospholipid syndrome, blood clots form in the mother's blood vessels that communicate with the placenta, as a result of which oxygen and nutrition may be blocked for the baby. Due to APS, miscarriages most often occur after 10 weeks of gestation. Treatment of recurrent miscarriage with APS is usually carried out after conception. A woman can be prescribed heparin and aspirin for long-term use, which tend to "thin" the blood and prevent the formation of blood clots in the vessels.

4. Malformations of the uterus. For example, a complete doubling of the uterus, a two-horned uterus, etc. These pathologies are congenital. At some stage of embryo formation, a teratogenic (most likely) effect was exerted on it, which is why this pathology arose. For women with reproductive system defects, it is not only problematic, if not impossible, to conceive and bear a child, but also difficult in everyday life, since malformations can be felt by pain, bleeding.

5. Infections. Cytomegalovirus, rubella, herpes are viruses that most often lead to miscarriages. From bacterial infections, genital infections that occur in a latent form can be distinguished, these are ureaplasma, mycoplasma, chlamydia. Every woman, even before trying to conceive a child, should be screened for these infections. It will not hurt to be tested for them and the future father.

6. Endocrine causes. Various pathologies of the thyroid gland, for example, hypothyroidism, can lead to miscarriage. Progesterone deficiency is often the cause of miscarriages. But this pathology can be dealt with - the main thing is to start taking progesterone preparations on time during pregnancy.

7. Pathology of the cervix. Namely - isthmic-cervical insufficiency. With her, the cervix begins to soften and shorten around the middle of pregnancy, as it happens before childbirth. This pathology is diagnosed by ultrasound examination. Treatment can be surgical - suturing the cervix, or nonsurgical - wearing an obstetric pessary on the cervix.

That is the habitual miscarriage, what it is and what are its causes - we figured it out. It remains to list the required tests and examinations.

1. Smears and blood for STIs (sexually transmitted infections).

2. Blood hormones (some are given on certain days of the cycle) - directions are given by a gynecologist and endocrinologist.

3. Ultrasound of the small pelvis in the first and second phases of the menstrual cycle.

4. Analysis for karyotype (directed by a geneticist) - surrendered by both spouses.

5. Analysis for antibodies to chorionic gonadotropin.

6. Hemostasiogram, lupus anticoagulant, antibodies to cardiolipin.

7. Analysis for group compatibility.

A woman has a history of 3 or more spontaneous abortions in a row. The classification of miscarriage in terms of the duration of the termination of pregnancy differs according to the WHO definition and adopted in Russia.

Definition by WHO

Adopted in Russia

Miscarriage (miscarriage) - interruption from the moment of conception to 22 weeks, from 22 weeks - premature birth. spontaneous miscarriages - pregnancy loss up to 22 weeks premature birth from 22 to 37 complete weeks of pregnancy with a fetal weight of 500 g: 22-27 weeks - very early preterm labor 28-33 weeks - early preterm labor 34-37 weeks - premature birth

Miscarriage - termination of pregnancy from the moment of conception to 37 full weeks (259 days from the last menstruation); spontaneous termination of pregnancy in the period from 22 to 27 weeks is not classified as premature birth. In case of death, a child born during this period is not registered and data about him is not included in the perinatal mortality rates if he has not lived 7 days after giving birth. With such spontaneous abortions of pregnancy in obstetric hospitals, measures are taken to nurture a deeply premature baby. early miscarriages (before 12 weeks of pregnancy) late miscarriages (12-22 weeks) the period of abortion from 22 to 27 weeks period of premature birth - from 28 weeks

Epidemiology
In case of sporadic miscarriage, the effect of damaging factors is transient, without disturbing the reproductive function of a woman in the future. For example, a violation in the process of gamete formation leads to the emergence of an abnormal egg and / or sperm cell and, as a consequence, to the formation of a genetically defective non-viable embryo, which can be the cause of spontaneous miscarriage. This situation in most cases is episodic and does not cause repeated interruptions of pregnancy.

