Fetal miscarriage. Habitual miscarriage, causes, treatment, prevention, risk

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

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

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

Often, in the early stages, 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

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

Divide the risk into the following subcategories:

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

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

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

habitual miscarriage

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

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

The causes of recurrent miscarriage are multifactorial. These include:

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

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

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

- Deviation of karyotyping.

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

— Genomic mutations of various origins.

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

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

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

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

– To exclude concomitant pathology, ultrasound examination 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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

- Organic defects of the genital area:

Acquired (isthmic-cervical insufficiency, or,).

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

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

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

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

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

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

5-6 weeks these are represented by genetic causes.

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

10-15 weeks: immunological causes.

15-16 weeks: CI and infectious etiology.

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

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

Symptoms of miscarriage

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

The symptom complex includes the following manifestations:

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

- Spasmodic pain, poorly relieved by medications.

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

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

- Alternate weakness, possibly nausea to vomiting.

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

Diagnosis of miscarriage

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

- If the blood types of the partners are different, an analysis for immune antibodies is performed, with a Rh conflict - the presence of Rh antibodies.

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

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

In addition, weekly diagnostic measures are classified:

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

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

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

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

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

Treatment of miscarriage

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Prevention of miscarriage

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

There are fundamental principles for the prevention of miscarriage:

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

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

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

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

- Timely treatment of thrombophilic diseases from early pregnancy.

- Elimination and prevention of placental insufficiency.

- Sanitation of chronic foci of infection.

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

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

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

MD, prof. Sidelnikova V.M., Head of the Department for Prevention and Treatment of Miscarriage

GU NTs AG and P RAMS RF

According to the WHO definition, a habitual miscarriage is considered to be the presence in a woman's history of three or more spontaneous abortions in a row in terms of up to 22 weeks. 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 a habitual miscarriage, followed by a mandatory examination and a set of measures to prepare for pregnancy.

Genetic, anatomical, endocrine, infectious and immunological factors are distinguished in the structure of habitual pregnancy losses.

Genetic factors

Among the causes of recurrent miscarriage are 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 is 1-15%. The difference in the data is associated with 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 the high risk of fetal disorders.

Anatomical factors

The anatomical factors of recurrent miscarriage include: congenital anomalies in the development of the uterus (complete duplication of the uterus, bicornuate, saddle-shaped, unicornuate uterus, partial or complete intrauterine septum), acquired anatomical defects, intrauterine synechia (Asherman's syndrome), submucosal uterine myoma, isthmic-cervical insufficiency (ICN).

The frequency of anatomical anomalies in patients with recurrent miscarriage ranges from 10-16%.

With anatomical pathology of the uterus, late abortions, premature births are more often noted, however, when implanted on the intrauterine septum or near the myomatous node, there may be early abortions.

With malformations of the uterus, it is necessary to pay attention to the pathology of the urinary tract (often associated with congenital anomalies) and the nature of the formation of the menstrual function (indication of a hematometer with a functioning rudimentary uterine horn).

For ICI, the pathognomonic sign is spontaneous abortion in the second trimester or early preterm birth, which occurs relatively quickly and with little pain.

In high-risk patients (who suffer from recurrent miscarriage in the second trimester), monitoring of the state of the cervix should be carried out from the 12th week of pregnancy every 2 weeks.

The most common methods of surgical correction of CI are suturing according to the McDonald method in modifications, U-shaped suture according to Lyubimova. Recent studies have shown that cervical closure in women with CI reduces the incidence of very early and early preterm births before 33 weeks of gestation. At the same time, it was noted that such patients require the appointment of tocolytic drugs, antibiotic therapy.

Preparing for pregnancy in patients with recurrent miscarriage due to ICI should begin with the treatment of chronic endometritis and the normalization of the vaginal microflora. An individual selection of antibacterial drugs is carried out, followed by an assessment of the effectiveness of treatment based on the results of bacteriological examination, PCR diagnostics, microscopy of the vaginal discharge.

Antibacterial therapy is also indicated for the treatment and prevention of infectious complications in CI. Antibiotics approved for use in obstetric practice are prescribed, taking into account the sensitivity of microorganisms: amoxicillin / clavulanate (oral), ampicillin (oral or intramuscular), josamycin (oral), carbenicillin, cefazolin, cefixime or cefotaxime (im).

Together with antibiotics, antiseptics and other antimicrobial drugs are used intravaginally to treat the vagina and sutures: miramistin, nifurantel, hydrogen peroxide, single-component or combined preparations with clotrimazole, metronidazole, miconazole, etc.

