Recurrent miscarriage: causes, risks, prevention and what to do. Causes of miscarriage

Miscarriage is the spontaneous termination of pregnancy before 37 weeks. Termination of pregnancy before 22 weeks is called spontaneous abortion (miscarriage), and within 28-37 weeks -

premature birth. The periods from 22 to 28 weeks are especially highlighted, termination of pregnancy during which abroad is classified as childbirth, and in our country - as late abortion if the child is born stillbirth. If a fetus born during these gestational periods survives for 7 days, it is registered as a live-born child.

Termination of pregnancy can be artificial: up to 28 weeks - induced abortion, after 28 weeks - artificially induced premature birth. Depending on the stage of pregnancy, abortion is distinguished in the early stages (up to 12 weeks) and in the late stages (from 13 to 27 weeks). In addition to spontaneous and artificial abortion, there are failed, criminal and septic abortions. The concept of habitual miscarriage is also distinguished.

SPONSORY ABORTION

Spontaneous abortion (miscarriage) occurs in 15-20% of all wanted pregnancies. It is believed that it is not included in the statistics big number termination of pregnancy in very early stages.

Many researchers believe that spontaneous miscarriages in the first trimester are a manifestation of natural selection, since when studying abortion material, up to 80% of embryos have chromosomal abnormalities.

The causes of spontaneous miscarriages cannot always be identified, since they are often mixed. The main reasons are considered social factors: bad habits; exposure to unfavorable production factors (chemical agents, being in a room with high temperature or vibration, etc.); medical factors: congenital pathology of the embryo/fetus; malformations of the uterus; endocrine disorders; infectious diseases; previous abortions; pregnancy after IVF, etc.

Spontaneous termination of pregnancy begins either with contraction of the uterus followed by detachment of the ovum, or with the onset of detachment ovum from the walls of the uterus, which is then joined by contraction of the uterine muscles. Sometimes these two mechanisms act simultaneously.

There are threatened abortion, in progress abortion, incomplete abortion, failed abortion, infected abortion and habitual abortion.

Threatened abortion- increased contractile activity of the uterus; the fertilized egg remains connected to the wall of the uterus.

Clinically, threatened abortion is manifested by a feeling of heaviness or nagging pain in the lower abdomen and in the sacral region. There is no bleeding. During vaginal examination, the cervix is ​​preserved, the external pharynx can let the tip of the finger through, the internal pharynx is closed, the tone of the uterus is increased. The size of the uterus corresponds to the duration of pregnancy.

Abortion in progress- detachment of the fertilized egg from the wall of the uterus. Blood discharge appears during uterine contractions, cramping pain in the lower abdomen and lumbar region. A vaginal examination determines that the cervix is ​​intact, its external os is closed or slightly open, and the size of the uterus corresponds to the gestational age.

In case of threatened and ongoing abortion, the pregnancy test (b-CG) is positive. An ultrasound reveals a fertilized egg in the uterine cavity, and a detachment of the chorionic membrane is visible.

Threatened and ongoing abortion should be differentiated from malignant or benign diseases of the cervix and vagina, which are diagnosed by careful examination in the speculum. If necessary, colposcopy or tissue biopsy is performed. Bloody discharge after a delay in menstruation may be due to menstrual irregularities, but there are no signs of pregnancy. It is not always easy to distinguish an interrupted tubal pregnancy from an abortion that has begun during early pregnancy. Diagnosis is aided by ultrasound, which reveals the location of the fertilized egg. Sometimes it is necessary to resort to laparoscopy for diagnosis (see Chapter 19 “Ectopic pregnancy”).

Treatment threatened and initiated abortion, in agreement with the patient, can be aimed at preserving the pregnancy. Treatment includes bed rest, sedatives, antispasmodics, vitamin E. Non-drug and physiotherapeutic treatment methods can be used: acupuncture, electroanalgesia, endonasal galvanization, etc. For late threatened miscarriage (after 20 weeks), b-adrenergic agonists are used.

When an abortion has begun, the treatment is basically the same as for a threatened one. Additionally, etamsylate (dicinone) and ascorutin are prescribed. In case of hormonal dysfunction, appropriate correction is carried out under the control of hormone levels. In women with a threat of miscarriage due to hyperandrogenism, corticosteroids are used under the control of DHA-S values ​​​​in the blood and 17-KS in the urine. In case of insufficiency of the corpus luteum in the first trimester, gestagens are prescribed. If amniotic fluid leaks in the early stages of pregnancy, it is not advisable to maintain it.

Abortion in progress- the fertilized egg completely exfoliates from the wall of the uterus and descends into its lower sections, including cervical canal.

The patient complains of cramping pain in the lower abdomen and severe bleeding. A fertilized egg is detected in the cervical canal, the lower pole of which can protrude into the vagina. Abortion in progress can result in incomplete or complete abortion.

At incomplete abortion after the expulsion of the fertilized egg, its remains are found in the uterine cavity, usually the membranes and parts of the placenta (according to ultrasound). A pregnancy test (b-CG) may be positive.

Two-handed examination indicates dilatation of the cervix, which freely allows a finger to pass through. Soft tissue may be found in the cervix - the remains of the fertilized egg. The size of the uterus is smaller than that for a certain stage of pregnancy. Blood discharge varies in intensity.

Treatment consists of instrumental removal of the fertilized egg, curettage of the uterine mucosa.

The remnants of the fertilized egg are removed with an abortion force and a large curette without dilating the cervical canal. The uterine mucosa is scraped out first with a large curette, and then with a sharper small curette (No. 5-6). This part of the operation corresponds to surgical intervention for artificial termination of pregnancy (see Chapter 31 “Obstetric operations”).

For minor bleeding from the uterus, a vacuum aspirator can be used. At the same time, measures are taken to enhance uterine contractions and stop bleeding (5-10 units of oxytocin intravenously), as well as to restore blood loss (crystalloids, fresh frozen plasma intravenously). After surgery, broad-spectrum antibiotics are prescribed to prevent infection. Patients with Rh-negative blood without antibodies require administration of anti-Rhesus gamma globulin.