At the same time, in 1-5% of women who have lost their first pregnancy, endogenous factors are found that prevent the normal development of the embryo (fetus), which subsequently leads to repeated terminations of pregnancy, i.e. to the symptom complex of habitual miscarriage. Habitual miscarriage accounts for 5 to 20% in the structure of miscarriage.

It was found that the risk of losing a repeated pregnancy after the first miscarriage is 13-17% (corresponds to the frequency of sporadic miscarriage in the population), while after 2 previous spontaneous interruptions, the risk of losing a desired pregnancy more than doubles and is 36-38%, the probability is 3 -th spontaneous miscarriage reaches 40-45%. Taking this into account, most specialists dealing with the problem of miscarriage currently believe that with 2 consecutive miscarriages, a married couple should be classified as a habitual miscarriage, followed by a mandatory examination and a set of measures to prepare for pregnancy.

The influence of the mother's age on the risk of early spontaneous miscarriages has been established. In women aged 20-29 years, the risk of spontaneous miscarriage is 10%, while in 45 years and older it is 50%. Probably, the age of the mother is a factor contributing to the increase in the frequency of chromosomal abnormalities in the fetus.

Among the causes of miscarriage are genetic, anatomical, endocrine, infectious, immunological and thrombophilic factors. If all of the above reasons are excluded, the genesis of habitual miscarriage is considered unclear (idiopathic).

The critical periods in the first trimester of pregnancy are 6-8 weeks (embryo death) and 10-12 weeks (ovum expulsion).

Causes of recurrent miscarriage

Infectious	bacterial-viral colonization of the endometrium	chronic endometritis
Genetic	chromosome change	structural: intrachromosomal, interchromosomal
		quantitative: monosomy, trisomy, polyploidy
Anatomical	congenital malformations	full doubling of the uterus, two-horned, saddle-shaped, unicorned uterus, partial or complete intrauterine septum
	acquired malformations	intrauterine synechiae - Asherman's syndrome, submucous uterine myoma, isthmic-cervical insufficiency
Endocrine	insufficiency of the luteal phase	defective folliculogenesis due to hyperprolactinemia, hyperandrogenism, hypothyroidism; impaired secretion of FSH and / or LH
	hyperandrogenism	adrenal genesis, ovarian genesis, mixed
Immunological	autoimmune	the presence of autoimmune antibodies in the blood (to thyroperoxidase, thyroglobulin, hCG, phospholipids, etc.); a generally recognized condition leading to death of the embryo / fetus is APS
	alloimmune	the presence of antigens of the main histocompatibility complex common with the husband
Thrombophilic	genetically determined thrombophilia	antithrombin III deficiency, factor V mutation (Leiden mutation), protein C deficiency, protein S deficiency, prothrombin G20210A gene mutation, methylenetetrahydrofolate reductase (MTHFR) gene mutation leading to hyperhomocysteinemia

Infectious causes of miscarriage

The role of an infectious factor as a cause of recurrent miscarriage is currently widely discussed. It is known that with primary infection in the early stages of pregnancy, damage to the embryo incompatible with life is possible, which leads to sporadic spontaneous miscarriage. However, the likelihood of reactivation of the infection in the same period with the outcome in repeated pregnancy losses is negligible. In addition, at present, no microorganisms have been found that provoke a habitual miscarriage. Recent studies have shown that in most women with a habitual miscarriage and the presence of chronic endometritis, the prevalence of 2-3 or more types of obligate anaerobic microorganisms and viruses is noted in the endometrium.

According to V.M. Sidelnikova et al., In women suffering from recurrent miscarriage, out of pregnancy, the diagnosis of chronic endometritis was histologically verified in 73.1% of cases, and in 86.7% of cases, persistence of opportunistic microorganisms in the endometrium was observed, which, of course, may serve as the reason for the activation of immunopathological processes ... Mixed persistent viral infection (herpes simplex virus, Coxsackie A, Coxsackie B, enteroviruses 68-71, cytomegalovirus) is significantly more common in patients with recurrent miscarriage than in women with a normal obstetric history. K. Kohut et al. (1997) showed that the percentage of inflammatory changes in the endometrium and decidual tissue in patients with primary recurrent miscarriage is significantly higher than in women after a miscarriage with a history of at least one timely delivery.

