Miscarriage: causes, treatment and prevention. The mechanism of development of pathology. Forecast and measures to prevent recurrent miscarriage
PREMATURE AND TELATED BIRTH.
MISCARRIAGE AND PRESENT PREGNANCY.
Lecture plan:
1. Introduction.
2. Etiopathogenesis of miscarriage.
3. Spontaneous miscarriage (abortion).
4. Premature birth.
5. Postterm and prolonged pregnancy.
Purpose of the lecture: to acquaint students with the main causes of miscarriage and overpregnancy, to highlight the issues of the course and management of pregnancy and childbirth in this pathology.
The problem of spontaneous premature termination of pregnancy has not only medical, but also social significance, because. is closely related to issues of infertility, stillbirth, the birth of sick, premature and hypotrophic children, giving a high incidence and determining the level of infant mortality.
Miscarriage is one of the most common types obstetric pathology, making up 10 – 25% to the number of pregnancies .
The rate of preterm birth is 5 – 10%
Premature babies account for more than 50% of stillbirths, 70-80% of early neonatal deaths, 65-70% of infant mortality.
Premature babies die 30-35 times more often than full-term babies, and perinatal mortality in miscarriage is 30-40 times higher than in term births.
Miscarriage (NB) this is spontaneous interruption pregnancy from conception to 38 weeks.
Terminology and classification of miscarriage:
Spontaneous miscarriage or abortion (early and late): fetal weight up to 500 g, height up to 25 cm; is 2 - 10%:
Ø early spontaneous abortion(miscarriage) - termination of pregnancy before 12 weeks
Ø late spontaneous abortion (miscarriage) - termination of pregnancy from 13 to 22 weeks.
Premature birth (PR) - termination of pregnancy in terms of 22 - 37 weeks of pregnancy;
· miscarriage- non-developing pregnancy with the death of an embryo or fetus up to 22 weeks;
· failed birth miscarriage - non-developing pregnancy with the death of the fetus in terms of 22 - 37 weeks;
· "habitual" miscarriage - the presence of 2 or more consecutive cases of NB in history.
I. Socio-biological (environmental) factors
Ø deterioration of the ecological environment
Ø unfavorable working and living conditions (mechanical, chemical biological factors)
Ø stressful situations
Ø mother's age up to 18 years and after 30 years
Ø bad habits (smoking, drinking alcohol, drugs)
II. Medical factors:
1. Endocrine disorders:
Ø ovarian dysfunction: ovarian hypofunction, congenital or acquired insufficiency of the receptor apparatus of the genital organs, hyperandrogenism of ovarian origin;
Ø pathology of the thyroid gland: the state of hypo- or hyperthyroidism affects the development of pregnancy, the formation and development of the thyroid gland in the fetus;
Ø pathology of the pituitary gland of functional and organic origin;
Ø pathology of the adrenal glands;
Ø pathology of the pancreas: the most common is diabetes mellitus, in which the mechanism of abortion is associated with a violation of glucose metabolism;
Ø neuroendocrine syndromes (especially hyperprolactinemic).
2. Immunological disorders in the mother-placenta-fetus system:
Ø The fetus should be considered as an allograft containing at least 50% paternal genetic information, i.e. alien to the mother;
Ø immune relations between mother and fetus are determined and regulated by many organs and systems;
Ø imperfection of their function leads to rejection of the fetoplacental complex.
3. Gene and chromosomal disorders:
Ø lead to early termination of pregnancy or to the birth of children with congenital malformations
4. Infectious factors:
Ø are the most common cause of NB;
Ø An important role is played by endogenous foci of genital and extragenital pathology, latent infection in the mother.
5. Extragenital diseases at mother.
6. Complications of the current pregnancy.
7. Anatomical and functional changes in the genital organs:
Violation of the mechanisms of transformation of the endometrium of functional and organic genesis
pathology of the receptor apparatus
malformations and tumors of the genital organs
infantilism
ICI (functional and organic origin) - insufficiency of the cervix as a result of structural or functional changes his isthmic department.
traumatic injuries of the cervix and body of the uterus (abortion, curettage, IUD, etc.)
8. Violations of spermatogenesis
v The causes of miscarriage are many and varied. Often in the pathogenesis of miscarriage, the impact of a combination of these factors plays a role, which indicates polyetiology of this pathology.
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 in various terms 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 starts at 28 weeks of pregnancy, includes the period of childbirth and ends after 7 full days newborn 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 resistant to birth trauma. How less weight newborn, the more 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:
occupational hazards;
immunological disorders;
any cause leading to fetal hypoxia.
genital infection;
anomalies in the development of the uterus and uterine fibroids;
diabetes;
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. Therefore, one of the main mechanisms for the development of the threat of abortion is underdevelopment 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 time of pregnancy is triggered by prostaglandins, they are produced by the decidual and aqueous membranes. gestational sac. 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 for 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 small drawing 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). Infection is especially common with artificial interruption 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 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. Special attention pay for softening and shortening of the neck, 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. High AFP concentration in the mother's blood serum is observed in: malformations of the brain, gastrointestinal tract, intrauterine death of the fetus, 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 estrogen. 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 CG on the process of implantation of the fetal egg)
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 placental insufficiency.
With the threat of premature birth at 28-33 weeks, prophylaxis is carried out respiratory distress syndrome in newborns by prescribing pregnant women glucocorticoid drugs (dexamethasone) 8-12 mg per course or lazolvan, ambroxol, ambrobene 800-1000 mg per day for 5 days intravenously.
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 CI develops as a result of traumatic injuries of the isthmic part of the cervix during artificial abortion, childbirth large fruit, operational childbirth (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.