Complete abortion consists in the complete expulsion of the fertilized egg from the uterus. In practice, such a condition is possible only after the formation of the placenta - at 12-13 weeks of pregnancy. Before this period, there is no confidence in the complete emptying of the uterus.

On vaginal examination, the cervix is ​​formed, the uterus is either of normal size or slightly enlarged. The discharge is bloody. On ultrasound, the uterine cavity is slit-like. b- HCG is not detected in the blood. You can never be sure of spontaneous complete emptying of the uterus; an instrumental examination (with a small curette) of the inner surface of the uterus should be performed. After 14-15 weeks of gestation and confidence in the integrity of the placenta, uterine curettage is not recommended.

After an abortion, women with Rh-negative blood without antibodies need to be given anti-Rh gamma globulin.

MISSORIARRY (NON-DEVELOPING PREGNANCY) Sometimes a pregnancy stops developing for no apparent reason, the embryo or fetus dies without signs of termination of pregnancy. This is a failed abortion ( missed).

abortion A dead fertilized egg can remain in the uterus sometimes for more than a month, undergoing necrosis and maceration. On early stages

During gestation, its autolysis is sometimes observed. In some cases, mummification and petrification of the embryo or fetus occurs. Due to a violation of the neurohumoral regulation of the reproductive system, uterine contractions may be absent. Clinical manifestations: dubious signs

pregnancies disappear; the uterus is smaller than it should be according to the period of delay of menstruation; Ultrasound does not detect the fetal heartbeat; spotting and bleeding is possible.

If the fertilized egg is retained for a long time in the uterine cavity, it is necessary to examine the hemostatic system, determine the blood type and Rh status, and also have everything necessary to stop coagulopathic bleeding. If the pregnancy is up to 14 weeks, immediate removal of the fertilized egg is possible (preferably by vacuum aspiration). To remove a dead fetus in the second trimester of pregnancy, the following methods can be used: injection of kelp into the cervical canal, oxytocin intravenously, prostaglandin F2a (dinoprost) intravenously or intraamnially. It is advisable to use prostaglandin gel (dinoprostone) intravaginally.

SEPTIC ABORTION

Infected abortion can be combined with inflammation of the uterine appendages (adnexitis), parametrium (parametritis) and generalized inflammation (sepsis).

The clinical picture of septic abortion is expressed in increased body temperature and chills. At gynecological examination the cervix, as a rule, misses the tip of the finger, the uterus is somewhat enlarged, soft, and painful. The discharge is purulent.

Septic abortion is an indication for aspiration of tissue from the uterus and washing it. If there is no effect, extirpation of the uterus and tubes is performed. General treatment is carried out in the same way as for sepsis of any origin (see Chapter 31 “Postpartum purulent-septic diseases”).

Habitual miscarriage

Habitual miscarriage- two miscarriages or two or more premature births in the anamnesis.

The causes of recurrent miscarriage are multifactorial. These include:

Endocrine disorders: various shapes hyperandrogenism, hyperprolactinemia, luteal phase deficiency;

Infections, the causative agent of which can be persistent viruses (coxsackie A, B, HSV I, II, CMV), opportunistic pathogens (mycoplasma, chlamydia, ureaplasma, group B streptococci), pathogenic microorganisms (Trichomonas, gonococci) or various combinations of bacterial and viral associations . The influence of the infectious agent is the development of not only intrauterine infection, but also chronic endometritis with damage to the uterine receptors;

Autoimmune disorders, such as antiphospholipid syndrome or the presence of antibodies to hCG, antisperm antibodies, HLA compatibility of spouses;

Uterine pathology: malformations of the uterus (saddle-shaped, bicornuate), intrauterine synechiae and septa, multiple uterine fibroids, scars on the uterus after myomectomy, especially with the placenta located in the area of ​​the postoperative scar, isthmic-cervical insufficiency;

Genetic factors (karyotype abnormalities);

Congenital defects of hemostasis (deficiency of antithrombin III, protein C, protein S, factor V mutation, prothrombin gene mutation G20210A, hyperhomocysteinemia).

Most etiological factors of miscarriage can disrupt the migration of cytotrophoblast into the spiral arteries, preventing the physiological formation of the placenta and contribute to damage to the embryo and fetus with subsequent termination of pregnancy.

Patients with recurrent miscarriage should be examined before planned pregnancy. In doing so, they examine:

Bacteriological and virological status (culture of flora from the cervical canal, markers of sexually transmitted diseases - STDs);

Antibodies to phospholipids, lupus anticoagulant, antisperm antibodies;

Karyotype of spouses, HLA typing;

Hemostasis with determination of its congenital defects.

In order to exclude anatomical changes in the internal genital organs, ultrasound scanning, hysteroscopy, and salpingography should be performed. According to indications, endometrial biopsy and laparoscopy are performed.

Therapeutic measures In cases of recurrent miscarriage, it is advisable to carry out this procedure before pregnancy. At the same time, the dominant etiological factor of miscarriage is eliminated.

In case of reproductive dysfunction of endocrine etiology, adequate hormonal correction is carried out.

To determine the tactics of preparing for pregnancy in patients with hyperandrogenism, the source of androgen expression is clarified.

At hyperproduction of adrenal androgens glucocorticoid therapy is carried out in individually selected doses (dexamethasone 0.25-0.5 mg/day) under the control of 17-OPK, DHEAS and functional diagnostic tests for 2-3 months.

At ovarian in the form of hyperandrogenism, drugs that have an antiandrogenic effect are used (Diane-35 from the 5th to the 25th day of the menstrual cycle, Androcur 10 mg from the 1st to the 10th day of the cycle) for 3 months. If there is no effect, ovulation stimulation is used with clostilbegide or clomiphene citrate at a dose of 50 mg from the 5th to the 9th day of the menstrual cycle for no more than three cycles in a row.

