Theoretical foundations of the pathology of miscarriage. Miscarriage is common, causes, treatment, prevention, risk

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

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

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

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

Risk of primary miscarriage

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

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

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

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

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

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

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

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

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

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

Causes of primary miscarriage

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

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

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

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

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

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

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

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

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

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

Symptoms and signs of primary miscarriage

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

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

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

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

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

Treatment and prevention of primary miscarriage

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Classification of miscarriage cases

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

1. Spontaneous abortion. If the miscarriage occurs before 11 weeks, the abortion is considered early. If the misfortune happened in the period from 11 to 21 weeks of gestation, the abortion is late. The interruption 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:

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

In addition, speaking of abortion in general, it is understood that it can be canceled and infected.

Causes of miscarriage

A great variety of factors causing this pathology have been found. It is often not one, but several reasons that stimulate miscarriage. Let's list them all.

Reasons depending on the expectant 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. This is a phenomenon when, on an immunological or genetic basis, the maternal organism rejects the embryo / fetus as a potential threat.

Complications during pregnancy:

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

Non-bearing factors:

• 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 reasons for 27, 5 - 63.5% of cases of miscarriage remain unclear. Pregnant women and the doctors leading them find themselves in such a difficult situation so often that the phenomenon has even been identified as idiopathic (non-explainable) abortion. Drug treatment in these cases is ineffective, and the psychological support of the woman comes to the fore, helping her to endure the pain of loss.

The mechanism of development of pathology

At the heart of self-interruption of intrauterine development of the fetus is hidden pathological destruction of the connection between cortical and cortical-subcortical factors, which occurs under the influence of many prerequisites. By prerequisites, we mean the most complex reflex relationships between the mother and the 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 due to 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. Bearing is interrupted due to active contractions of the uterus: 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 metamorphosis.
3. The death and rejection of the fetus occurs under the influence of mutations or genetic disorders.
4. Miscarriage occurs due to 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 loss into fetal loss syndrome. The generalized concept implies:

1. One or more miscarriages in a row during a pregnancy of 10 weeks or more.
2. The birth of a still child in the medical history.
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 a consequence of a combination of the interaction of a number of unfavorable reasons, the examination of the affected patients is complex. It involves clinical, instrumental and laboratory diagnostic methods, during which the doctor must not only find the "weak link" during pregnancy, but also study the state of the patient's reproductive system in order to prevent the recurrence of the misfortune.

Features of the examination before conception

Analyzing the medical history of a woman who has encountered recurrent miscarriage, the specialist will pay attention to the hereditary factor, cancer and neuroendocrine disorders. It also remains to be seen whether the patient has suffered from genital inflammatory diseases and viral infections in the past, whether she has undergone 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;
• determining the amount of excess weight according to BMI;
• assessment of the condition of the "thyroid gland";
• determination of the frequency of ovulation and the functional viability of the ovaries based on data from rectal temperature and 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 woman's body 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 cysts, adenomyosis and polyps.
3. Infection screening. The method involves examination under a microscope of biological material taken from the urethra, vagina and uterus.
4. Hormonal analysis. Allows you to clarify the level of prolactin, testosterone, cortisol, luteinizing, follicle-stimulating hormones and other important active substances in the patient's blood.

The potential father also undergoes an examination, during which his expanded 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 a position, she is monitored with particular care. The management 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 27 more hormones);
• periodic consultations with a psychologist.

Symptoms and treatment of miscarriage

Discharge of some blood from the vagina and painful discomfort in the lower abdomen are considered to be the main signs of a 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 a position is disturbed by pulling pains in the lower abdomen and in the lower back. If anxiety symptoms occur in mid-pregnancy, the pain tends to resemble labor pains. Slight bleeding is present. The uterus develops well, its volume corresponds to the gestational age, but there is hypertonicity.

The ultrasound procedure reveals such symptoms of threatening abortion as a fuzzy contour of the ovum or chorionic / placental detachment in a certain area.

Before prescribing supportive therapy for a pregnant woman with a threat of miscarriage, the doctor will certainly pay attention to the presence of such factors accompanying the woman's condition as:

• cases of self-abortion in the past;
• age over 34;
• bradycardia;
• lack of heartbeat in the embryo at CTE;
• slow growth or its absence in the ovum for 10 days;
• an empty ovum measuring 15 mm at a gestation period of 7 weeks and 21 mm at a gestation period of 8 weeks;
• the size of the embryo is significantly inferior to the size of the ovum;
• lowered hCG rates;
• lowered progesterone levels.

Despite the presence of all the warning signs of threatening abortion, targeted treatment helps to maintain the pregnancy. 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. A pregnant woman feels a 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 of gestation, an ultrasound scan shows complete or partial placental abruption.

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

With severe bleeding, which can threaten the patient's life, they act promptly: the embryo is removed from the uterus, without waiting for its rejection, and hemodynamics are stabilized. If an immediate operation to cure 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 parts of it remain there. Outwardly, this is manifested by cramping pain and discharge of blood from the vagina, and these symptoms can be of varying degrees of intensity. When examining the patient, the doctor determines that the cervix is ​​shortened and the pharynx is open. There is no uterine tone - the organ is soft and does not meet the gestation period. On ultrasound in the cavity of a muscular organ, vague outlines of heterogeneous tissues are found.

In case of an incomplete abortion, the uterine cavity is cleaned, removing the torn tissue from there, followed by laboratory research. They resort to a surgical or medical method of getting rid of the uterus from parts of the embryo.

The choice in favor of a surgical operation is made in the case of:

• intense spotting;
• the uterine cavity is open more than 50 mm;
• body temperature about 38 0 C.