Rejection expectant tactics and labor induction are carried out in the following cases:
in the presence of 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 illnesses 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. Whereas when occurring after twenty-eight weeks they are called this process 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 early dates, 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 likelihood of occurrence pathological process, with already appeared heartbeat, only 2%. And with a period of ten weeks and a satisfactory heartbeat, the threat reaches barely 0.7%.
Often in the early stages, scientists associate pathology with developmental disabilities, the mechanism of the so-called biological natural selection is connected. 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
Classify the risk pathological condition can be in 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: abuse of alcoholic beverages, tobacco and drug addiction, severe physical conditions labor, 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, presentation of the child transverse or buttocks, the presence of intrauterine or intrauterine infections.
habitual miscarriage
Every day, the diagnosis becomes more and 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 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 wins back important role, as it is the entrance gate for infection in 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:
With autoimmune - the response of aggression is directed to their own tissue antigens, in the blood there are antibodies to thyroid peroxidase, thyroglobulin, phospholipids. Under these 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 embryonic antigens 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 uterine hyperdistension occurs, 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 complicated.
The symptom complex includes the following manifestations:
- The fundamental and most significant manifestation is intermittent increasing bleeding or spotting 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, intermittent, 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. Learn the family genealogical tree women and men, 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, examination for the appearance of stretch marks, listening to cardiac activity, studying liver parameters, measuring blood pressure, identifying signs of metabolic disorders, 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 urine analysis and according to Nechiporenko, biochemistry and general analysis blood, testing 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 smear microscopy urethra, cervix and vagina, examination for virus carriers, blood for Ig M, Ig G to CMV, PCR - for carriage of HV, 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 of the contents of the neck for cytokines, a biopsy with endometrial histology, bacteriological examination 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 amount and qualitative definition, functioning of the whole system of blood coagulation. 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, as a primary indicator of the risk of an abnormal placenta, is being investigated.
— genetic research, mandatory for age-related couples, recurrence of miscarriages, stillbirth, 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 medical preparations, forcing to reject the contents of the uterus, but it is applicable only when normal condition health, because after the expenditure of vitality is required 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 carried out after thorough examination and identifying 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 gentle 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 concomitant appointment 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. Positive effect the combination of Duphaston with Clostilbegit, which improves the maturation of the follicle, supporting the first phase and the formation of a full 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 preferably its use in conjunction with low molecular weight heparin subcutaneously. 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.
- To normalize and prevent placental insufficiency, Actovegin, Piracetam, Infezol are used, mainly intravenously. With a threat, strict rest is needed, magnesium sulfate and hexoprenaline sulfate, fenoterol, NPP - Indomethacin, Nifedipine, Oxyprogesterone Capronate are taken according to the scheme. Used to relax the uterus non-pharmacological means– 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 taking the disease seriously from the outset. women's health 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, 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.
- It should be included in the preventive measures itself future mother: exclude addictions, lead healthy lifestyle life, the exclusion of uncontrolled sexual intercourse and adequate contraception in such cases, the rejection of artificial abortions.
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Miscarriage
1 Etiology and pathogenesis
Miscarriage is one of the most important problems of modern obstetrics. The frequency of this pathology in the total number of births is more than 15%.
The causes of spontaneous miscarriages are varied, often there is a combination of these causes leading to this complication of pregnancy.
CLASSIFICATION (1975).
Infectious diseases of the mother
complications associated with pregnancy
traumatic injuries
isoserological incompatibility of maternal and fetal blood
anomalies in the development of the female genital area
neuroendocrine pathology
various non-communicable diseases of the mother
chromosomal abnormalities
1. Infectious diseases of the mother. They occupy an important place among the structure of the causes of miscarriage. Chronic latent infections: chronic tonsillitis, chronic appendicitis, urinary tract infection. The mechanism of action of the infection is different: many toxins penetrate the placental barrier, therefore, in common infectious diseases, bacteria and viruses and their toxins can become pathogenic factors. In acute febrile illnesses, hyperthermia can also lead to abortion. This termination of pregnancy can occur as a result of intrauterine damage to the fetus, fetal membranes and due to premature uterine contractions.
For example: influenza, malaria, syphilis, toxoplasmosis, chlamydia, mycoplasmosis, rubella. Their recognition is carried out on the basis of the clinic and various studies: bacterioscopy, bacteriological, biological, pathomorphological.
Infections directly affecting the genitals: uterus, ovaries, etc. after inflammatory processes of the internal genital organs, there may be changes in the position of the uterus, etc. local inflammatory processes account for up to 34% of the cause of miscarriage.
2. Toxicosis of the first and second half of pregnancy. Premature discharge water, polyhydramnios, wrong position placenta, abnormal position of the fetus, multiple pregnancies.
Polyhydramnios is a pathology of pregnancy, usually infectious (infection of the membranes, placenta) is often combined with malformation of the fetus.
Premature discharge of water. If POV is observed in early pregnancy from 15 to 20 weeks, they are often associated with so-called cervical insufficiency (isthmic-cervical insufficiency).
3. Traumatic injuries: trauma, both physical and mental. More often, trauma to the uterus itself (as the main fruiting place). Surgery is the main cause of these injuries. induced abortion. During abortion, the cervix is injured, abortion can cause isthmic-cervical insufficiency: the cervix shortens and has a funnel shape, and the external and internal os gape - the cervix is actually open. Isthmic-cervical insufficiency can be of organic (structural or traumatic) genesis:
during gynecological operations
after complicated childbirth (rupture of the cervix)
diathermocoagulation
uterine malformations (5-10%)
with an open cervix, the fetal bladder prolapses and can become infected, and then there is a combination of causes. In addition to traumatization of the cervix during abortions, traumatization of the uterine cavity itself is also observed, and even after an abortion without complications, dystrophic changes in the myometrium can occur, and after traumatic abortions, infection of the uterine cavity occurs. If the infection is complete, then the woman suffers from infertility.