Preparing for pregnancy in patients with mixed a form of hyperandrogenism begins with a decrease in body weight, normalization of lipid and carbohydrate metabolism. At normal level glucose, insulin, lipids, it is advisable to prescribe gestagens (duphaston, utrogestan) in the second phase of the cycle while taking dexamethasone (0.25-0.5 mg/day), followed by stimulation of ovulation with clostilbegide.

Patients with luteal phase deficiency in preparation for pregnancy cyclic hormonal therapy is carried out with combined gestagen-estrogen drugs (Femoston, Regulon, Silest from the 5th to the 25th day of the cycle for 2-3 months). During the treatment period, ovulation is inhibited, and when the drug is discontinued, a rebound effect is observed - ovulation and full development of the corpus luteum, which ensures secretory transformation of the endometrium and its preparation for embryo implantation. If there is no effect, ovulation stimulation is used with clostilbegide or clomiphene citrate at a dose of 50 mg from the 5th to the 9th day of the cycle for no more than three cycles.

Hyperprolactinemia corrected by prescribing parlodel or bromocriptine in individually selected doses (2.5-5 mg), monitoring the level of prolactin in the blood serum and conducting functional diagnostic tests for 3-6 months.

In case of miscarriage infectious origin With clinical manifestations mixed urogenital infection requires the combined use of antibiotics (taking into account sensitivity to them), eubiotics (sequentially bifidumbacterin and acylact orally and in suppositories), antimycotic (Diflucan, Gino-Pevaril), immunomodulatory (immunoglobulins, interferons, Viferon) drugs.

For viral infections (HSV, CMV, etc.), treatment tactics depend on the characteristics of the process (latent, persistent, reactivation). In cases of an active, often recurrent process, chemotherapy is additionally used: acyclovir 0.5 g 2 times a day for 10 days, valacyclovir 0.5 g 2 times a day for 5-10 days.

In case of miscarriage autoimmune genesis It is possible to use metipred in small doses (4 mg/day) in the second phase of the menstrual cycle for 1-2 months before planning pregnancy in order to reduce the activity of the autoimmune process. If there is a persistent viral infection in autoimmune disorders, then antiviral and immunomodulatory therapy is prescribed. If a hemostasis disorder is detected, it is corrected.

In case of miscarriage uterine origin Before the planned pregnancy, surgical treatment is carried out (dissection of adhesions, septa, myomiliary polypectomy).

Management of pregnancy with recurrent miscarriage. Patients with recurrent miscarriage are carefully examined according to a standard procedure. Additionally carried out:

Hormonal studies (determination of basal temperature and levels of hCG, progesterone, estradiol, DHEAS, testosterone, 17-OP) in the first trimester of pregnancy;

Bacteriological culture from the cervical canal;

Virological examination; PCR study of cervical mucus;

Monitoring the condition of the cervix from 12 weeks using ultrasound;

Doppler measurements of fetal-placental blood flow from 28 weeks of pregnancy monthly and according to indications;

Cardiotocography weekly from 32 weeks.

Therapeutic measures in patients with recurrent miscarriage are carried out in the following areas:

Pathogenetic therapy taking into account the etiology of miscarriage in history;

Symptomatic treatment of threatened miscarriage;

Prevention placental insufficiency and chronic hypoxia.

Pathogenetic therapy in case of recurrent miscarriage, it should be carried out only according to indications and with laboratory confirmation (!) of deficiency or overproduction of a particular hormone, as well as with objective confirmation of the etiology of miscarriage in the anamnesis.

Endocrine miscarriage is an indication for hormonal therapy.

Glucocorticoid therapy for hyperandrogenic conditions is carried out taking into account the source of androgen production and the critical periods of pregnancy - 13, 24 and 28 weeks. These periods are associated with the functioning of the fetal endocrine organs, which can provoke increased production of androgens.

At adrenal hyperandrogenism those with elevated levels of 17-OP and/or DHEAS are treated with dexamethasone.

At ovarian hyperandrogenism it is possible to prescribe gestagens up to 12-16 weeks (morning).

At mixed hyperandrogenism therapy with dexamethasone is carried out up to 35-36 weeks of pregnancy, with gestagens - up to 12-16 weeks.

Patients receiving glucocorticoid therapy are given three courses of intravenous immunoglobulin at a dose of 25.0 ml every other day No. 3 in order to prevent activation of the infectious process.

In case of insufficiency luteal phase from the 6th to the 10-12th week of pregnancy, utrozhestan 100 mg, 1 capsule 2-3 times a day, orally or vaginally is prescribed.

When prescribing glucocorticoids, it is necessary to weigh their benefits against possible negative effects on the condition of the fetus, since synthetic glucocorticoids (dexamethasone and metipred), unlike natural ones, are not inactivated in the placenta and penetrate through it, having a lasting effect on the fetus. At the same time, activation of the hippocampal-hypothalamic-pituitary-adrenal system of the fetus with inhibition of the synthesis of proteins and nucleic acids, and, consequently, a decrease in its growth, cannot be ruled out. As a result, the administration of glucocorticoids to pregnant women can lead to the birth of low birth weight babies with signs of morphofunctional immaturity.

There is evidence in the literature that antenatal treatment with glucocortcoids programs their high secretion. This causes the development of arterial hypertension and type 2 diabetes in adults.

Long-term exposure to glucocorticoids during pregnancy may also lead to changes in fetal brain structures (reduced hippocampal volume) with memory deficits and behavioral changes in adulthood.

Treatment of urogenital infections in patients with recurrent miscarriage during pregnancy, it is carried out when its clinical manifestations occur. It includes antibacterial, desensitizing therapy, measures aimed at increasing immunoreactivity (immunoglobulin intravenously 25.0 ml 3 times a day, 3 courses per pregnancy, viferon in suppositories), eubiotics (lactobacterin, bifidumbacterin).

In case of miscarriage autoimmune genesis affect all links in the pathogenesis of miscarriage. Glucocorticoid, antiplatelet, anticoagulant and immunomodeling therapy are used.