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 medication method of cleaning. In case of incomplete abortion, large doses of prostaglandin are used (from 800 to 1200 mg). The most common choice is Misoprostol. After 4 - 6 hours after intravaginal administration, the uterus begins to contract and completely expels the ovum. 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 ovum 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 dense uterus with an open external os. If the patient's condition is satisfactory, then instrumental examination of the walls of the uterine cavity is not performed.

Failed abortion

In this case, the embryo stops developing, but does not leave the uterus. The patient at this time may have a rise in body temperature and an ichor. Subjective sensations of an “interesting” situation disappear. Ultrasound shows that the size of the embryo lags behind the gestation period. In addition, there is no heartbeat or movement of the embryo. If the diagnosis of a failed abortion is confirmed, an urgent operation is required to remove the embryonic or fetal material by surgery or medication.

Forecast and measures to prevent recurrent miscarriage

The prognosis of the development of pregnancy in the future in a patient whose medical history contains a mark of self-abortion depends on how the previous pregnancy ended. The most favorable prognosis in women whose pregnancy was interrupted 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 complex treatment, consisting of the use of medications and the implementation of the specialist's recommendations. 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 to the 28th week inclusive. The most popular drugs are progesterone, gonadotropin, Duphaston and Ethinylestradiol.
4. Using antibiotics to prevent infection.
5. Tocolytic treatment aimed at suppressing the contractile activity of the uterus.
6. Work to improve the metabolism of the fetoplacental complex, for which the patient is prescribed multivitamin complexes, preparations of ascorbic acid and tocopherol acetate.
7. Surgical surgery (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 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, one cannot give up - a woman must use all the opportunities and chances to become a mother. Therefore, planning a 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, for tests to analyze the hormonal background and bacteriological examination of the microflora of the internal genital organs, to determine the blood group 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 scrupulous analysis of the state of her endocrine and immune systems.

How to deal with the problem. Video

Miscarriage- this is the primary 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 removal of an embryo or fetus with a total weight of 500 grams or less from the mother's body.

According to generally accepted rules, it is believed that a miscarriage that happened before twenty-eight weeks is a spontaneous miscarriage or abortion. While if it occurs after twenty-eight weeks, this process is called premature birth. The public is faced with a serious family and psychological problem of families who 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 obvious discharge, starting from an early stage, of a hemorrhagic nature (12%) than in patients with no such (4%). The most dangerous thing in all this is an unreasonable interruption in the first trimester, namely, from the sixth to the eighth week. It is during this time interval that about 80% of miscarriages occur. Most of them occur before the onset of a heartbeat, that is, the embryo dies. At the same time, all a woman may not know about a previously onset and already interrupted pregnancy. Later than the eighth week, the likelihood of a pathological process, with the already appeared heartbeat, is only 2%. And with a period from the tenth week and a satisfactory heartbeat, the threat reaches barely only 0.7%.

Often in the early stages, scientists associate pathology with deviations in development, the mechanism of so-called biological natural selection is connected. And it was proved that the embryos had a chromosomal defect in 82% of cases.

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

The risk of miscarriage

The risk of this pathological condition can be classified into several subcategories, but the main forming factor is the number of previous miscarriages. With the initial occurrence, the probability of the subsequent one increases by 16%, in 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 the lesion reaches 35%. So, not on time started treatment leads to an increase in the occurrence of the subsequent threat of miscarriage up to 52%.

The risk is divided into the following subcategories:

- Pathological changes in the body of the expectant mother: diseases of the heart and blood vessels, asthmatic phenomena, kidney disease, diabetic manifestations.

- Low social factor: abuse of alcoholic beverages, tobacco and drug addiction, difficult physical working conditions, constant stress, unsatisfactory 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 and more common - habitual miscarriage, which is characterized by the recurrence of spontaneous miscarriage more than 3 times in a row. In world practice, out of 300 women, one will have this diagnosis. Often, a specialist in miscarriage already at the second consecutive interruption exposes this pathology as a diagnosis. The process of interruption itself is repeated at approximately the same period, 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 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 re-occurrence and subsequent impact on the ability to become pregnant and, subsequently, to bear a child.

The causes of recurrent miscarriage are multifactorial. These include:

- Disorders 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 opportunistic flora: gono- and streptococci gr. B, myco- and ureoplasm, chlamydia. And also, among them, various variations of the viral and bacteriological nature.

- Congenital pathologies of the uterus: bicorn, saddle-shaped, adhesions, additional septa, scars of any genesis, cervical-isthmus incompetence and multiple myomatosis. In this case, surgery is performed.

- Deviation of cartipation.

- 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 interfere with 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, the woman needs to plan and undergo examinations in advance. There are a number of specific techniques, they include:

- Determination of the constituent quantitative part of hormones responsible for reproduction - estradiol, progesterone, androgens, prolactin, DHEAS, testosterone, 17-OP, basal temperature measurement, hCG level. Bacterial sowing is carried out on flora from the cervical canal, determination of virological factors and diseases of the genital venereal sphere.

- Autoimmune analysis for antibodies (antibodies): phospholipid antibodies, antisperm antibodies, karyotype of a married couple, human leukocyte hypertension.

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

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

Causes of miscarriage

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

The factors are divided into emanating 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 (an increase in the recruitment to a full haploid one).

In a karyotypic study of a married couple, if any abnormalities are not detected, the probability of failure in subsequent cases of pregnancy is negligible - up to 1%. But, when identifying one of the pair, the risk increases significantly. If such a case occurs, genetic counseling and perinatal diagnostics are recommended. 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 provided anomaly. It is known that more than half of cases of miscarriage occurring specifically in the first trimester are caused by abnormalities in the 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 forming, and initially unviable 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 chromosomal abnormalities, provokes more than half of all pathological karyotypes. Its essence lies in the nondisjunction of the oocyte chromosomes during 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 abnormalities in it (thromboembolism, thrombosis, miscarriages, stillbirth, IUGR, early) are known in advance.