In acute viral infections or relapses of viral diseases, the introduction of normal human immunoglobulin (in / in drip) is indicated. Contraindications for this are individual intolerance, low levels of immunoglobulins A. Side effects of immunoglobulins include chilling, headache, fever. To relieve or reduce these symptoms, antihistamines, metamizole sodium are recommended. Preparations of recombinant interferons (interferon alpha-2b, including in combination with normal human immunoglobulin) in the form of rectal forms have an antiviral, immunomodulatory effect, enhance the effect of antibiotics.

Additional treatment for ICI also includes the appointment of tocolytic agents, the prevention of placental insufficiency, vitamin therapy.

endocrine factors

According to various authors, endocrine causes of miscarriage range from 8 to 20%. The most significant of them are: luteal phase deficiency (LFP), LH hypersecretion, hyperandrogenism, thyroid dysfunction, diabetes mellitus.

When diagnosing NLF, it is necessary to identify the cause of such disorders. NLF correction is carried out in two possible directions - cyclic hormone therapy and ovulation stimulation.

When diagnosing an excessive content of androgens (ovarian or adrenal) in patients with habitual miscarriage associated with NLF, drug treatment is indicated, taking into account the effect of androgens on the usefulness of ovulation and the state of the endometrium. Treatment of ovarian hyperandrogenism includes: weight loss, reduction of insulin resistance with the appointment of metformin at a daily dose of 1500 mg (the duration of therapy is 3-6 months) and stimulation of ovulation. Ovulation stimulation is carried out with clomiphene for 3 cycles, after which a break is recommended for 3 menstrual cycles with gestagenic support (dydrogesterone, progesterone) and the decision to either re-stimulate ovulation or surgical treatment.

Pregnancy management should be accompanied by progestogen support up to 16 weeks of pregnancy, dexamethasone is prescribed only in the first trimester of pregnancy. Monitoring is mandatory for timely diagnosis of CI and, if necessary, surgical correction of CI.

Adrenal hyperandrogenism is an autosomal recessive hereditary disease caused by genetic defects in steroidogenesis enzymes. The transfer of the adrenogenital syndrome (AGS) gene to the fetus leads to an increase in the fetus's own androgens and the girl's virilization.

A pathognomonic sign of the disease outside of pregnancy is an increase in plasma concentration of 17-hydroxyprogesterone (17-OP).

The main treatment for hyperandrogenism due to 21-hydroxylase deficiency is glucocorticoid therapy to suppress excessive androgen secretion, which disrupts the normal processes of folliculogenesis in the ovaries, leading to NLF and defective implantation. In this situation, the use of dexamethasone (which, unlike prednisolone, is able to cross the placental barrier and reduce androgen levels) is carried out to prevent the adverse effects of androgens on the fetus.

Dexamethasone treatment is given before pregnancy at an initial dose of 0.25 mg and continued at an individually adjusted dose (0.5 to 1 mg) throughout pregnancy.

It is necessary to carry out prenatal diagnostics: at 17-18 weeks of pregnancy, the level of 17-OP is determined in the mother's blood. With an increased level of the hormone in the blood, its concentration in the amniotic fluid is determined. If the content of 17-OP in the amniotic fluid is increased, AGS is diagnosed in the fetus. Unfortunately, it is impossible to determine the severity of AGS by the level of 17-OP in the amniotic fluid. The issue of maintaining pregnancy in this situation is decided by the parents.

If the father of the child is a carrier of the AGS gene and there have been cases of children born with AGS in the family, then the patient, even without adrenal hyperandrogenism, receives dexamethasone in the interests of the fetus, to prevent the virilization of the female fetus. At the 17-18th week of pregnancy, after determining the sex of the fetus and the expression of the AGS gene (according to the results of amniocentesis), a decision is made: if the fetus is a girl with AGS, treatment is continued until the end of pregnancy, if the fetus is a boy or girl who is not a carrier of the AGS gene, Dexamethasone can be discontinued.

Immunological factors

It is now known that up to 80% of all previously unexplained cases of recurrent pregnancy loss are associated with immunological disorders. There are autoimmune and alloimmune disorders leading to recurrent miscarriage.

In autoimmune processes, the mother's own tissues become the subject of aggression of the immune system, i.e. the immune response is directed against self antigens. In this situation, the fetus suffers a second time as a result of damage to maternal tissues.

In alloimmune disorders, the woman's immune response is directed against the antigens of the embryo/fetus received from the father and which are potentially foreign to the mother's body.