For confirmed congenital defects of hemostasis in pregnant women, anticoagulant (inhaled heparin, Clexane) and/or disaggregant (chimes, trental, aspirin) therapy is performed depending on the hemostasis indicators. Anticoagulant or antiplatelet therapy is also carried out for other causes of miscarriage if hemostasis parameters are changed.

Symptomatic therapy threats of interruption and prevention placental insufficiency do not differ from generally accepted measures for this pathology.

To prevent miscarriage, timely diagnosis and correction of isthmic-cervical insufficiency (ICI), which is the inferiority of the internal os and its inability to hold the fetus in the uterus, are of great importance. Accurate diagnosis of ICI is carried out using ultrasound. It is necessary to take into account both the length of the cervix and its width at the level of the internal os. The length of the cervix is ​​measured from the internal os to the external os, the width is measured at the level of the internal os. Normally, the internal os is closed (Fig. 17.1). With ICI, the internal os is expanded, the length of the cervix decreases (see Fig. 17.1). Ultrasound of the cervix for diagnosing ICI in pregnant women with recurrent miscarriage is advisable to perform additionally at 16-18 weeks of pregnancy in order to promptly carry out surgical correction - suturing.

Indications for applying a support suture to the cervix are shortening of the cervix by up to 2 cm and expansion of the internal os by more than 1 cm with a funnel length of more than 1 cm.

Rice. 17.1 The condition of the cervix is ​​normal (A) and with isthmic-cervical insufficiency (B).1 - internal os; 2 - external pharynx; 3 - length of the cervical canal; 4 - width of the V-shaped extension of the internal pharynx; 5 - depth of the V-shaped expansion of the internal throat; 6 - length of the preserved cervical canal

Correction of ICI is most often carried out using the McDonald method. The neck is exposed in the mirrors, fixed with bullet forceps and a circular suture is placed on the neck in the area of ​​the internal pharynx using mersilene thread, chrome-plated catgut or silk. The ends of the thread are tied in the area of ​​the anterior arch (Fig. 17.2).

Rice. 17.2 Suturing the cervix using the MacDonald method

When the fetal bladder prolapses in the vagina, a double U-shaped suture can be applied according to Lyubimova-Mamedalieva: after fixing the cervix with bullet forceps, the fetal bladder is inserted behind the internal os with a damp tampon, the cervix is ​​slightly pulled up and U-shaped sutures are applied, the threads are taken onto the clamp, then carefully remove the tuffer, while simultaneously tightening the threads that are tied in the anterior fornix.

Sutures from the cervix are removed at 36-37 weeks or with the onset of labor at any stage of pregnancy.

PREMATURE BIRTH

Premature birth is considered to be a birth that occurs before 37 weeks. The incidence of preterm birth varies from 6 to 15%.

According to WHO recommendations, in developed countries The boundary between miscarriage and childbirth is considered to be 22 weeks (154 days) of pregnancy. Childbirth that occurs from 22 to 28 weeks of pregnancy with a newborn weighing more than 500 g is considered early premature. Perinatal mortality rates are calculated from this period. Perinatal mortality rates up to 28 weeks do not include fetuses that died from birth defects, incompatible with life.

In Russia, birth is considered premature from 28 weeks of pregnancy with a fetal weight of 1000 g or more. Spontaneous termination of pregnancy at 22-27 weeks is classified as late miscarriage. Despite this, children born within the specified time frame with a weight of more than 500 g are provided with full resuscitation care in an obstetric hospital.

According to modern classification, the body weight of a premature newborn less than 2000 g is considered low, less than 1500 g is considered very low, and less than 1000 g is considered extremely low.

In developed countries and perinatal centers in our country, among those born at 23 weeks, 20% survive, at 26 weeks - 60%, at 27-28 weeks - 80%.

The survival rate of premature babies is due to the organization of intensive care units in perinatal centers, the use of surfactant, and the use of special breathing equipment for premature babies.

The survival rate of premature infants is closely related to their subsequent development. 10-12% of children born with low and extremely low body weight develop severe cerebral palsy (CP), retinopathy, and often experience retardation in physical and mental development.

The causes of premature birth, as well as recurrent miscarriage, are numerous. Premature birth can be caused by:

Socio-economic factors, which include unsettled family life, low level of education, unskilled labor, occupational hazards, unsatisfactory material and economic conditions, alcohol abuse, drug use;

Infectious diseases (pyelonephritis, cystitis, pneumonia, vaginosis, etc.) in association with urogenital and intrauterine infections;

Reproductive losses, history of artificial abortions;

Hormonal disorders;

Malformations of the uterus;

Complications of pregnancy: multiple pregnancy, gestosis, bleeding of various etiologies, isthmic-cervical insufficiency, etc.

In 31-50%, preterm birth may be idiopathic.

Premature births at 22-27 weeks account for 5% of the total. Most often they are caused by isthmic-cervical insufficiency, infection of the lower pole of the amniotic sac and its premature rupture. The fetal lungs are immature, and it is not always possible to accelerate their maturation with the help of medications prescribed to the mother. The outcome of childbirth for the fetus with a short gestation period is the most unfavorable - perinatal morbidity and mortality are extremely high.

Preterm birth at 28-33 weeks is caused by more diverse causes than early preterm birth. Despite the fact that the fetal lungs are still immature, with the help of glucocorticoids or other medications it is possible to accelerate their maturation. In this regard, the birth outcome for the fetus at this gestational age is more favorable.

The outcome for the fetus during premature birth at 34-37 weeks is usually favorable.

According to the clinical picture, threatening, beginning and beginning premature labor are distinguished.

Threatening Premature birth is manifested by pain in the lower abdomen and lumbar region. Objectively, increased uterine tone is determined by palpation, which can be recorded during hysterography. During vaginal examination, a preserved cervix is ​​determined; the external pharynx may be closed or allow the tip of the finger to pass through.