Other types of surgical trauma: removal benign tumors, operations for ectopic pregnancy(excision of the tubal angle).
4. Isoserological incompatibility by Rh factor or others. Caustically there is one cause of miscarriage, as a rule, it is combined with other causes.
5. From 4 to 11%. Uterine anomalies are difficult to diagnose and are diagnosed after termination of pregnancy. Hysterography, hysterosalpingography.
Saddle uterus. The uterus in the process of embryogenesis consists of 2 rudiments, therefore, in case of anomalies, a bifurcation occurs, as it were.
Double genital apparatus: 2 vaginas, 2 cervix, 2 uterus are usually underdeveloped. If pregnancy occurs, it ends in miscarriage. There may be several pregnancies in history, the duration of which increases with each pregnancy. At the same time, the fetal container develops.
Double uterus.
6. Neuroendocrine pathology.
Diabetes mellitus, if uncompensated in the early stages. Diabetes mellitus is often accompanied by polyhydramnios, a large fetus.
Hypo- and hyperthyroidism ovarian pathology: unsteady cycle, underdeveloped reproductive system, painful menstruation, hormonal deficiency in the form of a decrease in progesterone, gonadotropin, estrogen. In case of insufficiency of ovarian function: the mucosa is underdeveloped, the egg cell develops poorly in this mucosa, the placenta is underdeveloped, functional cervical insufficiency develops.
Dysfunction of the adrenal cortex: phenomena of hyperandrogenism.
7. Estragenital pathology not associated with inflammatory processes: ischemic heart disease, anemia, various intoxications (benzene, nicotine).
8. Chromosomal abnormalities. In older parents, when using contraceptives pregnancy is accidental. The use of antidiabetic drugs. Radiation exposure, etc. diseases during pregnancy: rubella, influenza, hepatitis.
2 Examinationwomen suffering from miscarriage
The examination should be, if possible, outside of pregnancy, it is necessary to exclude all types of pathology, and to cure several possible causes. First you need to exclude infectious causes since it is impossible and impossible to treat infections during pregnancy. Secondly, to exclude genetic pathology.
Functional diagnostics to exclude neuroendocrine pathology.
Hysterosalpingography to rule out uterine malformations.
To rule out changes in adrenal function - a urine test for corticosteroids, hormonal tests.
PREPARATION FOR PREGNANCY.
Treatment of all infections of the woman and her spouse.
Hormone therapy. Adrenal hyperandrogenism is treated with prednisolone (1 tablet 4 times a day for 10 days, reduced to 1-2 tablets a day until the first half of pregnancy.
With the threat of termination of pregnancy, the possibilities are limited:
compulsory hospitalization
normalization of the neuropsychic state: conversations, psychotropic drugs.
Eliminate the cause of miscarriage
symptomatic therapy.
During pregnancy, you can prescribe penicillin, ampicillin in the early stages of pregnancy. In case of hormonal disorders, progesterone, vitamin E, estrogens, chorionic gonadotropin, sigetin with glucose, antispasmodics: metacin, no-shpa, magnesia intramuscularly are prescribed, in the later stages - tocolytes - adrenomimetics.
In case of cervical insufficiency, a circular suture is applied to the cervix after 12 weeks with lavsan up to 36 weeks. If a fistula forms in the cervix, childbirth can pass through it.
3 Classication of spontaneous miscarriages
Miscarriage - termination of pregnancy before 28 weeks, after 28 weeks - premature birth, up to 1 kg - a fetus, more than 1 kg - a child.
From 5 to 14-16 weeks - early miscarriage, from 16 to 27 weeks - late miscarriage.
CLASSIFICATION BY DEVELOPMENT.
Threatened miscarriage. There is a threat. Unexpressed, pulling pains in the lower abdomen are characteristic, the tone can be increased, sometimes spotting. When viewed with the help of mirrors: the cervix - structural changes no, that is, the neck is intact, the external pharynx is closed. See above for treatment.
A miscarriage that has begun - detachment of the fetal egg, spotting, constant pain in the lower abdomen, which can take on a cramping character, increased uterine tone, the presence of moderate spotting. When viewed in the mirrors, there are practically no structural changes in the cervix: the cervix is intact. The external pharynx is closed, always slight spotting. You can save the pregnancy. Treatment see above + hormones for hormonal deficiency.
Abortion is on the way. Practically, the entire fetal egg has already exfoliated - strong frequent contractions in the lower abdomen, the cervix opens, frequent severe cramping pains, copious spotting, bleeding is profuse. The condition is severe, there may be post-hemorrhagic shock, anemia. On internal examination, the cervix is shortened, the canal is open, it passes 1-2 fingers, the uterus corresponds to the gestational age, profuse spotting. Pregnancy cannot be saved. Stop bleeding, replenish blood loss. Stopping bleeding is carried out by curettage of the uterine cavity. Contraindication is - infection (the fetal egg is removed with an abortion clamp).
Incomplete abortion - reduction of pain in the lower abdomen, bleeding continues. The condition may be severe. The pregnancy cannot be saved. The neck is shortened, 2 fingers pass, the dimensions are less than the gestational age. The tactics are the same as in point 3.
Complete abortion: no complaints - no pain, no bleeding. History of abortion. Bleeding should not be, if there is, then this is an incomplete abortion. It is rare, the uterus is dense, the cervix is shortened, the canal is passable, which indicates that a miscarriage has occurred. Help is almost non-existent. So often there is an abortion with isthmic-cervical insufficiency. Hormonal examination not earlier than six months later.