Bacterial-viral colonization of the endometrium is, as a rule, a consequence of the inability of the immune system and nonspecific defenses of the body (complement system, phagocytosis) to completely eliminate the infectious agent, and at the same time, its spread is limited due to the activation of T-lymphocytes (T-helpers, natural killer cells) and macrophages. In all of the above cases, persistence of microorganisms occurs, characterized by the attraction of mononuclear phagocytes, natural killers, T-helpers synthesizing various cytokines to the focus of chronic inflammation. Apparently, this state of the endometrium prevents the creation of local immunosuppression in the preimplantation period, which is necessary to form a protective barrier and prevent the rejection of a half-foreign fetus.

Diagnostics

Anamnesis: as a rule, late miscarriages and premature birth, premature rupture of amniotic fluid, but there may be early habitual pregnancy losses due to exposure to infection.

: carried out outside of pregnancy

• microscopy of smears from the vagina and cervical canal according to Gram;
• bacteriological examination of the detachable canal of the cervix with a quantitative determination of the degree of colonization by pathogenic and opportunistic microflora and the content of lactobacilli;
• detection of gonorrheal, chlamydial, trichomonas infections, carriage of HSV and CMV using PCR;
• determination of IgG and IgM to HSV and CMV in the blood;
• study of the immune status: subpopulation analysis of the T-cell link of immunity with the determination of activated NK cells (CD56 +, CD56 + 16 +, CD56 + 16 + 3 +);
• assessment of interferon status with the study of the individual sensitivity of lymphocytes to interferon inducers;
• study of the concentration of pro-inflammatory cytokines in the blood and / or discharge of the cervical canal - tumor necrosis factor-α, interleukins (IL-1β, IL-6), fibronectin, insulin-like growth factor 1, etc.);
• endometrial biopsy on days 7-8 of the menstrual cycle with histological examination, PCR and bacteriological examination of material from the uterine cavity is performed to exclude an infectious cause of miscarriage.

Treatment: If an infectious genesis of recurrent miscarriage is detected, treatment is carried out with individually selected drugs. At the end of treatment, normobiocenosis is restored, confirming this by bacteriological research (the concentration of lactobacilli should be at least 10 7 CFU / ml).

Pregnancy after treatment is planned with the normalization of indicators.

Pregnancy care: control of the state of the vaginal biocenosis, microbiological and virological control. On an outpatient basis, the first assessment method is vaginal smear microscopy. With normocenosis of the vagina, additional studies are not performed in patients with early spontaneous pregnancy loss.

If an increase in the level of leukocytes in a vaginal smear, a violation of the composition of microflora (dysbiosis) is detected, then a complete bacteriological and virological examination is shown.

In the first trimester of pregnancy in patients with infectious genesis of miscarriage, immunoglobulin therapy is the method of choice. From the first trimester of pregnancy, placental insufficiency is prevented. In the II and III trimesters of pregnancy, repeated courses of immunoglobulin therapy, interferon therapy are indicated. If a pathological flora is identified according to the results of the examination, it is advisable to carry out individually selected antibiotic therapy with simultaneous treatment of placental insufficiency. If, against the background of inflammatory changes, symptoms of the threat of termination of pregnancy are noted, then hospitalization in a hospital, carrying out tocolysis is indicated.

Genetic causes of miscarriage

Research	Sporadic miscarriages	Habitual miscarriage
Genetic study of abortion	has a chromosomal abnormality: monosomy (loss of one chromosome), trisomy (presence of an extra chromosome), polyploidy (increase in the set of chromosomes by a full haploid set)	has structural changes in chromosomes (intrachromosomal and interchromosomal)
Study of the karyotype of the parents	karyotype without pathology	balanced chromosomal rearrangements (7%): reciprocal translocations, sex chromosome mosaicism, chromosome inversion, ring chromosomes
Offspring	healthy chromosomal disease in the fetus (child) in subsequent pregnancies - 1%	usually not viable viable can be carriers of severe chromosomal pathology - 1-15%

Diagnostics

Anamnesis: a history of hereditary diseases, congenital malformations, infertility and / or miscarriage of unknown genesis in family members, the birth of children with mental retardation, unclear cases of perinatal mortality.