Beginning premature birth is manifested by cramping pain in the lower abdomen, the cervix is ​​shortened or smoothed. Possible premature rupture of amniotic fluid.

ABOUT started Premature birth is indicated by the appearance of regular contractions, smoothing and dilatation of the cervix up to 4 cm.

Premature birth may be accompanied by:

Premature rupture of amniotic fluid;

Intrauterine infection, chorioamnionitis, especially with a long anhydrous interval;

Anomalies of labor. At the same time, both weak and excessively strong labor activity is observed equally often;

Monotonous frequency and intensity of contractions;

Increased speed of cervical dilatation, relative to timely birth, both in the latent and active phases of labor;

Diagnostics threatening and beginning labor is carried out by the excitability of the tone of the uterine muscles (the most objective information is provided by hysterotocography, in which it is possible to simultaneously determine the cramping contractions of the uterus along with the heart rate) and changes in the cervix (the cervix shortens, smoothes, and opens). The most objective criterion for impending labor is the length of the cervix, determined by ultrasound.

Lead tactics threatening and beginning premature birth. It is advisable to prolong pregnancy, which includes the following measures:

Predicting the onset of premature birth;

Increasing fetal viability (prevention of fetal RDS);

Therapy aimed at maintaining pregnancy

Treatment of placental insufficiency;

Prevention and treatment of infectious complications due to premature rupture of amniotic fluid.

Predicting the onset of preterm labor carried out in patients with a threat of termination of pregnancy on the basis of:

Detection of fetal fibronectin: its absence in cervical mucus is prognostically favorable;

Determination of cervical length using a vaginal sensor - a cervical length of less than 2.5 cm with intact membranes and a gestational age of less than 34 weeks is prognostically unfavorable;

Determination in cervical mucus using the Actim PARTUS test of phosphorylated insulin-like growth factor binding protein-1, released during separation of the fetal membrane from the decidua;

Assessment of uterine contractile activity using tocography.

For prevention of fetal respiratory distress syndrome mothers are given corticosteroids, which stimulate surfactant production, increase the elasticity of lung tissue and increase maximum lung capacity.

Betamethasone 12 mg every 24 hours or dexamethasone 6 mg every 12 hours 4 times or 4 mg 3 times a day for 2 days are administered intramuscularly. The optimal effect of adrenal hormones administered to the mother is observed at the birth of children, starting at 24 hours, and continues for 7 days after the start of their administration. It is advisable to administer corticosteroids to pregnant women at risk of preterm labor or premature rupture of membranes before 34 weeks of gestation. Repeated administration of dexamethasone is not indicated, since this is associated with the possible development of necrotizing enterocolitis, septic condition, adrenal insufficiency, impaired glucose tolerance, and delayed brain development in the child.

Therapy aimed at maintaining pregnancy consists of tocolysis. To carry out tocolysis, b-adrenomimetics (partusisten, ginipral, ritodrine), oxytocin receptor blockers (atosiban), calcium channel blockers (nifedipine), hormones (utrozhestan), prostaglandin synthetase inhibitors (indomethacin), magnesium sulfate are used.

The most widely used drugs in cases of threatened miscarriage are b-mimetics and oxytocin receptor blockers. β-adrenergic agonists are administered by infusion pump. Tocolysis can be carried out for a long time, followed by the administration of tablet forms. When beta-agonists are administered, complications such as palpitations, tremor, nausea, vomiting, chills, and hyperglycemia are possible. In this regard, b-adrenergic agonists are used in combination with finoptin.

Atosiban is one of the new class of tocolytics. It causes less side effects cardiovascular and respiratory systems and metabolism compared to b-adrenergic agonists. Atosiban is less likely to cause hyperglycemia.

Utrogestan (natural progesterone) suppresses the binding of endogenous oxytocin to receptors in the uterus, increases progesterone receptors in the myometrium, and reduces the expression of receptors responsible for the activation of uterine contractions. Utrozhestan has a positive effect in cases of threatened premature birth, especially in cases of contraindications to the use of b-mimetics.

Nifedipine is more effective in pregnancy more than 34 weeks.

Indomethacin after 14-15 weeks is the tocolytic of choice for pregnant women with heart disease, hyperthyroidism, diabetes mellitus or hypertension. However, with its use, premature closure of the ductus arteriosus, development of pulmonary hypertension, preservation of other fetal communications, intraventricular hemorrhages, and necrotizing colitis are possible.

In pregnant women with hypertension and mild gestosis, a solution of magnesium sulfate is used to reduce the contractile activity of the uterus. There are reports of an increased incidence of intraventricular hemorrhage in the fetus with its use. In this regard, a number of obstetricians do not recommend the administration of magnesium sulfate if there is a threat of premature birth.

Treatment of placental insufficiency. Placental insufficiency often develops with a long-term threat of miscarriage. Measures for its prevention and treatment do not differ from those for other obstetric complications with placental insufficiency.

Tactics when premature rupture of amniotic fluid.

In case of premature rupture of amniotic fluid, especially before 34 weeks, a wait-and-see approach is followed until labor begins independently. For symptoms of threatened miscarriage, tocolytics are indicated.

Prevention of septic complications due to premature rupture of membranes is carried out with antibacterial drugs. Antibiotics for preterm birth significantly reduce the infectious morbidity of mothers and their children.

Antibacterial therapy is carried out taking into account the sensitivity of the microflora and their effect on the fetus. Premature birth

It is advisable to conduct it against the background of the administration of tocolytics.

In order to slow down the advancement of the head and reduce its trauma, childbirth, especially the second stage, is best conducted with the woman in the position on her side, during the eruption of the head, do not use perineal protection, and at the end of the second stage of labor, perform an episiotomy or perineotomy.

If labor is weak, uterotonics should be used with caution.

The decision to deliver by caesarean section in case of premature birth, in the interests of the fetus is taken individually, taking into account the possibility of nursing premature babies in a maternity institution.