- 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 a single one and is highly debated in the scientific world. In addition, no single proven agent has been identified that provokes repeated miscarriages; the viral population prevails in the flora of the endometrium.

According to the data studied, persistent infections can independently trigger immunopathological processes, causing disruptions in the work of the whole organism. The viruses 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 interferes with the formation of local immunosuppression during the preimplantation interval, during the formation of a defense barrier and preventing the expulsion of a partly foreign fetus.

Often, placentitis develops along the way, with a thinning of the walls and leads to the insecurity 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. Chorionamnionitis develops due to exposure to prostaglandins with increased uterine contractions. Also when performing a diagnostic biopsy.

The state of the vaginal flora plays an important role, since it is the entrance gateway for infection into the uterine cavity, and is the leading cause of intrauterine infection.

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

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

Excess androgens are associated with increased testosterone production. adrenal is a genetically inherited abnormality. 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 maintain 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 the child. Divided into two subcategories:

When autoimmune - the response of aggression is directed to its own tissue antigens, in the blood 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, foreign to the mother's body, the response is disturbed and it will be directed against the antigens of the fetus.

That is, the groups of immunity breakdowns have been disclosed: in the humoral, associated with APS and cellular, the response of the maternal organism to the father's embryonic antigens.

- Organic defects of the genital area:

Acquired (ischemic-cervical insufficiency, or,).

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

The above-described deviations lead to the impossibility of introducing the abnormal uterine wall of the ovum, so that full development occurs.

With intrauterine septa, the risk of miscarriage is 60%, with adhesions - 58-80%, depending on the location. If 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 is enhanced, caused by a malnutrition of the nodes.

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 go into the cervical canal, and it is opened. This phenomenon is observed closer to the end of the gestation of a pregnant child, but it may appear slightly earlier.

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

5-6 weeks these are the genetic reasons.

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

10-15 weeks: immunological reasons.

15-16 weeks: ICI and infectious etiology.

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

28-37 weeks: infection, drainage of water, fetal distress syndrome, stress not associated with the gynecological area, autoimmune attacks, conditions in which the uterus is overstretched, uterine defects.

Symptoms of miscarriage

The symptom complex clearly does not manifest itself, which complicates the diagnosis of 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 increased bleeding or spotting drip outside of menstruation, without significant reasons.

- Spasmodic pains, poorly controlled by medications.

- Pain that spreads down to the pubic region, as well as radiating to the lumbar region, unstable, of a character 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 unreasonable, in the absence of infectious symptoms or other genesis.

- Alternating weakness, possibly nausea to vomiting.

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

Diagnosis of miscarriage

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

First of all, the life history of each applicant is scrupulously studied, the doctor notes: the number of previous pregnancies, their course, the presence of monitoring, the period of termination, the use of drugs, attempts to preserve and specifically applicable drugs, the available analyzes and their interpretation, the pathology of abortion.

Genealogical diagnostics is the collection of information to clarify causal and hereditary abnormalities. 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 has brothers and sisters, whether they are healthy or not. The incidence rate, the presence of chronic diseases, and the social standard of living are determined. A survey is conducted regarding the nature of menstruation, what was the beginning, their abundance and duration. Were there any diseases of an inflammatory nature and whether therapy was used, whether operations were performed in the gynecological sphere. And most importantly, the determination of the reproductive reproductive capacity 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, the reception of preventive preventive measures and the development of a protocol for the management of a pregnant woman.

Clinical examination is a general examination of the skin and mucous membranes, determining the type of physique, mass body index, whether there are, how pronounced are secondary sexual characteristics, examination for the appearance of stretch marks, listening to cardiac activity, studying liver parameters, measuring blood pressure, identifying signs of disorders metabolism, examine the breast 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 examine absolutely everything systematically.

The gynecological status is also determined: the state of the ovaries, ovulation processes according to the basal temperature and the calendar of menstruation, which is maintained by the woman. Determination of female body hair, neck size. Detection of existing warts, defects, hypoplasia, tumors, scars on the cervix. With this type of diagnosis, the following is carried out:

- Bacterial culture, urine analysis general and according to Nechiporenko, biochemistry and general blood analysis, 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 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 carriage, 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, examination of the concentration of the cervix for cytokines, biopsy with endometrial histology, bacteriological examination and PCR to confirm the presence of an infectious factor.

- Studying the hormonal background, the first priority is to determine the progesterone function, 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 correcting therapeutic doses of drugs is resolved in case of an inconsistent luteal stage and an imbalance of hormones is determined. For auxiliary purposes, groups of hormones of the adrenal glands, thyroid gland, ovaries, hypothalamus are examined.

- 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. A study of interferons is carried out to determine the personal sensitivity of lymphocytes to interferon inducers, an endometrial biopsy is performed, and the quantitative content of pro-inflammatory cytokines is determined.

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

- Genetic studies, mandatory for mature couples, recurrent miscarriages, stillbirth, lack of treatment effect. Includes genealogy described earlier and cytogenetic study - karyotyping to detect chromosomal abnormalities, analysis of abortion and karyotyping of neonatal death.

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

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

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

In addition, diagnostic measures are classified weekly:

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

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

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

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

The frequency of check-ups should be carried out every week, more often if necessary, with possible hospital follow-up.

Miscarriage treatment

If the miscarriage is complete and the uterine cavity is clean, then usually no special treatment is required. But, when the uterus is not completely cleansed, a curettage procedure is performed, which consists in carefully opening the uterus and removing the fetal remains or placenta. An alternative method is to take specific medications that force the contents of the uterus to be rejected, but it is applicable only in normal health, since then the costs of vitality are required to restore the body.

As of today, 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, 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, they use:

- Vitamin therapy. Especially Tocopherol (fat-soluble vitamin E, vitamin of life) 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 Coffee for neuromuscular blockades.