Missed miscarriage (missed pregnancy). Detachment occurred, but the fetal egg remained in the uterus. The fetus dies, the uterus stops growing.
earlier, they waited for an independent miscarriage until the development of a generic dominant, while the fetus was mummified. This is fraught with bleeding postpartum period. Frozen pregnancy often leads to pathology of blood clotting (DIC).
One-stage curettage, stimulation with oxytocin. Often there is afibrinogenemia - bleeding that is very difficult to stop.
4 Bleeding in the postpartum and early labor period
Previously, they died from these bleedings.
The normal afterbirth period lasts 2 hours (within 2 hours the placenta should separate from the walls of the uterus). The placenta is normally located on the back wall of the uterus with the transition to the side (or bottom). Separation of the placenta occurs in the first 2-3 contractions after the birth of the fetus, although it can also separate from the walls during the birth of the fetus.
In order for the placenta to separate, the contractility of the uterus must be high (that is, equal to that in period 1).
The placenta is separated due to the fact that there is a discrepancy between the volume of the uterine cavity and the placental site. Separation most often occurs in the first 10-15 minutes after the birth of the fetus (in classical obstetrics, the placenta can separate within 2 hours after birth).
The mechanism of hemostasis in the uterus.
Retraction of the myometrium - the most important factor is the contractility of the uterus.
Hemocoagulation factor - the processes of thrombus formation of the vessels of the placental site (they do not apply to other organ systems). Provide the processes of thrombosis:
plasma factors
formed elements of blood
biologically active substances
Childbirth is always accompanied by blood loss, since there is a hematochorionic type of placental structure.
tissue factors
vascular factors.
Prof. Sustapak believes that part of the placenta, amniotic fluid and other elements of the fetal egg are also involved in the process of thrombosis.
These assumptions are correct because violations at:
Antenatal fetal death (stillbirth) If the fetus is born more than 10 days after death, DIC may develop. Therefore, with antenatal death, childbirth tends to end as quickly as possible.
Amniotic fluid embolism (mortality rate 80%) also leads to DIC.
Violations in any link of hemostasis can lead to bleeding in the afterbirth and early postpartum period.
Normal blood loss is no more than 400 ml, all that is higher is a pathology (no more than 0.5% of body weight).
Separation of the placenta occurs from the center (formation of a retroplacental hematoma) or from the edge, hence the clinical difference during the period:
if the placenta separates from the center, the blood will be in the membranes and there will be no spotting until the birth of the placenta.
If it separates at the edge, then when signs of separation of the placenta appear, blood discharge appears.
Risk groups for the development of bleeding (in general).
I. If we proceed from the fact that muscle retraction is the main mechanism of hemostasis, then 3 risk groups can be distinguished:
violation of the contractility of the uterus before the onset of childbirth:
malformations of the uterus
tumors of the uterus (fibromyoma)
if there were inflammatory diseases uterus (endometritis, metroendometritis).
dystrophic disorders.
Women who have overstretched myometrium:
large fruit
polyhydramnios
multiple pregnancy
Women who have somatic and endocrine pathology.
II risk group.
Women who have uterine contractility disorders during childbirth.
Childbirth complicated by anomalies of labor activity (excessive labor activity, weakness of labor activity).
With excessive use of antispasmodic drugs.
Women with traumatic injuries (uterus, cervix, vagina).
III risk group. These are women who have impaired processes of attachment and separation of the placenta and anomalies in the location of the placenta:
placenta previa complete and incomplete
PONRP develops during childbirth
dense attachment of the placenta and true accreta of the placenta
retention of parts of the placenta in the uterine cavity
spasm of the internal pharynx with separated placenta.
That is, risk groups are women with extragenital pathology, with a complication of the course of pregnancy, with a complication of the course of childbirth.
Bleeding in the aftermath.
It is caused by a violation of the processes of separation of the placenta and the allocation of the placenta.
There are 2 phases during the period:
separation of the placenta
excretion of the placenta
Violation of the process of separation of the placenta:
in women with weakness of labor
with tight attachment and true increment
Dense attachment of the placenta is when the chorionic villi do not extend beyond the compact layer of the decidua. It can be complete or incomplete, depending on the length.
True increment - the villi penetrate the muscular membrane of the uterus up to the serosa and sometimes cause uterine rupture. Occurs in 1/10,000 births. It happens complete and incomplete, depending on the length.
If there is a complete true increment and a complete dense attachment, then there will never be bleeding, that is, when the entire placental site adjoins or grows into the muscle wall.
With a true partial increment, part of the placenta separates and bleeding occurs in the afterbirth period.
Bleeding in the afterbirth period can develop when parts of the placenta are retained, when part of the placenta separates and is released, and a few lobules remain or a piece of the shell remains and interferes with uterine contraction.
Violation of the excretion of the placenta.
Violation at:
hypotension of the uterus
spasm of the internal os
Spasm can occur with improper use of contractile agents in the afterbirth period.
Follow-up tactics.
Principle: hands off the uterus!
Before checking the contact signs, it is necessary to check the non-contact ones: look at the umbilical cord, which is lengthening (positive sign of Alfeld). The uterus deviates to the right, upwards and flattens (Schroeder's sign), retraction of the umbilical cord with a deep breath (Dovzhenko's sign).
It is necessary to proceed to the separation of the placenta immediately as soon as signs of its separation appear.
Or physiologically (strain)
external methods (Abuladze, Genter, Krede-Lazarevich) - these methods can only separate the separated placenta.