Special research methods:

• The study of the karyotype of parents is indicated for married couples with a history of miscarriage at the birth of a child with malformations, as well as with recurrent early miscarriage (level of evidence C)
• Cytogenetic analysis of abortion to identify genetic causes of miscarriage
• Determination of the karyotype of a child in cases of stillbirth or neonatal death

Indications for consulting other specialists
If changes in the karyotype are detected in the parents, a consultation with a geneticist is indicated to assess the risk of having a child with pathology or, if necessary, to decide on the donation of an egg or sperm.

Pregnancy care:
If the spouses have a pathological karyotype, even one of the parents is shown prenatal diagnosis [chorionic biopsy, cordocentesis, placentocentesis (amniocentesis)] due to the high risk of fetal disorders.

Anatomical causes of miscarriage

Diagnostics

Anamnesis: an indication of the pathology of the urinary tract (often accompanied by congenital anomalies of the uterus, for example, a single kidney); late termination of pregnancy and premature birth, early termination of pregnancy - with implantation on the intrauterine septum or near the myomatous submucous node; fast and slightly painful premature birth - isthmic-cervical insufficiency.

Special research methods:

• Hysterosalpingography in the first phase of the menstrual cycle (7-9th dmts)
• Hysteroscopy (diagnostic and treatment)
• Ultrasound: in the first phase of the menstrual cycle - submucous uterine myoma, intrauterine synechiae; in the second phase of the cycle - intrauterine septum, bicornuate uterus
• Sonohysterography: transvaginal ultrasound with preliminary introduction of isotonic sodium chloride solution into the uterine cavity
• MRI - in difficult cases to verify the diagnosis

Treatment: surgical, using hystero-, laparoscopy. In the postoperative period, the effectiveness of introducing a spiral, a Folley catheter into the uterine cavity has not been proven. To improve the growth of the endometrium during 3 menstrual cycles, cyclic hormone therapy with 17-β-estradiol and dydrogesterone is performed.

Planning pregnancy 3 months after surgery with a preliminary examination of the state of the endometrium and blood flow according to ultrasound data.

Pregnancy care: There is no special therapy that reliably increases the frequency of preserved pregnancies, but this does not exclude the use of traditional therapy regimens (antispasmodics, sedatives, gestageno- and hemostatic therapy) as an element of psychotherapy.

Endocrine causes of miscarriage

According to various authors, endocrine causes of miscarriage are noted in 8-20% of cases. At the same time, the influence of individual hormonal disorders on the formation of the symptom complex of habitual miscarriage remains controversial. The most significant of them are considered to be luteal phase failure, hyperandrogenism, hyperprolactinemia, thyroid dysfunction and diabetes mellitus.

It is now known that about 80% of all previously unexplained cases of repeated pregnancy losses (after excluding genetic, anatomical, hormonal causes) are associated with immunological disorders.

There are autoimmune and alloimmune disorders leading to recurrent miscarriage.

• With autoimmune processes, the immune system develops aggression against the mother's own tissues, i.e. the immune response is directed against its own antigens. In this situation, the fetus suffers a second time as a result of maternal tissue damage.
• In alloimmune disorders, the immune response of the pregnant woman is directed against the antigens of the embryo (fetus) received from the father and potentially foreign to the mother's body.

The autoimmune disorders most often found in patients with recurrent miscarriage include the presence of antiphospholipid, antithyroid, antinuclear autoantibodies in the blood of a pregnant woman. It was found that in 31% of women with recurrent miscarriage outside of pregnancy, autoantibodies to thyroglobulin, thyroid peroxidase were detected. In these cases, the risk of spontaneous miscarriage in the first trimester of pregnancy increases to 20%. In case of recurrent miscarriage in the case of the presence of antinuclear and antithyroid antibodies, further examination is indicated to identify the autoimmune process and verify the diagnosis. A recognized autoimmune condition leading to the death of the embryo / fetus is currently