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

- Treatment, with an infectious genesis, depends on the microorganism that provokes the disease. They try to use sparing methods with the complete elimination of the pathogenic agent, these include immunoglobulin therapy, antibiotic therapy with the determination of individual sensitivity for a quick and effective resolution of the disease, interferon therapy - KIP-feron suppositories, Viferon suppositories, Betadin, Klion-D, iv human immunoglobulin or Octagam. Tocolytic therapy is applicable, which removes an 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, use biological products - Atsilak and Lactobacterin. If the indicators are normal, you can plan a pregnancy.

- Treatment of genetic abnormalities in partners with a congenital disease consists in carrying out a genetic consultation and subsequent treatment by the method, with a donor egg or sperm, depending on whom the abnormality was determined. An alternative is artificial insemination with your own cells, but with preimplantation genetic diagnosis.

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

- For the treatment of luteal phase insufficiency, progesterone is preferably used. The greatest efficiency in gestagens is Dyufaston 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 drugs should last up to 16 weeks. In the case of sensitization to progesterone, immunoglobulins and immunotherapy with the introduction of the spouse's lymphocytes are administered.

If the MRI study excludes the pathology of the sella turcica - pituitary adenoma, then therapy with Bromcriptine or Parlodelai is performed. With the concomitant pathology of the thyroid gland, add Levothyroxine sodium, continue after the onset of pregnancy.

The use of antispasmodics - Papaverine, No-shpa, herbal sedatives - Valerian's infusions, Magne B6 preparation is also applicable.

- In the treatment of antiphospholipid syndrome, which leads to placental thrombosis, antiaggregatory drugs are used - Heparin subcutaneously and Aspirin. They are especially effective with the simultaneous intake of vitamin D and Calcium, 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 it is desirable to use it in conjunction with low molecular weight heparin subcutaneously. The provided schemes are very dangerous for the woman and the fetus, but the AF syndrome itself deals a significant blow to the body. Another method is plasmapheresis, but it is also limited due to the individually significant effect. Plasmapheresis with a course of three sessions, consists in removing BCC 600-1000 ml of plasma per session and replacing it with rheological solutions, thus eliminating toxins, partly antigens, improving microcirculation, and decreasing increased coagulability.

- To normalize and prevent placental insufficiency, Actovegin, Piracetam, Infezol are used, mainly intravenously. With a threat, strict rest is needed, taking according to the scheme magnesium sulfate and hexoprenaline sulfate, fenoterol, NPP - Indomethacin, Nifedipine, Capronate hydroxyprogesterone. To relax the uterus, non-pharmacological agents are used - electro-relaxation and acupuncture.

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

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

Prevention of miscarriage

Prevention consists in an initially serious attitude towards the 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 the timely appointment of rehabilitation therapy.

There are basic principles for preventing miscarriage:

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

- Initial examination during pregnancy planning of 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, with the use of an intravaginal transducer in ultrasound examination, 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.

- Remediation 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 it is identified and it is impossible to avoid harmful consequences, the careful provision of information to the woman and the search for alternative individually selected methods of conception and childbirth.

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

Miscarriage is the spontaneous termination of pregnancy in the period from conception to 37 weeks, counting from the first day of the last menstruation. Spontaneous termination of pregnancy up to 28 weeks is called spontaneous abortion, from 28 to 37 weeks - premature birth. In a number of countries, according to the WHO proposal, termination of pregnancy in the period from 22 to 28 weeks is considered early preterm birth and perinatal mortality is calculated from 22 weeks. Habitual N.b. or habitual miscarriage, is called abortion in a row two or more times. The frequency of miscarriage is 10-25% of the total number of pregnancies.

What are the reasons for miscarriage?

N. etiology. varied. An important role is played by unfavorable socio-biological factors. So, premature termination of pregnancy is often observed in women whose work is associated with physical activity, vibration, noise, chemicals (dyes, benzene, insecticides). On the frequency N.b. factors such as the interval between pregnancies (less than 2 years), the amount of housework, the nature of family relationships, etc. also affect.

Genetically determined disorders of the development of the embryo (fetus), which can be hereditary or arise under the influence of various factors (infection, hormonal disorders, chemical, including some drugs, drugs, etc.) are the most common cause of miscarriage in the 1st trimester ... In 2.4% of patients with habitual N. b. show significant structural abnormalities of the karyotype (10 times more often than in the population). Along with obvious chromosomal abnormalities in women with habitual N. b. and their spouses often reveal the so-called chromosomal variants, which can cause a genetic imbalance in the embryo and lead to spontaneous abortion.

Early miscarriage

In the etiology of spontaneous abortion in the 1st trimester, hormonal disorders in the woman's body play an important role - most often, the insufficiency of the corpus luteum and an increase in the production of androgens of various origins. For N. b. usually characterized by erased forms of hormonal disorders that appear only during pregnancy. Endocrine diseases (for example, diabetes mellitus, dysfunction of the thyroid gland or adrenal cortex) complicate the course of pregnancy and often lead to its termination. In some cases N.b. due to a violation of the receptor apparatus of the endometrium; most often it occurs in patients with malformations of the uterus, genital infantilism, chronic endometritis.

Among the reasons N.b. one of the first places is occupied by infectious and inflammatory diseases of a pregnant woman, primarily latent ones: pyelonephritis, infections caused by cytomegalovirus, herpes simplex virus, etc. Abortion is often observed in acute infectious diseases: viral hepatitis, rubella, influenza, etc.