If bleeding occurs in the afterbirth period, then the first task of the obstetrician is to determine whether there are signs of placental separation.
|
There are signs of separation of the placenta. |
There are no signs of separation of the placenta. |
|
|
Immediately highlight the afterbirth with external methods evaluate blood loss administer or continue uterotonics put ice and weight on the stomach clarify the condition of the woman in labor and the amount of blood loss examine the placenta and the integrity of its tissues |
Estimate general state women in labor and blood loss Give intravenous anesthesia and start or continue the introduction of uterotonics after having previously performed an external massage of the uterus Proceed to the operation of manual separation of the placenta and removal of the placenta. |
|
|
If blood loss is normal, then: take care of the woman inject uterotonics for another 30-40 minutes. |
||
|
If the blood loss is pathological, then you need to do: Check the condition of the woman Compensate for blood loss: with blood loss 400-500 ml - gelatinol + saline solution+ intravenous oxytocin. If the blood loss is more than 500 ml, then hemodynamic disorders occur, it is necessary to transfuse blood. |
The operation of manual separation of the placenta and the allocation of the placenta.
The hand is inserted into the uterine cavity.
Professor Akinints proposed a method - a sterile sleeve is put on the hand and the fingers are closed when inserted into the vagina; the assistants pull the sleeve towards themselves and thus the infection is reduced.
The hand must fall between the wall of the uterus and the fetal membranes, so that with sawing movements they reach the placental site, separate it from the wall and secrete the afterbirth.
Reassess blood loss. If the blood loss before surgery is 300-400, then during the operation it increases due to traumatic injuries.
Compensate for blood loss.
Continue intravenous administration of uterotonics.
With full true increment and full tight attachment, there is no bleeding (according to classical laws, 2 hours are expected). In modern conditions, the rule is: to separate the placenta 30 minutes after the birth of the fetus, if there are no signs of separation of the placenta in the absence of bleeding. It is carried out: the operation of manual separation of the placenta and the allocation of the placenta.
Further tactics depend on the result of the operation:
if the bleeding stopped as a result of the operation, then it is necessary:
evaluate blood loss
If bleeding continues due to accretion, attachment of the placenta, etc. then this bleeding turns into early postpartum period.
Prior to the operation of manual removal of the placenta, according to no data, it is impossible to make a differential diagnosis of dense attachment or true accreta of the placenta. Differential Diagnosis only during surgery.
With a tight attachment, the hand can separate the decidula from the underlying muscle tissue with a true increment, this is impossible. You can not be zealous, as very heavy bleeding can develop.
With a true increment, it is necessary to remove the uterus - amputation, extirpation, depending on the location of the placenta, obstetric history, etc. it's the only way to stop the bleeding.
Bleeding in the early postpartum period.
Most often it is a continuation of complications in all periods of childbirth.
The main reason is the hypotonic state of the uterus.
risk group.
Women with weakness of labor activity.
Childbirth with a large fetus.
Polyhydramnios.
Multiple pregnancy.
Pathogenesis. Violation of thrombus formation due to the exclusion of the muscle factor from the mechanisms of hemostasis.
Also, the causes of bleeding in the early postpartum period can be:
injuries of the uterus, cervix, vagina
blood diseases
Variants of hypotonic bleeding.
Bleeding immediately, profusely. In a few minutes, you can lose 1 liter of blood.
After taking measures to increase the contractility of the uterus: the uterus contracts, the bleeding stops after a few minutes - a small portion of blood - the uterus contracts, etc. and so gradually, in small portions, blood loss increases and hemorrhagic shock occurs. With this option, the vigilance of the staff is reduced and it is they who often lead to death, since there is no timely compensation for blood loss.
The main operation that is performed in case of bleeding in the early postpartum period is called MANUAL EXAMINATION OF THE UTERINE CAVITY.
Tasks of Operation ROPM:
establish whether there are any retained parts of the afterbirth in the uterine cavity, remove them.
Determine the contractile potential of the uterus.
To determine the integrity of the walls of the uterus - whether there is a rupture of the uterus (it is sometimes difficult to diagnose clinically).
Determine whether there is a malformation of the uterus or a tumor of the uterus (a fibromatous node is often the cause of bleeding).
The sequence of the operation of manual examination of the uterine cavity.
Determine the volume of blood loss and the general condition of the woman.
Treat the hands and external genitalia.
Give intravenous anesthesia and start (continue) the introduction of uterotonics.
Empty the uterine cavity from blood clots and retained parts of the placenta (if any).
Determine the tone of the uterus and the integrity of the walls of the uterus.
Examine the soft birth canal and suturing damage, if any.
Reassess the condition of the woman for blood loss, compensate for blood loss.
SEQUENCE OF ACTION WHEN STOPPING HYPOTONIC BLEEDING.
Assess the general condition and volume of blood loss.
Intravenous anesthesia, start (continue) administration of uterotonics.
Proceed to the operation of manual examination of the uterine cavity.
Remove clots and retained parts of the placenta.
Determine the integrity of the uterus and its tone.
Examine the soft birth canal and suture the damage.
Against the background of ongoing intravenous administration of oxytocin, simultaneously inject 1 ml of methylergometrine intravenously in a stream, and 1 ml of oxytocin can be injected into the cervix.
The introduction of tampons with ether in the posterior fornix.
Reassessment of blood loss, general condition.
Compensation for blood loss.
Obstetricians also secrete atonic bleeding (bleeding during total absence contractility - Kuveler's uterus). They differ from hypotonic bleeding in that the uterus is completely inactive, and does not respond to the introduction of uterotonics.
If hypotonic bleeding does not stop with ROPM, then further tactics are as follows:
suture the posterior lip of the cervix with a thick catgut ligature - according to Lositskaya. Mechanism of hemostasis: reflex contraction of the uterus, since a huge number of interoreceptors are located in this lip.
This is the same mechanism with the introduction of a swab with ether.
The imposition of clamps on the cervix. Two terminal clamps are inserted into the vagina, one open branch is located in the uterine cavity, and the other in the lateral fornix of the vagina. The uterine artery departs from the iliac in the region of the internal pharynx, is divided into descending and ascending parts. These clamps occlude the uterine artery.