Caesarean section for premature birth in the interests of the fetus is advisable when:

Breech presentation;

Multiple births;

Discoordination or weakness of labor;

Pregnancy after IVF;

A burdened obstetric history (lack of living children, miscarriage, long-term infertility, etc.).

Characteristic premature baby. A premature baby has pink skin, a lot of cheese-like lubricant and vellus hair, subcutaneous fatty tissue is underdeveloped, the hair on the head is short, the ear and nasal cartilages are soft, the nails do not extend beyond the fingertips, the umbilical ring is located closer to the pubis, in boys the testicles are not lowered into the scrotum; in girls, the clitoris and labia minora are not covered by the labia majora. The baby's cry is weak ("squeaky").

The most common and severe complication in premature infants whose birth weight is 2000 g or less is respiratory distress syndrome caused by the immaturity of the surfactant system. In this regard, after birth, not only the general condition of the premature baby is assessed according to the Apgar scale, but also respiratory function according to the Silverman scale, which includes five clinical signs of respiratory failure: the nature of the respiratory movements of the upper part chest; retraction of the intercostal spaces and inferolateral parts of the chest; retraction in the area of ​​the xiphoid process; swelling of the wings of the nose; sonority of exhalation.

Each criterion is assessed using a three-point system (0, 1, 2) with subsequent calculation of the total points.

0 points - no respiratory dysfunction.

1 point - asynchronous movements of the chest with a slight retraction of the anterior chest wall during inspiration, retraction of the intercostal spaces and sternum, the wings of the nose participate in the act of breathing, the lower jaw sinks, breathing is rapid, noisy, sometimes with a groan.

2 points - asynchronous movements of the chest and anterior abdominal wall, significant retraction of the anterior chest wall during inspiration, significant retraction of the intercostal spaces and sternum, the wings of the nose are swollen, the lower jaw sinks, breathing is noisy, with groaning, stridor.

The higher the score, the more severe the pulmonary insufficiency in the newborn.

Premature infants are easily exposed to cooling, which causes the development of hypoxemia, metabolic acidosis, rapid depletion of glycogen stores and decreased blood glucose levels.

Maintaining optimal ambient temperature is one of the most important aspects of caring for a premature baby. The anatomical features of premature infants predispose them to heat loss. The heat balance in premature babies is less stable than in full-term babies.

A common complication in premature infants is intracranial hemorrhage, primarily in the ventricles of the brain, as a result of the immaturity of the vascular system.

With premature rupture of amniotic fluid, infection with the development of intrauterine pneumonia is possible.

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

The relevance 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 the woman, and leads to conflict situations in the family. Despite many scientific studies on the causes, treatment and prevention, miscarriage still remains the most important problem of modern obstetrics.

Terminology

In official language, miscarriage is an independent termination of pregnancy 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 occurs:

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

In addition, miscarriage also includes the cessation of fetal development followed by its death at any stage - a frozen or non-developing pregnancy.

When a pregnancy is terminated prematurely two or more times, this condition is called “recurrent miscarriage.”

Statistics

The incidence of miscarriage is not that low—about a quarter of pregnancies end prematurely. In addition, embryo rejection can occur before the start of the next menstruation (in such cases, the woman may not even suspect the existence of pregnancy), therefore, the incidence of miscarriage is much more common.

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

Recurrent miscarriage is usually caused by a serious impairment of female reproductive function and occurs in approximately 20–25% of all spontaneous abortions.

Main reasons

The factors causing disruption of the normal course of pregnancy are very numerous and varied. In most cases, the development of this pathology is influenced by several causes, which act either simultaneously or are added 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).
• Negative action external factors.
• Infection.
• Immunological.
• Genetic.
• Extragenital pathology (acute and chronic somatic diseases of the mother).
• Injuries, surgical interventions during pregnancy of any location (especially in the abdomen and genital area).

In approximately every third woman, the exact cause of spontaneous abortion cannot be diagnosed.

The high frequency of fetal loss during the first three months of gestation is due to a kind of “natural selection”, since in approximately 60% it is due to genetic reasons (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.

For more later pregnancy disruption is usually caused by 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 fertilized egg (its membranes and placenta).

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

• Chlamydia.
• Myco- and ureaplasma.
• Herpes.
• Toxoplasma.
• Cytomegalovirus.
• Rickettsia.
• Trichomonas.
• Enteroviruses.
• Rubella viruses, chickenpox 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 in its death and, accordingly, termination of pregnancy.

At later stages, 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 membranes, etc. All this can contribute to termination of pregnancy.

An important role is also given to opportunistic pathogenic flora (OPF), which can manifest their negative properties against the background of physiological immunosuppression (decreased general and local immunity) in a pregnant woman. In addition, with miscarriage, the presence of several infectious pathogens (associations of microorganisms) is quite common.

Infection can enter the uterine cavity in several ways, the main ones being:

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

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

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 (long-term presence 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 injuries 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 to term) also creates the preconditions 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 a cause of spontaneous abortion, occupies one of the leading positions. Such disorders are especially common hormonal levels:

• Insufficiency of the luteal phase (hypofunction of the ovaries).
• Hyperandrogenism.
• Thyroid gland dysfunction.
• Diabetes.

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

Ovarian hypofunction

As is known, 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. Consequently, if a reduced level of female hormones is detected, problems can occur at any level: from the hypothalamus to, in fact, the ovaries.

The influence of female sex hormones during pregnancy is difficult to overestimate. Their action begins long before conception: they influence the process of maturation and release of the egg, prepare the uterine mucosa for implantation, etc. During pregnancy, estrogens provide control of blood flow in the uterus, increase its functional activity, and prepare the mammary glands for subsequent lactation. Progesterone keeps the uterus at rest, thereby facilitating pregnancy. And this is not all the types of effects of sex hormones on the female body.

What contributes to the development of ovarian hypofunction:

• Diseases suffered by the mother - various infections, irrational treatment with hormones, some somatic pathology, etc.
• Pathological births and abortions in the past.
• Disruption of the normal maturation of the reproductive system in the pre- and puberty period.
• Infectious 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 contractile activity of the uterus and termination of pregnancy in the first trimester. As it progresses, insufficient functioning of the placenta is often revealed, which often leads to delayed 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 the pathological synthesis of androgens, it is:

• Adrenal.
• Yaichnikova.
• Mixed.