The literature discusses the importance of immunological causes of N. b. If not long ago spontaneous abortion was assessed as a hyperimmune reaction of the maternal organism, then at present, termination of pregnancy is considered as an immunodeficiency state in which reduced immunological reactions of the maternal) organism cannot provide the necessary level of immunosuppression to form the blocking properties of serum and protect the embryo (fetus) from immune mother's aggression. This condition can be caused, on the one hand, by a violation of placentation processes and a decrease in trophoblast function, on the other hand, by the incompatibility of the organisms of the mother and the fetus with respect to the antigens of the HLA system. The pathology of miscarriage can also be associated with autoimmune processes, for example, with antiphospholipid syndrome, the appearance of antinuclear antibodies, antibodies to cardiolipins.

Second trimester miscarriage

One of the most common causes of termination of pregnancy in the second trimester is isthmic-cervical insufficiency due to structural and (or) functional changes in the isthmic part of the uterus. Structural changes are often the result of previous curettage of the mucous membrane of the cervical canal and the body of the uterus, ruptures of the cervix, pathological childbirth; they are especially dangerous in women with malformations of the uterus, genital infantilism. Functional cervical insufficiency is a consequence of disturbances in the response of the structural elements of the cervix to neurohumoral stimuli. Frequent causes of abortion are uterine fibroids, uterine malformations, intrauterine synechiae (adhesions). With extragenital diseases of the mother (primarily diseases of the cardiovascular system, chronic diseases of the kidneys, liver), premature births often occur.

Premature birth in the third trimester

Termination of pregnancy in the II and III trimester is often caused by complications associated with pregnancy: toxicosis that occurs in the second half of pregnancy, anomalies of attachment and premature placental abruption, abnormal fetal position, multiple pregnancy, polyhydramnios, etc.

Miscarriage treatment

N.'s treatment. effective on condition of a thorough and comprehensive examination of the married couple outside of pregnancy (since during pregnancy in almost half of the cases it is not possible to identify the reason for its termination). The examination can be carried out in the antenatal clinic, the "Family and Marriage" consultation, and in the diagnostic centers. Examination outside of pregnancy is necessary to establish the cause of N. b.

Prevention of miscarriage

The examination of a woman begins with the collection of anamnesis, special attention is paid to information about past illnesses, the menstrual cycle, and fertility. Anamnesis, general examination data (the nature of the physique, body hair) and the results of a gynecological examination help to suggest the reasons for N. and outline a plan for further examination, which includes carrying out functional diagnostic tests (recording during three menstrual cycles); metrosalpingography on the 20-24th day of the menstrual cycle, which makes it possible to exclude isthmic-cervical insufficiency, uterine malformations, intrauterine synechiae; ultrasound examination with registration of the size of the uterus, ovaries and determination of the structure of the ovaries; bacteriological examination of the contents of the cervical canal; determination of the excretion of 17-ketosteroids. Assessment of the husband's health is mandatory, incl. examination of his semen.

If, after the examination, the reason N. not detected, it is necessary to determine the content of testosterone, lutropin, follitropin, prolactin and progesterone in the woman's blood (on the 7-8th day and 21-23rd day of the menstrual cycle) to exclude latent forms of hormonal deficiency. With an increase in the excretion of 17-ketosteroids, a dexamethasone test is indicated to determine the source of androgen overproduction. In cases of early termination of pregnancy, stillbirth, fetal malformations, medical and genetic counseling is necessary. If an infectious genesis is suspected, N. carry out studies aimed at identifying mycoplasmas, chlamydia, toxoplasma, viruses in the contents of the vagina, cervical canal and urethra.

Unfortunately, pregnancy does not always end with the birth of a child at the time set by nature. In such cases, we are talking about miscarriage.

The urgency of this pathology is very high both in the obstetric sense and in the socio-economic sense. Miscarriage causes a decrease in fertility, causes psychological and physiological trauma to a woman, and leads to conflict situations in the family. Despite a lot of scientific research on the causes of occurrence, treatment and prevention, miscarriage is still the most important problem of modern obstetrics.

Terminology

In official language, miscarriage is its self-termination at any time from the moment of conception to 36 weeks and 6 days. Based on the gestational age at which the pregnancy was terminated, the following types of miscarriage are distinguished:

• Miscarriage or spontaneous abortion - up to 21 weeks and 6 days.
• Premature birth - 22–37 weeks.

Spontaneous abortion happens:

• Early (up to 12 weeks gestation).
• Late (13 to 22 full weeks).

In addition, miscarriage also includes the termination of the development of the fetus with its subsequent death at any time - a frozen or undeveloped pregnancy.

When the pregnancy is prematurely terminated two or more times, this condition is called "recurrent miscarriage."

Statistics

The frequency of miscarriage is not that low - about a quarter of pregnancies end prematurely. In addition, embryo rejection can occur even before the onset of the next menstruation (in such cases, a woman may not even be aware of the existence of pregnancy), therefore, the incidence of miscarriage is much more frequent.

Most often, pregnancy is terminated during the first months - in 75–80% of cases. In the second trimester, the frequency of spontaneous abortion decreases to about 10-12% of cases, and in the third - about 5-7%.

Habitual miscarriage is usually caused by a serious impairment of female fertility and occurs in about 20-25% of all spontaneous interruptions.

Main reasons

The factors causing the disruption of the normal course of pregnancy are very numerous and varied. In most cases, the development of this pathology is influenced by several reasons at once, which either act simultaneously or join over time.

The main causes of miscarriage can be grouped into several groups, which will be discussed in detail below:

• Endocrine.
• Anatomical and functional disorders of the female genital organs.
• Complicated pregnancy (for example, placental insufficiency).
• The negative effect of external factors.
• Infection.
• Immunological.
• Genetic.
• Extragenital pathology (acute and chronic somatic diseases of the mother).
• Injuries, surgical interventions during pregnancy of any localization (especially in the abdomen and genitals).

In about one in three women, it is not possible to diagnose the exact cause of spontaneous abortion.