Antiphospholipid syndrome (APS) remains a generally recognized autoimmune condition leading to embryo/fetal death. Among patients with recurrent miscarriage, APS is 27-42%; without treatment, embryo/fetal death is observed in 85-90% of women with autoantibodies to phospholipids.

There are primary and secondary APS. The development of secondary APS is associated with autoimmune, oncological, and infectious diseases.

A number of authors highlight the so-called. catastrophic APS, characterized by sudden onset and rapidly developing multiple organ failure, most often in response to provoking factors (infectious diseases or surgical interventions).

Clinical criteria for APS:

A history of venous, arterial thrombosis;

One or more unexplained antenatal death of a morphologically normal fetus;

One or more premature births with a morphologically normal fetus before 34 weeks of gestation due to severe preeclampsia or severe placental insufficiency;

Three or more unexplained miscarriages before 10 weeks of gestation.

Laboratory criteria for API:

Detection in the blood of anticardiolipin antibodies IgG and / or IgM in medium or high titer, at least twice, with an interval of 6 weeks;

Determination of lupus anticoagulant in plasma at least twice with an interval of at least 6 weeks according to the methods according to the recommendations of the International Society for Thrombosis and Hemostasis.

These techniques include the following steps:

Establishing the fact of elongation of the phospholipid-dependent phase of plasma coagulation based on the results of such screening tests as APTT, kaolin time, Russell test with dilution, PT with dilution;

Failure to correct prolonged screening time by mixing with normal platelet-free plasma;

Shortening the time of screening tests or its normalization after the addition of excess phospholipids to the test plasma, and the exclusion of other coagulopathies, such as the presence of a factor VIII inhibitor or heparin.

Therapy during pregnancy includes: the appointment of glucocorticoids in low doses - 5-15 mg / day (in terms of prednisolone); correction of hemostasiological disorders with antiplatelet agents and anticoagulants; prevention of reactivation of a viral infection in the carriage of herpes simplex virus type II and CMV, the introduction of immunoglobulin (in / in); prevention and treatment of placental insufficiency; therapeutic plasmapheresis (according to indications).

The use of low doses of glucocorticoids aims to prevent thrombophilic reactions in both mother and fetus due to the transplacental transfer of antiphospholipid autoantibodies.

Alloimmune factors of recurrent miscarriage include the presence of antibodies to CG, which is observed in the serum of 26.7% of women suffering from recurrent miscarriage. The mechanism of action of antibodies probably consists not only in preventing the binding of CG to the ovarian corpus luteum receptors, but also in a direct damaging effect on the cells of the embryonic trophectoderm.

Treatment of patients with sensitization to chronic hepatitis consists in the correction of thrombophilia with low molecular weight heparins under the control of hemostasiogram and the appointment of glucocorticoid therapy at doses of 5-15 mg / day (in terms of prednisolone). Treatment should begin in the first trimester of pregnancy, because. the peak production of hCG and, as a result, antibodies occurs in the first weeks of pregnancy.

Other alloimmune processes leading to fetal rejection include:

The presence in spouses of an increased number (more than 3) of common antigens of the major histocompatibility complex system (often observed in related marriages);

Low maternal serum blocking factors;

Increased content of natural killer cells (NK cells CD-56+, CD-16+) in the endometrium and peripheral blood of the mother both outside and during pregnancy;

High levels of a number of cytokines, in particular gamma-interferon, tumor necrosis factor-alpha, IL-1, -2 in the endometrium and serum.

Currently, these alloimmune factors leading to early pregnancy losses and ways to correct the above conditions are under study.

The thrombophilic conditions during pregnancy, leading to recurrent miscarriage, include the following forms of genetically determined thrombophilia: antithrombin III deficiency; factor V mutation (Leiden mutation); protein C deficiency; protein S deficiency; mutation of the prothrombin gene G20210A; hyperhomocysteinemia. An examination for hereditary thrombophilia is carried out if there is a family history of thromboembolism under the age of 40 years in relatives; with unclear episodes of venous and / or arterial thrombosis at the age of 40 years; recurrent thrombosis in patients and close relatives; thromboembolic complications during pregnancy; after childbirth when using hormonal contraception (repeated pregnancy losses, stillbirths, intrauterine growth retardation, placental abruption, early onset of preeclampsia, HELLP syndrome).

Treatment is carried out with antiplatelet agents, anticoagulants, with hyperhomocysteinemia - the appointment of folic acid, vitamins of group B.

infectious factors

For infectious genesis of miscarriage, late miscarriages and premature births are more characteristic. About 40% of preterm births and about 80% of cases of premature rupture of amniotic fluid are caused by an infectious factor. However, early habitual pregnancy losses may be due to the impact of infection, the formation of chronic endometritis with a high level of activated immune cells.