Miscarriage is the spontaneous termination of pregnancy in the period from conception to 37 weeks, counting from the first day of the last menstruation. Termination of pregnancy in the period from conception to 22 weeks is called spontaneous abortion (miscarriage). Termination of pregnancy between 28 weeks and 37 weeks is called preterm labor. The gestation period from 22 weeks to 28 weeks according to the WHO nomenclature is referred to as very early premature birth, and in most developed countries, perinatal mortality is calculated from this gestational age. In our country, this gestational age is not attributed to premature birth and perinatal mortality, but at the same time, assistance is provided in the maternity hospital, and not in the gynecological hospital, and measures are taken to nurture a deeply premature newborn. In case of his death, a pathological examination is carried out, and if the child survived 7 days after childbirth, this death is referred to as indicators of perinatal mortality.

Spontaneous abortion belongs to the main types of obstetric pathology. The frequency of spontaneous miscarriages ranges from 15 to 20% of all desired pregnancies. It is believed that the statistics do not include a large number of very early and subclinical miscarriages.

Many researchers believe that spontaneous abortions of the first trimester are a tool of natural selection, as in the study of abortions, 60 to 80% of embryos with chromosomal abnormalities are found.

The causes of sporadic spontaneous abortion are extremely varied and not always clearly defined. These include a number of social factors: bad habits, harmful production factors, unsettled family life, hard physical labor, stressful situations, etc. Medical factors: genetic damage to the karyotype of parents, embryos, endocrine disorders, uterine malformations, infectious diseases, previous abortions and etc.

Habitual miscarriage - spontaneous abortion two or more times in a row. The frequency of recurrent miscarriage in the population is 2% of the number of pregnancies. In the structure of miscarriage, the frequency of habitual miscarriage ranges from 5 to 20%.

Habitual miscarriage is a polyetiological complication of pregnancy, which is based on violations of the reproductive system. The most common causes of recurrent miscarriage are endocrine disorders of the reproductive system, erased forms of adrenal dysfunction, damage to the receptor apparatus of the endometrium, clinically manifested in the form of an inferior luteal phase (LF); chronic endometritis with persistence of opportunistic pathogens and / or viruses; isthmic-cervical insufficiency, uterine malformations, intrauterine synechiae, lupus anticoagulant and other autoimmune disorders. Chromosomal pathology for patients with recurrent miscarriage is less significant than for sporadic abortions; nevertheless, in women with recurrent miscarriage, structural abnormalities of the karyotype occur 10 times more often than in the population and amount to 2.4%.

The reasons for sporadic abortion and recurrent miscarriage may be identical, but at the same time, a married couple with recurrent miscarriage always has a pathology of the reproductive system that is more pronounced than with sporadic interruption. When managing patients with habitual loss of pregnancy, it is necessary to examine the state of the reproductive system of a married couple outside of pregnancy.

According to the current definition in our country, miscarriage is its termination from the moment of conception to 37 full weeks (259 days from the last menstruation). This long time period is subdivided into the periods of early miscarriages (up to 12 weeks of pregnancy), late miscarriages (from 12 to 22 weeks); the period of termination of pregnancy in the period from 22 to 27 weeks, from 28 weeks - the period of premature birth. In the classification adopted by WHO, spontaneous miscarriages are distinguished - loss of pregnancy up to 22 weeks and premature birth from 22 to 37 complete weeks of pregnancy with a fetal weight of 500 g (22–27 weeks - very early, 28–33 weeks - early premature birth, 34 –37 weeks - premature birth). In our country, spontaneous termination of pregnancy in the period from 22 to 27 weeks is not classified as premature birth, and in case of death, a born child is not registered and data about him is not included in the perinatal mortality rate if he has not lived 7 days after birth. With such spontaneous abortions of pregnancy in obstetric hospitals, measures are taken to nurture a deeply premature baby.

According to the WHO definition, a habitual miscarriage is considered to be a woman's history of 3 or more spontaneous abortions up to 22 weeks in succession.

• N96 Habitual miscarriage
• 026.2 Medical care for a woman with recurrent miscarriage.