The high frequency of fetal loss during the first three months of gestation is due to a kind of "natural selection", since about 60% of it is caused by genetic causes (chromosomal abnormalities of the embryo, which are often incompatible with life). In addition, during these periods, the embryo, due to the lack of protection (the placenta, which is fully formed at 14-16 weeks), is more susceptible to the negative damaging influence of external factors: infection, radiation, etc.

In later stages, a violation of pregnancy is usually due to its complicated course or anatomical defects of the uterus (for example, isthmic-cervical insufficiency).

Infection

The leading role in the development of miscarriage is played by an infectious factor with concomitant inflammatory diseases of the internal genital organs and the ovum (its membranes and placenta).

The causes of an infectious and inflammatory process can be a variety of pathogenic bacteria and viruses, for example:

• Chlamydia.
• Myco- and ureaplasma.
• Herpes.
• Toxoplasma.
• Cytomegalovirus.
• Rickettsia.
• Trichomonas.
• Enteroviruses.
• Rubella, chickenpox viruses and some others.

Primary infection is most dangerous during pregnancy, especially in its first three months. In these cases, serious damage to the embryo often occurs, which often ends with its death and, accordingly, termination of pregnancy.

At a later date, the influence of infection can also cause damage to the fetus and amniotic membranes. In this case, chorioamnionitis often develops, which is manifested by low or polyhydramnios, premature rupture of the membranes, etc. All this can contribute to the termination of pregnancy.

An important role is also assigned to opportunistic flora (UPF), which can manifest its negative properties against the background of physiological immunosuppression (decrease in general and local immunity) in a pregnant woman. In addition, during miscarriage, the presence of several infectious pathogens (associations of microorganisms) is quite common.

Infection into the uterine cavity can penetrate in several ways, the main of which are:

• Hematogenous - with blood flow.
• Ascending (through the cervical canal from the vagina) is the most frequent.

Sources of penetration of the infectious agent into the uterine cavity are often any acute and chronic inflammatory processes localized both in the genital area and outside them.

Chronic endometritis

Almost 70% of women suffering from recurrent miscarriage are diagnosed with chronic inflammation of the endometrium (endometritis), which is often caused by the persistence (prolonged stay in the body) of various microorganisms. In more than half of these patients, endometritis is caused by UPF or its combination with a viral infection. Moreover, in most of these women, the course of the inflammatory process in the uterus is practically asymptomatic.

Predisposing factors for the formation of chronic endometritis are endometrial trauma during intrauterine interventions (for example, curettage of the uterine cavity). A decrease in general and local immunity during pregnancy (aimed at the possibility of carrying it) also creates the prerequisites for the activation of a "dormant" infection and the formation of an inflammatory process in the uterus.

Endocrine Disorders

Hormonal dysfunction of any origin, as the cause of spontaneous abortion, occupies one of the leading positions. Especially often such hormonal disorders are detected:

• Insufficiency of the luteal phase (hypofunction of the ovaries).
• Hyperandrogenism.
• Disruption of the thyroid gland.
• Diabetes.

The most common are ovarian hypofunction and hyperandrogenism. Let's consider these endocrine disorders in more detail.

Ovarian hypofunction

As you know, normally the ovaries synthesize the most important female sex hormones: estrogen and progesterone. Their production is carried out through a complex chain of biochemical reactions, controlled by the brain. Therefore, when a reduced level of female hormones is detected, malfunctions can be at any level: from the hypothalamus to, in fact, the ovaries.

The influence of female sex hormones during pregnancy can hardly be overestimated. Their action begins long before conception: they affect the process of maturation and release of the egg, prepare the uterine lining for implantation, etc. During pregnancy, estrogens control blood flow in the uterus, increase its functional activity, prepare the mammary glands for subsequent lactation. Progesterone keeps the uterus at rest, thereby promoting pregnancy. And this is far from all the types of effects of sex hormones on the female body.

What contributes to the development of ovarian hypofunction:

• Diseases transferred by the mother - various infections, irrational treatment with hormones, some somatic pathology, etc.
• Pathological childbirth and abortion in the past.
• Disruption of the normal maturation of the reproductive system in the pre- and pubertal period.
• Infectious and inflammatory diseases, especially chronic ones.

In this condition, a decrease in the synthesis of estrogen and, to a greater extent, progesterone is often detected. This leads to an increase in the contractile activity of the uterus and abortion in the first trimester. With its progression, insufficient functioning of the placenta is often revealed, which often leads to a delay in the intrauterine development of the fetus, its hypoxia and contributes to premature birth.

Hyperandrogenism

Normally, in all women, male sex hormones (androgens) are produced in small quantities by the ovaries and adrenal glands. Their increased synthesis is called hyperandrogenism. According to the predominant localization of pathological androgen synthesis, it happens:

• Adrenal.
• Ovarian.
• Mixed.

An increase in the level of androgens of any genesis is accompanied by a decrease in the content of progesterone.

The effect of hyperandrogenism on pregnancy is accompanied by the following manifestations:

• Spasm of the vessels of the utero-chorionic and uteroplacental space. This leads to an early disorder of blood flow in these areas, the formation of placental insufficiency, followed by a delay in fetal development (up to its death).
• An increase in the contractile activity of the uterus, which may result in miscarriage or premature birth.
• Contribute to the formation of isthmic-cervical insufficiency.

Increased or insufficient synthesis of thyroid hormones (hyper- or hypothyroidism) has the most direct effect on the course of pregnancy. Uncompensated dysfunction of this endocrine organ often leads to severe complications:

• Intrauterine fetal death.
• Stillbirth.
• Preeclampsia and others.

All this can ultimately lead to spontaneous abortion at any gestational age.

Anatomical and functional disorders

Almost the entire development cycle, from the first weeks of gestation to the moment of delivery, the unborn child passes in the so-called fetus - the uterus. Accordingly, various violations of its anatomical structure or functional state do not have the most favorable effect on the possibility of normal pregnancy.