During pregnancy, it is necessary to control the state of the vaginal biocenosis, microbiological and virological control. In the first trimester of pregnancy in patients with an infectious genesis of miscarriage, the method of choice is immunoglobulin therapy (10% normal human immunoglobulin for intravenous administration, 50 ml, every other day, 3 times).

In the II and III trimesters of pregnancy, repeated courses of immunoglobulin therapy are carried out, it is possible to administer imunofan (1 ml, intramuscularly, every other day, 5 times), interferon-alpha2b. If pathological flora is detected based on the results of the examination, it is advisable to conduct individually selected antibiotic therapy against the background of systemic enzyme therapy with simultaneous treatment of placental insufficiency. Such therapy can be carried out in a day hospital or in a hospital. If, against the background of inflammatory changes, manifestations of the threat of termination of pregnancy are noted, then hospitalization in a hospital is indicated.

Symptomatic treatment of threatened miscarriage

In the early stages of pregnancy, if there are pulling, aching pains in the lower abdomen and in the lower back, the appearance of bloody discharge in women with habitual miscarriage, hospitalization is indicated.

Along with pathogenetic therapy, treatment should be carried out aimed at normalizing the tone of the uterus. Up to 12 weeks of pregnancy, therapy includes: semi-bed rest; physical and sexual rest; the appointment of antispasmodic drugs: drotaverine hydrochloride - 40 mg 2-3 times a day / m, or 40 mg 3 times a day inside; papaverine hydrochloride - 20-40 mg 3 times a day or 40 mg 2-3 times a day rectally; magnesium preparations (magnesium lactate + pyridoxine hydrochloride) in an average daily dose of 4 tablets (1 tablet in the morning and afternoon and 2 tablets in the evening).

The duration of treatment is set individually depending on the symptoms of a threatened abortion.

In the presence of partial detachment of the chorion or placenta (up to 20 weeks of pregnancy), along with antispasmodic, hemostatic therapy is used - tranexamic acid (orally or parenterally, 250 mg 3 times a day), etamsylate (250 mg 3 times a day, orally or with severe bleeding - 250 mg 3 times a day / m).

With abundant bloody discharge for hemostatic purposes, tranexamic acid is used intravenously 5-10 ml (250-500 mg) per day per 200 ml of 0.9% sodium chloride solution, followed by a transition to oral administration at a dose of 250 mg 3 times a day until the bright spotting stops. Fresh frozen plasma may be used.

According to the indications, hormonal therapy with gestagens is carried out, in particular dydrogesterone in a daily dose of 30-40 mg with a gradual decrease to 20 mg.

With retrochorial and retroplacental hematomas in the organization stage, systemic enzyme therapy with Wobenzym in a daily dose of 3 tablets is recommended. 3 times a day 30 minutes before meals. The duration of treatment is 14 days.

If pronounced tonic contractions of the uterus occur at 16-20 weeks of gestation and the ineffectiveness of antispasmodic drugs, indomethacin is used rectally or orally in a daily dose of not more than 200 mg (course dose - not more than 1000 mg); nifedipine - 10 mg 3-4 times a day. You can use magnesium therapy (magnesium sulfate). At gestation periods of more than 26 weeks - tocolytic therapy, in particular beta-agonists (hexoprenaline, salbutamol, fenoterol).

According to the Department of Prevention and Treatment of Miscarriage of the State Research Center for Hypertension and P of the Russian Academy of Medical Sciences, when causative factors are identified, violations are corrected outside of pregnancy, and monitoring during pregnancy, the birth of viable children in couples with habitual miscarriage reaches 95-97%. According to world literature (Hill J., 1999), positive results are about 70%. This discrepancy is due to the examination of the couple before pregnancy and the establishment of the causes of habitual pregnancy loss, thorough rehabilitation therapy before pregnancy, monitoring during pregnancy and pathogenetic therapy during pregnancy, prevention and treatment of placental insufficiency. In clinics where preparation for pregnancy is carried out, similar results are obtained (Beer A., ​​Kwak J., 1999).

Literature

1. Makatsaria A.D., Bitsadze V.O. Thrombophilic conditions in obstetric practice// M., Russo.-2001.

2. Manukhin I.B., Tumilovich L.G., Gevorkyan M.A. Clinical lectures on gynecological endocrinology. - M .: "Medicine". - Information agency. - 2001.

3. Milovanov A.P. Pathology of the mother-placenta-fetus system. - M .: "Medicine", 1999.

4. Posiseeva L.V., Tatarinov Yu.S., Petrunin D.D. Specific alpha-2-microglobulin of the human reproductive system. 20 years from functional research to implementation in clinical practice. - Ivanovo: MIK, 1998.