An increase in the level of androgens of any origin is accompanied by a decrease in progesterone levels.

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

• Vascular spasm of the uterochorionic and uteroplacental space. This leads to early disruption of blood flow in these areas, the formation of placental insufficiency with subsequent delay in fetal development (up to its death).
• Increased contractile activity of the uterus, which can 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 a direct impact 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 stage of gestation.

Anatomical and functional disorders

Almost the entire developmental cycle, from the first weeks of gestation to the moment of birth, unborn child takes place in the so-called fetal receptacle - the uterus. Accordingly, various violations of its anatomical structure or functional state do not have the most favorable effect on the possibility of a normal pregnancy.

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

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

All of the above anomalies most directly affect the possibility of pregnancy. Thus, if implantation of a fertilized egg fails on the septum of the uterine cavity or near the submucosal node, a disruption 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 deficiency), 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 - in the first.

Isthmic-cervical insufficiency

The frequency of this pathological condition is quite high - approximately every fifth woman with recurrent pregnancy loss is diagnosed with cervical incompetence. Pregnancy loss usually occurs in the second trimester.

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

There are certain risk factors for the development of ICI:

• Trauma to the cervix and cervical canal in the past. This can happen during abortions, pathological childbirth(cervical ruptures during the birth of a large fetus, the use of obstetric forceps and some other conditions). In addition, certain types of surgical interventions to correct cervical pathologies, such as 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 with the subsequent opening of the internal pharynx. This process is most often not accompanied by any sensations, such as pain. Subsequently, the fetal bladder protrudes through the “opened” cervix into the vagina and ruptures with the release of amniotic fluid. Subsequently, a miscarriage or premature birth occurs (the child is often born very premature).

Chromosomal abnormalities

Violations of the chromosome set of the embryo usually lead to a stop in its further development and death. This is the reason for 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 a genetic abnormality.

You need to know that in the vast 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 during the division of the zygote (early stages of embryo development). Examples of such factors could be:

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

After one spontaneous abortion, which was caused by chromosomal abnormalities of the embryo, subsequent pregnancies usually end normally.

If there are several such cases, mandatory consultation of the married couple with a medical geneticist is required to identify hereditary pathologies.

Fetoplacental insufficiency

Disruption of the normal functioning of the placenta or fetoplacental insufficiency (FPI) plays an important role among the causes of miscarriage. In this pathological condition, almost all functions of the placenta are disrupted, for example, transport, nutrition, and 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 hypotrophy (developmental delay).
• Decline functional activity fetus
• Hypoxia (oxygen starvation), which can be acute or chronic.
• Premature placental abruption.
• Placental infarction.
• Increased incidence of morbidity and mortality in newborns.

Many factors lead to the development of FPN. Examples might be:

• Chronic infectious pathology.
• Endometrial dysfunction (for example, previous intrauterine manipulations during abortions, miscarriages).
• Endocrine disorders.
• Complicated pregnancy: threatened miscarriage, preeclampsia, multiple births, immunological incompatibility, etc.
• Extragenital diseases in the mother: chronic pyelonephritis, hypertension, diabetes mellitus, pathology of the blood and coagulation system and many others.

There is also often a combination of reasons that provoke the development of placental insufficiency.

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

Extragenital pathology and external factors

The presence of any acute and chronic somatic diseases in the mother, the influence of external (exogenous) causes, injuries, and 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, and some autoimmune diseases (for example, systemic lupus erythematosus). In addition, such diseases can be life-threatening for the woman herself.

There has been a connection between inflammatory bowel diseases and an increased incidence of preterm birth.

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

• 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 causes of possible termination of pregnancy and its unfavorable course.

Injuries sustained by the mother during pregnancy (especially the abdomen and genitals) can have a 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 operation of the human immune system is designed in such a way as to reject and, if possible, destroy all foreign cells that enter the body. During conception, the 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 normal pregnancy to occur, evolutionary mechanisms for overcoming tissue incompatibility between the mother and fetus are activated. Violation of these mechanisms leads to an immune conflict.

The most studied immunological conflicts are:

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

The immunological factors of miscarriage are still not well understood.

Isosensitization

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

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

For isosensitization to occur during pregnancy, two conditions must exist:

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

ABO isosensitization occurs when fetal blood of a different blood type 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 its presence 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 type or Rh factor, isosensitization does not always occur. This requires the presence of special cells – antibodies – in the mother’s bloodstream. There are Rh antibodies and group antibodies (alpha and beta). When these antibodies combine with antigens (receptors on the surface of “foreign” red blood cells of the fetus), an immune reaction and isosensitization occurs.

Risk factors and manifestations

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

• Previous pregnancy with a fetus of Rh-positive type or with a blood type different from the maternal one. In this case, the outcome of such a pregnancy does not matter: childbirth, abortion, miscarriage, ectopic.
• Pathological birth – caesarean section, manual examination of the uterine cavity.
• Blood transfusions.
• Administration of vaccines and serums made from blood components.

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

Immune conflicts involving the Rh factor are the most severe. At the same time, everything Negative consequences Such pathologies affect exclusively the unborn child. The severity of the manifestations depends on the level of Rh antibodies in the mother's body. In especially severe cases, fetal death occurs followed by miscarriage. If pregnancy progresses, so-called hemolytic disease of the fetus and then of the newborn may develop. It is characterized by severe damage to almost all systems and organs of the baby (the central nervous system is especially affected). 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 its own blood 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 (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 some viruses and their effect on lymphocytes, as one of the links in 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. It is natural that the gestational age decreases with each subsequent terminated pregnancy.