These methods are sometimes used to stop bleeding and are sometimes pre-op steps (because they reduce bleeding).
Massive blood loss is considered to be blood loss during childbirth 1200 - 1500 ml. Such blood loss dictates the need for surgical treatment - removal of the uterus.
Starting the operation of removing the uterus, you can try another reflex method to stop bleeding:
ligation of vessels according to Tsitsishvili. Vessels passing in the round ligaments, the proper ligament of the ovary and in the uterine section of the tube, and on the uterine arteries are ligated. The uterine artery runs along the rib of the uterus. If it does not help, then these clamps and vessels will be preparatory in removal.
Electrical stimulation of the uterus (now they are moving away from it). Electrodes are placed on abdominal wall or directly on the uterus and a discharge is given.
Acupuncture
Along with stopping bleeding, blood loss is compensated.
Prevention of bleeding.
Bleeding can and should be predicted by risk groups:
extragenital pathology
pregnancy complications
preeclampsia (chronic stage of DIC)
multiparous
large fruit, polyhydramnios, multiple pregnancy
weakness of labor during childbirth
This requires examination of a woman during pregnancy:
blood test for platelets
blood coagulation potential
qualified childbirth
Prevention of bleeding in the afterbirth and early postpartum period:
The introduction of uterotonics depending on the risk group.
Minimum risk group: women not weighed down by a somatic history. Bleeding can be because childbirth is a stressful situation, and the reaction of the body can be different. The introduction of uterotonics intramuscularly after the birth of the placenta: oxytocin, pituitrin, hyphotocin 3-5 U (1 U = 0.2 ml) is a higher risk group. Intravenously drip oxytocin, which begins in the second stage of labor and ends within 30-40 minutes after childbirth. Or according to the scheme: methylergometrine 1 mg in 20 ml of physiological saline (5% glucose solution) intravenously in a stream at the time of head eruption.
In the high-risk group, a combination of intravenous drip of oxytocin + simultaneous administration of methylergometrine.
Violation of hemostasis in childbirth is detected as follows:
test according to Lee-White (blood is taken from a vein into a test tube and they look when the blood clots).
You can determine the clotting potential on a glass slide using Folia's methods: 2-3 drops from a finger and it is determined after how many minutes the blood will clot.
The first stage of labor is 3-5 minutes.
The second stage of labor is 1-3 minutes.
The third period is 1-3 minutes.
LEE-WHITE NORM.
The first period is 6-7 minutes.
The third period is 5 minutes.
Early postpartum period 4 minutes.
A woman at risk should be provided with blood substitutes and blood before entering into labor.
Bibliography
For the preparation of this work, materials from the site http://referat.med-lib.ru were used.
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Among the most important problems of practical obstetrics, one of the first places is occupied by miscarriage, the frequency of which is 20%, i.e., almost every 5th pregnancy is lost, and does not tend to decrease, despite numerous and highly effective diagnostic and treatment methods developed in last years. It is believed that the statistics do not include a large number of very early and subclinical miscarriages. Sporadic termination of pregnancy at short terms is considered by many researchers as a manifestation of natural selection with a high frequency (up to | 60%) of the abnormal karyotype of the embryo. Habitual pregnancy loss (childless marriage) occurs in 3-5% of couples. With recurrent pregnancy loss, the frequency of abnormal embryonic karyotype is much lower than with sporadic miscarriage. After two spontaneous miscarriages, the frequency of termination of a subsequent pregnancy is already 20-25%, after three - 30-45%. Most specialists dealing with the problem of miscarriage now come to the conclusion that two consecutive miscarriages are enough to classify a married couple as habitual pregnancy loss, followed by a mandatory examination and a set of measures to prepare for pregnancy.
Miscarriage- its spontaneous interruption in terms from conception to 37 weeks. In world practice, it is customary to distinguish between early pregnancy loss (from conception to 22 weeks) and premature birth (from 22 to 37 weeks). Premature births are divided into 3 groups, taking into account the gestational age from 22 to 27 weeks - very early preterm birth, from 28 to 33 weeks - early preterm birth and at 34-37 weeks of gestation - premature birth. This division is quite justified, since the causes of termination, treatment tactics and pregnancy outcomes for the newborn are different during these periods of pregnancy.
As for the first half of pregnancy, it is completely illogical to bring everything into one group (early pregnancy losses), since the causes of termination, management tactics, and therapeutic measures differ even more than with a gestational age after 22 weeks.
In our country, it is customary to single out early and late miscarriages, termination of pregnancy at 22-27 weeks and premature birth at 28-37 weeks. Early pregnancy losses up to 12 weeks make up almost 85% of all losses, and the shorter the gestational age, the more often the embryo dies at first, and then the symptoms of abortion appear.
The causes of abortion are extremely diverse, and often there is a combination of several etiological factors. Nevertheless, there are 2 main problems in terminating a pregnancy in the first trimester:
The first problem is the state of the embryo itself and chromosomal abnormalities that arise de novo or are inherited from parents. Hormonal diseases can lead to chromosomal disorders of the embryo, leading to disturbances in the processes of maturation of the follicle, the processes of meiosis, mitosis in the egg, in the sperm.
2nd problem - the state of the endometrium, i.e., a characteristic of the pathology due to many reasons: hormonal, thrombophilic, immunological disorders, the presence of chronic endometritis with persistence in the endometrium of viruses, microorganisms, high level pro-inflammatory cytokines, high content of activated immune cells.
However, both in the 1st and 2nd groups of problems, there is a violation of the processes of implantation and placentation, improper formation of the placenta, which subsequently leads either to termination of pregnancy, or when it progresses to placental insufficiency with delayed fetal development and the occurrence preeclampsia and other complications of pregnancy.