5. Serova L.D., Minishkina T.V. et al. The HLA system in medical genetic counseling for women with recurrent miscarriage and infertility of unknown origin. Manual for doctors. - M., 1997.

6. Sidelnikova V.M. Habitual pregnancy loss. M.: Triada-Kh.- 2002.- S.304.

7. Yarilin A.A. The system of cytokines and the principles of its functioning in normal and pathological conditions // Immunology.-1997.-5.-7-14.

8. Battram V.C. Milleran anomalies and their management// Fertil. Steril..- 1983.- 40.- 2.- P. 159.

9. Beer A.E., Kwak J. Reproductive medicine program Finch University of Health Science// Chicago Medical School.- 1999.- P.132.

10. Benirschke K. Cytogenetics in reproductive endocrinology.- In the book: "Reproductive endocrinology".- M.: "Medicine".-1998.- P. 354-421.

11. Clark D. Critically examining the immunologic causes of recurrent miscarriage// Medscape women's Health.-1999.- 4(3).

12. Coulam C.B., Stephenson M., et al. Immunotherapy for recurrent pregnancy loss: Analysis of results from clinical trials// Amer. J. Reprod. Immunol.- 1996.- 35.- P. 352-359.

13. Hill J.A. Recurrent pregnancy loss// Kistner’s Gynecology womens Health.- 7th ed.- Mosby.- 1999.

14. Kimber S. Molecular in interaction at the maternal-embryonic interface during the early phase of implantation// Semin. reproduction. Med.- 2000.- 18(3).- 237-253.

15. Loke Y.W., King A. Immunological aspects of human implantation// J. Reprod. fertil. Supplement.-2000.-55.- P. 83-90.

16. Nikas G. Endometrial receptivity: changes in cell-surface morphology// Sem. Reproductive Med..- 2000.- 18(3).- P. 229-235.

Miscarriage refers to the spontaneous termination of a pregnancy before the full 37 weeks. Of the total number of diagnosed pregnancies, fetal mortality occurs in 15-20% of cases. This statistic is a big obstetric - gynecological problem and often leads to serious psychological consequences for the whole family. The possible causes of miscarriages, the diagnosis, treatment and prevention of such pathologies are discussed in detail in the article.

Causes of miscarriage

- genetic abnormalities of the fetus

Spontaneous miscarriages resulting from genetic disorders have been studied by medicine quite deeply. In the structure of causal relationships, this factor is up to 5% of all others. In the first trimester, the percentage of miscarriages in 40 - 60% of cases occurs due to abnormal chromosomes of the fetus.

The most common type of chromosomal abnormality is autosomal trisomy, when the cells contain an increased number of homologous chromosomes. A chromosomal or gene mutation leads to the non-viability of the embryo and its impaired development inside the amniotic fluid. Also, quite often there are signs of triploidy or tetraploidy, characterized by the development in the cell instead of two chromosomes, three or four.

All this leads to the fact that already at a period of 3-5 weeks, the pregnancy stops at the stage of implantation and is transiently interrupted.

- infectious diseases of the mother

As a result of infection in the mother's body through the placenta, the infection also penetrates to the fetus through the blood. At the same time, a woman may not be aware of the presence of microorganisms in her, or experience symptoms characteristic of the disease. Passing through the placenta, the pathogen provokes placentitis with corresponding histopathological changes.

Reference! Various bacteria (gram-negative and gram-positive cocci, listeria, treponema and mycobacteria), viruses and protozoa such as plasmodium and toxoplasma can have access to the fetus's body.

The impact of infection, the severity of the lesion on the fetus depends on its ability to give an immune response. Also, in many ways, pathological changes in the body of the embryo depend on the duration of the mother's illness and the state of her body's defense mechanisms.

In connection with many infections, the vaginal microflora changes. As a result, anaerobic conditionally pathogenic bacteria qualitatively and quantitatively change the composition of the microflora of the vagina and cervix. The intensity of colonization of microorganisms increases and the frequency of their isolation increases.

- endocrine causes

Endocrine factors affect spontaneous abortion in 17 - 23% of cases. These include:

• Inferiority of the luteal phase. A complete transformation and high-quality preparation of the endometrium for fertilization of the egg occurs only with a sufficient level of estrogen and progesterone. The luteal phase is disturbed by elevated prolactin levels and a shift in the timing of ovulation. Against this background, the growth and full maturation of the follicles is disrupted and a pathological corpus luteum is formed.
• Elevated levels of adrenal and ovarian androgens. There is a low placenta previa, which leads to inferior development of the embryo and the extinction of its functions.
• The risk of miscarriage is often observed in women suffering from thyroid disease.
• With diabetes carrying a child is very difficult.