The most common anatomical and functional disorders of the uterus include:

• Defects (anomalies) of its development - two-horned, saddle-shaped, one-horned. In addition, sometimes complete or incomplete doubling of the body or even the entire uterus is diagnosed. Sometimes, outwardly, the uterus has an anatomically correct shape and size, and a connective tissue or muscular septum is found in its cavity - partial or complete.
• Asherman's cider. This is an acquired anatomical defect of the uterus, in which so-called synechiae, or adhesions, of varying severity, are formed in its cavity. The most common reason for the formation of this condition is repeated intrauterine interventions, for example, curettage of the uterine cavity.
• Submucous (submucous) uterine leiomyoma.
• Internal endometriosis or adenomyosis.
• Isthmico-cervical insufficiency.

All of the above abnormalities directly affect the possibility of carrying a pregnancy. So, in case of unsuccessful implantation of a fertilized egg on the septum of the uterine cavity or near the submucous node, a violation of the normal blood supply to the embryo occurs, which soon dies. In addition, the presence of leiomyoma and / or adenomyosis is often accompanied by various hormonal disorders (luteal phase insufficiency), which aggravate the course of pregnancy.

With anatomical defects of the uterus, pregnancy is usually terminated in the second or third trimester. And in case of severe pathology - and in the first.

Isthmic-cervical insufficiency

The frequency of this pathological condition is quite high - about every fifth woman with a habitual loss of pregnancy is diagnosed with cervical incompetence. Loss of pregnancy usually occurs in the second trimester.

The cervix is ​​normally in a closed state almost until the very term of delivery. With isthmic-cervical insufficiency (ICI), there is a gaping of the internal (and often external) pharynx, accompanied by a gradual decrease in the length of the neck itself. Inconsistency of the cervix develops, and it ceases to perform its functions.

There are certain risk factors for the development of ICI:

• Traumatization of the cervix and cervical canal in the past. This can occur during abortion, pathological childbirth (rupture of the cervix at the birth of a large fetus, the use of forceps and some other conditions). In addition, some types of surgical interventions for correcting pathologies of the cervix, for example, conization or amputation, often lead to ICI.
• Congenital incompetence of the cervix.
• Functional ICN. The reason for its development in such cases is various endocrine disorders, for example, hyperandrogenism.
• Pathological course of pregnancy with multiple pregnancy, large fetus, polyhydramnios.

The main symptom of ICI is the gradual shortening of the cervix followed by the opening of the internal os. This process is most often not accompanied by any sensations, such as pain. Subsequently, there is a protrusion of the fetal bladder through the "opened" cervix into the vagina and rupture with the outflow of amniotic fluid. In the future, a miscarriage or premature birth occurs (in this case, the child is often born deeply premature).

Chromosomal abnormalities

Violations of the chromosomal set of the embryo usually lead to a stop of its further development and death. This is the reason for the termination of pregnancy (miscarriage), which usually occurs in the first few months of gestation. According to statistics, the cause of more than 70% of spontaneous abortions up to eight weeks is precisely a genetic anomaly.

You need to know that in the overwhelming majority of cases, chromosomal abnormalities detected in the embryo are not hereditary. The reason for their formation is failures in the process of cell division under the influence of external or internal factors. This can occur both at the stage of formation of germ cells in both parents and in the process of zygote division (early stages of embryo development). Examples of such factors include:

• Elderly age of future parents.
• Alcoholism.
• Addiction.
• Unfavorable working conditions (usually in industrial enterprises), etc.

After one spontaneous abortion caused by chromosomal abnormalities in the embryo, the subsequent pregnancy usually ends normally.

If there are several such cases, compulsory consultation of the married couple by a medical geneticist is required to identify hereditary pathology.

Placental insufficiency

Disruption of the normal functioning of the placenta or placental insufficiency (FPI) plays an important role among the causes of miscarriage. In this pathological condition, almost all functions of the placenta are violated, for example, transport, nutritional, endocrine. As a result, the fetus does not receive enough nutrients, oxygen, the hormonal activity of the placenta is disrupted, etc. All this ultimately leads to the following consequences:

• Intrauterine fetal malnutrition (developmental delay).
• Decreased functional activity of the fetus.
• Hypoxia (oxygen starvation), which can be acute or chronic.
• Premature placental abruption.
• Placental infarction.
• Increase in the incidence of morbidity and mortality in the newborn child.

Many factors lead to the development of FPI. Examples include:

• Chronic infectious pathology.
• Dysfunction of the endometrium (for example, previous intrauterine manipulations during abortion, miscarriages).
• Endocrine Disorders.
• Complicated pregnancy: the threat of termination of pregnancy, preeclampsia, multiple pregnancy, immunological incompatibility, etc.
• Extragenital diseases in the mother: chronic pyelonephritis, hypertension, diabetes mellitus, pathology of the blood and coagulation system, and many others.

Also, a combination of reasons that provoke the development of placental insufficiency is often noted.

The most unfavorable is FPN, which develops in the early stages (up to 16 weeks of pregnancy). It is in such cases that the pregnancy is terminated most often.

Extragenital pathology and external factors

The presence of any acute and chronic somatic diseases in the mother, the influence of external (exogenous) causes, trauma, surgical interventions directly affect the course of pregnancy.

The risk of premature termination of pregnancy increases significantly with severe pathology of the kidneys, heart and lungs, some autoimmune diseases (for example, systemic lupus erythematosus). In addition, such diseases can be a threat to the life of the woman herself.

An association of inflammatory bowel diseases with an increase in the incidence of preterm birth has been noted.

Among external factors, the following have the greatest influence on the normal course of pregnancy:

• Bad habits: alcohol, smoking, drugs, caffeine.
• Stress.
• Work in hazardous production. The toxic effects of ionizing radiation, lead, mercury and some other compounds are proven reasons for the possible termination of pregnancy and its unfavorable course.