In this regard, there are 6 large groups of causes of habitual pregnancy loss. These include:
- genetic disorders (inherited from parents or arising de novo);
- endocrine disorders (insufficiency of the luteal phase, hyperandrogenism, diabetes, etc.);
- infectious causes;
- immunological (autoimmune and alloimmune) disorders;
- thrombophilic disorders (acquired, closely related to autoimmune disorders, congenital);
- pathology of the uterus (malformations, intrauterine synechia, isthmic-cervical insufficiency).
Each stage of pregnancy has its own pain points, which for most women are the leading causes of abortion.
When a pregnancy is terminated up to 5-6 weeks
the leading reasons are:
1. Features of the karyotype of parents (translocations and inversions of chromosomes). Genetic factors in the structure of the causes of recurrent miscarriage account for 3-6%. With early pregnancy losses, anomalies in the karyotype of the parents, according to our data, are observed in 8.8% of cases. The probability of having a child with unbalanced chromosomal abnormalities in the presence of balanced chromosomal rearrangements in the karyotype of one of the parents, it is 1–15%. The difference in the data is related to the nature of the rearrangements, the size of the involved segments, the gender of the carrier, and family history. If a couple has a pathological karyotype even in one of the parents, prenatal diagnosis during pregnancy is recommended (chorionic biopsy or amniocentesis due to high risk chromosomal abnormalities in the fetus).
2. In recent years, much attention in the world has been paid to the role of the HLA system in reproduction, protection of the fetus from the mother's immune aggression, and in the formation of tolerance to pregnancy. The negative contribution of certain antigens, the carriers of which are men in married couples with early miscarriage, has been established. These include HLA class I antigens - B35 (p< 0,05), II класса - аллель 0501 по локусу DQA, (р < 0,05). Выявлено, что подавляющее число анэмбрионий приходится на супружеские пары, в которых мужчина имеет аллели 0201 по локусу DQA, и/или DQB, имеется двукратное увеличение этого аллеля по сравнению с популяционными данными. Выявлено, что неблагоприятными генотипами являются 0501/0501 и 0102/0301 по локусу DQA, и 0301/0301 по локусу DQB. Частота обнаружения гомозигот по аллелям 0301/0301 составляет 0,138 по сравнению с популяционными данными - 0,06 (р < 0,05). Применение лимфоцитоиммунотерапии для подготовки к беременности и в I триместре позволяет доносить беременность более 90% женщин.
3. It has been established that the immunological causes of early pregnancy losses are due to several disorders, in particular, a high level of pro-inflammatory cytokines, activated NK cells, macrophages in the endometrium, and the presence of antibodies to phospholipids. High levels of antibodies to phosphoserine, choline, glycerol, inositol lead to early pregnancy losses, while lupus anticoagulant and high levels of antibodies to cardiolipin are accompanied by intrauterine fetal death in later pregnancy due to thrombophilic disorders. A high level of pro-inflammatory cytokines has a direct embryotoxic effect on the embryo and leads to chorionic hypoplasia. Under these conditions, it is not possible to maintain pregnancy, and if with more low levels cytokines, pregnancy persists, then primary placental insufficiency is formed. Endometrial large granular lymphocytes CD56 account for 80% of the total population of immune cells in the endometrium at the time of embryo implantation. They play an important role in trophoblast invasion, change the mother's immune response with the development of pregnancy tolerance by releasing progesterone-induced blocking factor and activating Tn2 to produce blocking antibodies; provide the production of growth factors and pro-inflammatory cytokines, the balance of which is necessary for trophoblast invasion and placentation.
4. In women with failures in the development of pregnancy, both in recurrent miscarriage and after IVF, the level of aggressive LNK cells, the so-called lymphokine-activated (CD56+l6+ CD56+16+3+), increases sharply, which leads to an imbalance between regulatory and pro-inflammatory cytokines towards the predominance of the latter and to the development of local thrombophilic disorders and abortion. Very often, women with high levels of LNK in the endometrium have a thin endometrium with impaired blood flow in the vessels of the uterus.
With habitual abortion at 7-10 weeks The leading causes are hormonal disorders:
1. insufficiency of the luteal phase of any genesis,
2. hyperandrogenism due to impaired folliculogenesis,
3. hypoestrogenism at the stage of choosing a dominant follicle,
4. defective development or overmaturation of the egg,
5. defective formation of the corpus luteum,
6. defective secretory transformation of the endometrium.
As a result of these disorders, defective invasion of the trophoblast and the formation of an inferior chorion occur. Pathology of the endometrium due to hormonal disorders, not
always determined by the level of hormones in the blood. The receptor apparatus of the endometrium may be disturbed, there may be no activation of the genes of the receptor apparatus.
With habitual miscarriage over 10 weeks The leading causes of violations in the development of pregnancy are:
1. autoimmune problems,
2. closely related thrombophilic, in particular antiphospholipid syndrome (APS). With APS without treatment, in 95% of pregnant women, the fetus dies due to thrombosis, placental infarction, placental abruption, development of placental insufficiency and early manifestations of gestosis.
Thrombophilic conditions during pregnancy leading to recurrent miscarriage include the following forms genetically determined thrombophilias:
-deficiency of antithrombin III,
- factor V mutation (Leidin mutation),
-deficiency of protein C,
-deficiency of protein S,
-mutation of the prothrombin gene G20210A,
- hyperhomocysteinemia.
An examination for hereditary thrombophilia is carried out with:
- the presence of thromboembolism in relatives under the age of 40,
- unclear episodes of venous and / or arterial thrombosis under the age of 40 with recurrent thrombosis in the patient and close relatives,
- with thromboembolic complications during pregnancy, after childbirth (repeated pregnancy losses, stillbirths, intrauterine growth retardation, placental abruption, early onset of preeclampsia, HELLP syndrome),
-when using hormonal contraception.