- autoimmune causes

Autoimmune factors account for 40-50% of all preterm pregnancies. The foreign agent should ideally be recognized by the immune response in the mother's body. This role is taken by HLA antibodies, which are divided into two types:

1. Antigens A, B and C. Their role is reduced to the recognition of transformed cells.
2. Antigens DR, DP, DQ. In the process of the immune response, interaction between macrophages and T-lymphocytes is provided.

Important! If the interaction of one of these types of antigens is disturbed, a shift occurs in the development of the embryo. The fetus cannot fully exist in the amniotic tract of the mother and its rejection begins.

- pathology of the female genital organs

Female genital organs may have congenital or acquired pathology. Congenital malformations include disruption of the uterine ducts, anomalies and branching of the uterine arteries. Acquired are Asherman's syndrome, endometriosis and uterine fibroids.

In all these situations, abortion occurs due to a violation of the process of implantation of the fetal egg. In this case, there is often a close arrangement of the internal genital organs, which leads to increased excitability of the infantile uterus. The threat of miscarriage in such cases can be observed at various times.

- isthmic-cervical insufficiency

It is the most common cause of perinatal losses in the second trimester of pregnancy (about 13 - 20% of cases). It is characterized by pathological shortening of the cervix with its inevitable opening, which leads to the loss of the child.

As a rule, isthmic-cervical insufficiency is present in those women who have had abortions before or had gaps in previous births. The cervix during these processes is severely damaged and inadequately performs its assigned function.

The uterus may also have a congenital malformation and cannot cope with the increased load during childbearing, for example, with polyhydramnios, a large fetus, or multiple pregnancies.

- Rhesus conflict

If the mother does not have Rh, the body reacts to its invasion, recognizes it as a foreign protein and produces the appropriate antibodies. This reaction is designed to protect the internal environment of the mother from the penetration of foreign genetic material. With a negative Rh during pregnancy, antibodies begin to contact the Rh antigen in red blood cells, directly on the surface of the fetus. At the same time, blood cells are destroyed and their decay products are converted into toxic bilirubin.

A reduced number of red blood cells causes anemia, and bilirubin speaks of its effect due to the induced jaundice. At the same time, urine and skin become yellow, the lumen of the umbilical and hepatic veins narrows, and pressure in the portal vein system increases. As a result, metabolism and protein synthesis in the liver are disturbed. The fetus cannot fully develop in such conditions and soon dies.

- other reasons

Other common causes of miscarriage include:

• social factors. Difficult working conditions during pregnancy, work in night and extracurricular shifts.
• Stressful situations at work and at home.
• The presence of addictions after conception (smoking, alcohol).
• Burdened history. This may include past failed pregnancies, infertility, IVF treatment, caesarean section, or pelvic surgery.
• age reasons. Women under 16 and women over 35 are at risk of miscarriage.

Classification of miscarriage

Depending on the timing of gestation, the following classification of miscarriage is distinguished:

• spontaneous interruption (up to 28 weeks);
• premature birth (for a period of 28 to 37 weeks).

Spontaneous interruption is divided into three classes:

1. Early. From conception to 12 weeks. This pathology manifests itself in 85% of all cases.
2. Later. 13 - 21 weeks after conception.
3. Spontaneous abortion at 22 - 27 weeks of pregnancy.

Diagnostics

Attention! To diagnose a possible miscarriage, the doctor initially interviews the patient for the presence of certain symptoms. Characteristic clinical signs are pulling pains in the lower abdomen and spotting from the genitals. With the inconsistency of these symptoms, we can talk about a short-term tone of the uterus, and with their cyclicity and constancy - about the threat of miscarriage.

A woman needs to undergo a comprehensive examination:

• Take blood tests. Blood should be provided to both parents in order to determine chromosomal abnormalities, as well as hormonal and immunological changes.
• Get tested for chromosomal abnormalities of the aborted tissues. During a miscarriage, the remains of the genetic material are taken, and a study is conducted on the causal factors of the pathology that has occurred.
• Ultrasound examination of the uterus and hysteroscopy. The uterine cavity lends itself to a holistic examination by introducing a video camera into its area.
• Hysterosalpingography. A special study of the uterus, based on the introduction of contrast agents into it. With this method, it is possible to identify many uterine diseases.
• Biopsy of the inner layer of the uterus (endometrium). Hormonal examination of a small piece of tissue taken from the lining of the uterus.