Injuries sustained by the mother during pregnancy (especially the abdomen and genitals) can have the most direct impact on the possibility of miscarriage or premature birth.

Immunological factors

Among all the reasons that have a negative impact on fertility, approximately 20% are due to immunological conflicts.

The principle of the human immune system is built in such a way as to reject and, if possible, destroy all foreign cells that enter the body. During conception, a female egg is fertilized by a sperm, which, in fact, carries foreign information. Accordingly, the unborn child will have the chromosome set of both the mother and the father.

For the body of a pregnant woman, the fetus is a foreign substance. However, for the normal bearing of pregnancy, evolutionarily established mechanisms for overcoming tissue incompatibility between the body of the mother and the fetus are included. Violation of these mechanisms leads to immune conflict.

The most studied are such immunological conflicts:

• Isosensitization for the Rh factor or the ABO system (blood group).
• Antiphospholipid syndrome (APS).
• Autosensitization to chorionic gonadotropin.

The immunological factors of miscarriage are still insufficiently understood.

Isosensitization

It is formed when the mother and fetus are incompatible with various erythrocyte antigens.

It is known that each person has a certain blood group. Currently, four of them are known: O (I), A (II), B (III), AB (IV). In addition, the Rh factor is also determined, which in its essence is a special protein contained in erythrocytes. A person can be Rh-positive (determined by the Rh factor) or Rh-negative.

For isosensitization to occur during pregnancy, there must be two conditions:

• Penetration of fetal blood into the mother's bloodstream.
• The presence of special cells in the maternal blood - antibodies.

Isosensitization by ABO is formed when the fetal blood, which has a different blood group, enters the mother's bloodstream. Most often, an immune conflict occurs with the first blood group in the mother, and the second or third in the fetus.

Rh-conflict pregnancy can develop in the absence of the Rh factor in the mother (Rh-negative blood type) and in the presence of it in the fetus (inherited from the father).

Throughout pregnancy, there is constant contact between the circulatory system of the mother and the fetus. However, even with a difference in blood group or Rh factor, isosensitization does not always occur. This requires the presence of special cells in the mother's bloodstream - antibodies. There are Rh antibodies and group antibodies (alpha and beta). When these antibodies combine with antigens (receptors on the surface of "foreign" fetal erythrocytes), an immune response and isosensitization occurs.

Risk factors and manifestations

There are certain factors that increase the risk of Rh and group antibodies. These include:

• The presence in the past of pregnancy with a fetus with a Rh-positive type or with a blood group other than the maternal. In this case, the outcome of such a pregnancy does not matter: childbirth, abortion, miscarriage, ectopic.
• Pathological childbirth - cesarean section, manual examination of the uterine cavity.
• Blood transfusion.
• Administration of vaccines and serums based on blood components.

It was found that each subsequent pregnancy with a Rh-positive fetus in women with a negative Rh factor increases the risk of isosensitization by 10%.

The most difficult are immune conflicts for the Rh factor. Moreover, all the negative consequences of such a pathology are reflected exclusively in the unborn child. The severity of manifestations depends on the level of Rh antibodies in the mother's body. In especially severe cases, fetal death occurs, followed by miscarriage. If the pregnancy progresses, the so-called hemolytic disease of the fetus may develop, and then the newborn. It is characterized by severe damage to almost all systems and organs of the baby (especially the central nervous system suffers). The birth of such a child may be premature.

Antiphospholipid syndrome (APS)

It is an autoimmune condition in which a woman's body produces antibodies to the endothelium (inner lining) of her own vessels. As a result, their damage occurs, which triggers a cascade of various biochemical reactions. This leads to an increase in blood clotting ability and, ultimately, to the development of thromboembolic complications (the formation of blood clots in small and large vessels).

The reasons for the appearance of such antibodies have not yet been identified. There are studies on the role of certain viruses and their effect on lymphocytes as one of the links of the immune system.

According to statistics, APS is detected in almost 40% of women with recurrent miscarriage. Its interruption occurs more often in the second or third trimesters. Naturally, the gestational age decreases with each subsequent terminated pregnancy.

The main manifestations of APS during pregnancy:

• Dysfunction of the placenta (fetoplacental insufficiency) due to multiple microthrombosis of the placental vessels. As a result, intrauterine growth retardation of the fetus develops, its hypoxia up to death.
• Lots or low water.
• Premature rupture of membranes.
• Complications of the course of pregnancy: preeclampsia, eclampsia, HELLP syndrome, etc.
• Premature detachment of a normally located placenta.

Even at the birth of a full-term baby, he may develop various pathological conditions that significantly worsen the course of the neonatal period and may even lead to death (hyaline membrane syndrome, cerebrovascular accident, respiratory disorder syndrome, etc.).

To diagnose this serious pathology, a number of diagnostic tests are used, the leading of which is the determination of specific antibodies (anticardiolipin and antiphospholipid).

Prophylaxis

Prevention of miscarriage is, first of all, to the competent approach of future parents to the birth of offspring. For this purpose, a number of activities have been developed, which is called "pre-conceptional preparation". To reduce the risk of problems with conception and subsequent gestation, a married couple is advised to:

• Pass an examination to identify abnormalities in both the somatic and reproductive spheres.
• It is imperative to maintain a healthy lifestyle: giving up bad habits, minimizing the influence of environmental factors (for example, occupational hazards), avoiding stress, etc.
• If any foci of infection are detected, they should be sanitized.

If a woman has already had cases of termination of pregnancy at any time, it is necessary to find out the possible reasons for this as fully as possible and carry out the necessary correction. A gynecologist is engaged in the treatment of this pathology, with the possible involvement of doctors of other specialties, depending on the violations identified.