Treatment is carried out with antiplatelet agents, anticoagulants, in case of hyperhomocysteinemia - by prescribing folic acid, vitamins of group B.
During pregnancy after 15-16 weeks the causes of miscarriage of infectious genesis (gestational pyelonephritis), isthmic-cervical insufficiency come to the fore. In connection with the local immunosuppression characteristic of pregnant women during these periods, candidiasis, bacterial vaginosis, and banal colpitis are often detected. Infection by the ascending route in the presence of isthmic-cervical insufficiency leads to premature rupture of amniotic fluid and the development of contractile activity of the uterus under the influence of the infectious process.
Even this by no means small list of reasons shows that it is impossible to solve these problems during pregnancy. It is possible to understand the causes and pathogenesis of interruption only on the basis of a thorough examination of a married couple before pregnancy. And for the examination, modern technologies are needed, i.e., highly informative research methods: genetic, immunological, hemostasiological, endocrinological, microbiological, etc. You also need a high professionalism of a doctor who can read and understand a hemostasiogram, draw conclusions from an immunogram, understand information about genetic markers pathology, on the basis of these data, select etiological and pathogenetic, and not symptomatic (ineffective) therapy.
The greatest discussions are caused by problems arising with a gestational age of 22-27 weeks . According to WHO recommendations, this period of pregnancy is referred to as premature birth. But children born at 22-23 weeks practically do not survive and in many countries births from 24 or 26 weeks are considered premature. As a result, preterm birth rates vary across countries. In addition, during these periods, possible fetal malformations are clarified according to ultrasound data, according to the results of fetal karyotyping after amniocentesis, and abortion is performed according to medical indications. Can these cases be classified as preterm births and included in the indicators? perinatal mortality? Often, fetal weight at birth is taken as a marker of gestational age. If the fetus weighs less than 1000 g, it is considered an abortion. However, about 64% of babies up to 33 weeks' gestation have intrauterine growth retardation and a birth weight that does not match their gestational age.
The gestational age more accurately determines the outcome of childbirth for a premature fetus than its weight. Analysis of pregnancy losses at 22-27 weeks' gestation at the Center showed that the main immediate causes of abortion are isthmic-cervical insufficiency, infection, prolapse of the membranes, premature rupture of water, multiple pregnancy with the same infectious complications and malformations.
Nursing children born during these terms of pregnancy is a very complex and expensive problem, requiring huge material costs and high professionalism of medical personnel. The experience of many countries, in which preterm births are counted from the above terms of pregnancy, indicates that with a decrease in perinatal mortality during these terms, disability from childhood increases by the same amount.
Pregnancy 28-33 weeks accounts for approximately 1/3 of all preterm births, the rest are preterm births at 34-37 weeks, the outcomes of which for the fetus are almost comparable to those in full-term pregnancy.
An analysis of the immediate causes of abortion showed that up to 40% of preterm births are due to the presence of infection, 30% of births occur due to premature rupture of amniotic fluid, which is also often due to ascending infection.
Isthmic-cervical insufficiency is one of the etiological factors of preterm birth. The introduction into practice of assessing the state of the cervix by transvaginal ultrasound showed that the degree of competence of the cervix can be different and often isthmic-cervical insufficiency manifests itself in late pregnancy, which leads to prolapse of the fetal bladder, to infection and to the onset of labor.
Another significant cause of preterm labor is chronic fetal distress caused by the development of placental insufficiency in preeclampsia, extragenital diseases, and thrombophilic disorders.
Overdistension of the uterus during multiple pregnancy is one of the causes of premature birth and extremely complicated pregnancy in women after the use of new reproductive technologies.
Without knowing the causes of preterm birth, there can be no successful treatment. Thus, tocolytic drugs with different mechanisms of action have been used in world practice for more than 40 years, but the frequency of preterm birth does not change.
Most perinatal centers In the world, only 40% of preterm births are spontaneous and pass through the natural birth canal. In other cases, abdominal delivery is performed. The outcome of childbirth for the fetus, the incidence of newborns during abortion by surgery may differ significantly from the outcomes of childbirth for a newborn with spontaneous preterm birth. So, according to our data, in the analysis of 96 preterm births at a period of 28-33 weeks, of which 17 were spontaneous and 79 ended with a caesarean section, the outcome of childbirth for the fetus was different. The stillbirth rate for spontaneous delivery was 41%, for caesarean section - 1.9%. Early neonatal mortality was 30% and 7.9%, respectively.
Given the adverse outcomes of preterm birth for the child, it is necessary to pay more attention to the problem of preterm birth prevention at the level of the entire population of pregnant women. This program should include:
Examination outside of pregnancy of women at risk of miscarriage and perinatal losses and rational preparation of spouses for pregnancy;
- control of infectious complications during pregnancy: in world practice adopted
screening for infections at first visit, followed by bacteriuria and Gram smear evaluation every month. In addition, attempts are being made to determine markers of early manifestations of intrauterine infection (fibronectin IL-6 in the mucus of the cervical canal, TNFa IL-IB in the blood, etc.);
- timely diagnosis of isthmic-cervical insufficiency (ultrasound with a transvaginal sensor, manual assessment of the cervix up to 24 weeks, and with multiple pregnancy up to 26-27 weeks) and adequate therapy - antibacterial, immunotherapy;
- prevention of placental insufficiency from the first trimester in risk groups, control and therapy of thrombophilic disorders, rational therapy of extragenital pathology;
- prevention of preterm birth by improving the quality of management of pregnant women at the level of the entire population.