Treatment

Treatment for a woman, depending on the causes of miscarriage, is prescribed by a doctor. In the case of an inferior luteal phase, plant-based sedatives, hormonal (Dufaston, human chorionic gonadotropin) and antispasmodics of the No-shpa type are prescribed. Against the background of sensitization to progesterone, Duphaston, glucocorticoids and immunoglobulin preparations are prescribed.

Placental insufficiency is treated with Piracetam, Actovegin and Infezol. At the risk of premature rupture of amniotic fluid or in the presence of infectious agents in the body, tocolytic agents, antibiotics, antifungal and bacterial drugs are used.

At the slightest threat of miscarriage, a woman is prescribed strict rest. The doctor, depending on the patient's tests, prescribes her treatment according to the scheme with such drugs as magnesium sulfate, hexoprenaline and salbutamol sulfate, fenoterol, indomethacin, nifedipine, oxyprogesterone capronate. To relax the uterus, non-drug procedures are used, such as uterine electrorelaxation and acupuncture.

In case of intolerance to some drugs, in the presence of allergic diseases and preeclampsia of pregnancy, plasmapheresis is performed in the amount of no more than 3 sessions. Its essence is to remove a certain amount of plasma from the circulating blood volume and replace it with rheological and protein solutions. The procedure is aimed at removing some of the toxins and antigens. As a result of this, microcirculation and blood clotting are noticeably improved.

Prevention

As a preventive measure, the following is carried out:

• Registration of every woman of childbearing age and identification of patients among them who are at risk.
• Timely examination of a married couple (long before the planned pregnancy), as well as rational preparation for such a responsible decision.
• Control of special services over the epidemiological situation and prevention of infectious complications. Carrying out adequate antibacterial, immune and anti-inflammatory work.
• Timely diagnosis of pathologies such as cervical insufficiency. Up to 24 weeks of pregnancy, an ultrasound examination is performed using a transvaginal probe. With multiple pregnancy, this procedure relies until 26 or 27 weeks of pregnancy.
• Prevention of placental insufficiency from the very first weeks after conception.
• When a pathology is detected and it is impossible to avoid sad consequences, specialists need to fully inform the woman about alternative methods of fertilization and childbirth.

In order for the pregnancy to go easily, without disturbances and not end in miscarriage, you need to thoroughly approach this process long before conception. The expectant mother, preferably together with her husband, must undergo all the necessary examinations and be guided by the instructions of specialists. With a high risk of pathology, it is important to weigh the pros and cons and make an adequate decision about other methods of conception.

Especially for- Elena Kichak

When you can’t get pregnant or bear a baby, another failure follows failure, a woman’s psyche changes. She is suffering mentally.

Specialists come to the rescue in such cases: obstetricians - gynecologists. By all means they are trying to save the pregnancy. When a woman comes after 5-6 failures and as a result a healthy baby is born to her on time - this is such a big holiday, not only for the family, but also for the specialists who have kept the pregnancy!

The head of the department of pathology, in one of the clinics of obstetrics and gynecology, keeps in her office a picture that was drawn by a 5-year-old boy. The boy in the picture portrayed a doctor. According to her, this boy got to his mother very hard. When she looks at this cute picture, thoughts always come to her mind that if it were not for her work, this child might not have been.

Causes of miscarriage

In miscarriage, there are a lot of reasons that can affect the course of pregnancy. These factors are very diverse:

1. inflammatory factor. It is necessary to investigate the infectious background: take smears, cultures, detailed tests for all infections.
2. Rolling system. There are kinetic forms of violation of the coagulation system, when small blood clots are formed that do not allow blood to penetrate to the fetal egg. Consequently, the fetal egg stops its development, or placental abruption occurs and the fetus dies.
3. immunological factors. This is a determination in blood tests of the presence or absence of certain antibodies.
4. endocrine factors. It is necessary to study the hormonal status. Determination of the level of hormones, not only sex, but also thyroid hormones, adrenal hormones, which also affect the development of pregnancy.
5. Genetic abnormalities that in most cases lead to miscarriage in early pregnancy.

What you need to know when planning a pregnancy to avoid miscarriage

It does not matter whether this is the first pregnancy, or a series of losses followed before pregnancy, but before each pregnancy, it is necessary to undergo an examination by a gynecologist:

• If you are planning your first pregnancy, then these are elementary tests - hormonal levels, taking smears and sowing for all types of infections.
• If there has already been an unsuccessful pregnancy, it is necessary to undergo a study with specialists who deal with miscarriage, because such professionals will tell you what examination you should undergo and what tests you need to pass in order to avoid problems in the future and be able to give birth to a healthy child.

Symptoms of miscarriage

In order to prevent miscarriage, you should pay attention to the following symptoms and consult a doctor immediately if:

1. There are pains in the lower abdomen. In pregnant women, physiological pains, tingling, sipping are not excluded, since the blood supply to the uterus increases. There are definitely some sensations associated with pregnancy in the lower abdomen. But, pulling or cramping pains in the lower abdomen and in the lower back - this is the moment that should make a pregnant woman immediately consult a doctor in order to receive the necessary prescriptions.
2. There is spotting during pregnancy. They should alert the woman. With this symptom, hospitalization is usually indicated.
3. At long stages of pregnancy - the absence or a reduced number of fetal movements, weak activity, or vice versa, too rapid movement may indicate an unfavorable condition of the child.

Expectant mothers should carefully monitor the process and without wasting time consult a doctor for the necessary help.

Sexual life with the threat of termination of pregnancy

Very often, women are embarrassed to ask a question about the presence or absence of sexual activity during pregnancy. No need to be shy - this is a completely normal question that the doctor will answer for you. With a normal, physiological pregnancy, when everything is fine - if this is the first pregnancy or there were no problems with pregnancy in the past, sexual activity is not a contraindication. With a successful pregnancy, the doctor can only recommend some special positions for a woman in the position and intensity of sexual intercourse. Don't be afraid to ask these questions.

During pregnancy with the threat of termination, sexual activity is prohibited, because sexual intercourse in this case can aggravate the situation and cause a miscarriage.

Prevention of miscarriage

A pregnant woman with a threatened miscarriage should adhere to a certain style of behavior:

• Observe the regime of work and rest:
  • There should be a shortened working day.
  • You should get enough sleep, that is, sleep so much time that after waking up you feel rested.
  • Be sure to take daily walks in the fresh air. The supply of oxygen to the body of a woman contributes to the proper development of the placenta and, accordingly, the correct development of the fetus. Therefore, walks in parks, forests and outside the city are useful.
• Proper nutrition:
  • You should include in the diet foods rich in fiber, vitamin C, folate - all of which are found in fruits and vegetables.
  • The use of complex carbohydrates, which are found in bakery and pasta products, is shown.
  • Essential fatty acids, which are found in fish and vegetable oil, are essential in the diet of expectant mothers.
  • Meat, nuts and seeds should be included in the diet of pregnant women.
  • It is recommended to use a sufficient amount of liquid - 30 ml. per 1 kg. body weight, this is the minimum that a woman needs in position.
• Long distance trips:
  • You should not plan long trips, as a long road is a threat in case of a problem pregnancy.
  • It is not recommended to change the climate zone.
  • Flights are completely contraindicated in case of a threat of premature birth.

When flying by plane, the following occurs:

• Change in pressure at altitude.
• Changes in the coagulation system in the body - a tendency to form blood clots.
• Diseases of acute respiratory infections, acute respiratory viral infections, since closed air conditioning systems on board aircraft very often contain various viruses and bacteria.

The body of pregnant women is very susceptible to infections. During pregnancy, immunity is weakened so that the new baby's body in the mother's body develops without problems and there is no rejection. Any encounter with an infection, if a non-pregnant woman does not cause any consequences, then a woman in position has a great chance of getting acute respiratory infections, acute respiratory viral infections or poisoning.

Based on this, long trips, trips with flights, with a change in the climatic zone and to Asian countries, where there are still a lot of toxic infections, are not recommended.

You need to take care of yourself during pregnancy and approach this situation very responsibly. If you are worried and suspect any symptoms of a threat to your pregnancy, contact highly professional specialists in a timely manner.

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

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

Classification of cases of miscarriage

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

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

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

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

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

Causes of miscarriage

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

Reasons depending on the future mother:

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

Complications that occur during pregnancy:

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

Factors not related to gestation:

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

Adverse environmental impact:

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

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

The mechanism of development of pathology

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

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

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

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

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

Diagnosis of pathology

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

Features of the examination before conception

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

Clinical examination is represented by the following procedures:

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

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

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

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

Features of the examination after conception

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

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

Symptoms and treatment of miscarriage

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

Threatened abortion

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

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

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

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

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

Abortion on the go

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

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

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

incomplete abortion

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

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

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

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

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

Complete abortion

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

Missed abortion

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

Forecast and measures to prevent recurrent miscarriage

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

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

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

Prevention of miscarriage

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

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

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

How to deal with the problem. Video