The main manifestations of APS during pregnancy:

• Impaired placental function (fetoplacental insufficiency) due to multiple microthrombosis of placental vessels. As a result, intrauterine growth retardation of the fetus develops, its hypoxia even leads to death.
• Much or little water.
• Premature rupture of membranes.
• Complications of pregnancy: preeclampsia, eclampsia, HELLP syndrome, etc.
• Premature abruption of a normally located placenta.

Even when a full-term baby is born, he may develop various pathological conditions, which significantly worsen the course of the neonatal period and can even lead to death (hyaline membrane syndrome, cerebrovascular accident, respiratory distress syndrome, etc.).

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

Prevention

Prevention of miscarriage lies, first of all, in the competent approach of future parents to the birth of their offspring. For this purpose, a whole series of activities has been developed, which is called “pre-gravid preparation”. To reduce the risk of problems with conception and subsequent pregnancy, a married couple is recommended to:

• Be examined to identify abnormalities in both the somatic and reproductive spheres.
• Maintaining a healthy lifestyle is mandatory: avoiding bad habits, minimizing the influence of environmental factors (for example, occupational hazards), avoiding stress, etc.
• If any foci of infection are identified, they should be sanitized.

If a woman has already had a miscarriage at any stage, it is necessary to find out the possible reasons for this as fully as possible and carry out the necessary correction. This pathology is treated by a gynecologist with the possible involvement of doctors of other specialties, depending on the identified disorders.

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

The cause of miscarriage can be various diseases that are difficult to cure or have become chronic. However, these diseases do not relate to the sexual sphere. Important feature This kind of pathology is due to the unpredictability of the process, since for each specific pregnancy it is difficult to determine the true cause of termination of pregnancy. Indeed, at the same time, a pregnant woman’s body is influenced by many different factors that can act covertly or overtly. The outcome of pregnancy in the case of recurrent miscarriage is largely determined by the therapy performed. If there are three or more spontaneous miscarriages before 20 weeks of pregnancy, the obstetrician-gynecologist diagnoses recurrent miscarriage. This pathology occurs in 1% of all pregnant women.

After the fertilized egg is “placed” in the uterine cavity, the complex process of its engraftment there begins - implantation. Future baby first develops from a fertilized egg, then becomes an embryo, then it is called a fetus, which grows and develops during pregnancy. Unfortunately, at any stage of bearing a child, a woman may encounter a pregnancy pathology such as miscarriage.

Miscarriage is the termination of pregnancy between the moment of conception and 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%.

In case of miscarriage, a complete or incomplete (fertilized egg has separated from the wall of the uterus, but remains in its cavity and does not come out) miscarriage occurs within a period of up to 22 weeks. At a later stage, between 22 and 37 weeks, spontaneous termination of pregnancy is called premature birth, resulting in an immature but viable baby. Its weight ranges from 500 to 2500 g. Premature and prematurely born children are immature. Their death is often noted. Developmental defects are often recorded in surviving children. The concept of prematurity, in addition to short term pregnancy, includes low fetal 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 can a newborn be considered premature.

When miscarriage develops, certain risk factors are indicated.

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

A woman with first-trimester miscarriage should undergo a long-term examination even before the expected pregnancy and during pregnancy to identify the real reason miscarriage. A very difficult situation arises when a spontaneous miscarriage occurs against the background of a normal 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 chromosomal abnormalities of the fetus. Chromosomes are microscopic elongated structures located in the internal structure of cells. Chromosomes contain genetic material that determines 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, 46 in total, with one part inherited from the mother organism, and the second - from the father's. Two chromosomes in each set are called sex chromosomes and determine the sex of a person (XX chromosomes determine the female sex, XY chromosomes determine the male sex), while the other chromosomes carry the rest of the genetic information about the entire organism and are called somatic.

It has been established that about 70% of all miscarriages are early stages pregnancy is caused by anomalies of somatic chromosomes in the fetus, while most chromosomal abnormalities of the developing fetus occurred due to the participation of a defective egg or sperm in the fertilization process. This is due to the biological process of division, when the egg and sperm, during their preliminary maturation, divide in order to form mature germ cells in which the set of chromosomes is equal to 23. In other cases, eggs or sperm are formed with an insufficient (22) or excessive (24) set chromosomes. In such cases, the mature embryo will develop with a chromosomal abnormality, leading to miscarriage.

The most common chromosomal defect can be considered trisomy, in which an embryo is formed by the fusion of a germ cell with chromosome set 24, as a result of which the set of fetal chromosomes is not 46 (23 + 23), as it should be normally, but 47 (24 + 23) chromosomes . Most trisomies involving somatic chromosomes lead to the development of a fetus with defects 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 period.

An example of the most well-known developmental anomaly caused by trisomy is Down's disease (represented by trisomy 21).

A woman’s age plays a major role in the occurrence of chromosomal disorders. 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 is diagnosed with congenital genetic diseases, mandatory consultation with a geneticist is suggested. In certain cases, it is proposed to carry out IVF (in vitro fertilization - artificial insemination in a test tube) with a donor egg or sperm, which directly depends on which partner has such chromosomal abnormalities.

Causes of primary miscarriage

There can be many reasons for the occurrence of such violations. The process of conceiving and carrying 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 expectant mother’s body begins to produce hormones incorrectly, then hormonal imbalances pose a threat of miscarriage.

Never take it yourself hormonal drugs. Taking them can seriously impair reproductive function.

The following congenital or acquired lesions of the uterus can threaten the course of pregnancy.

• Anatomical malformations of the uterus - duplication of the uterus, saddle uterus, bicornuate uterus, unicornuate uterus, partial or complete uterine septum in the cavity - are congenital. Most often, they prevent the fertilized egg from successfully implanting (for example, the egg “sits” on the septum, which is not able to perform the functions of the inner layer of the uterus), which is why a miscarriage occurs.
• Chronic endometritis is 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 a woman, 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 impairs its functionality. It will not be easy for the fertilized egg to attach and grow and develop normally on such endometrium, which can lead to pregnancy loss.
• Endometrial polyps and hyperplasia - proliferation of the mucous membrane of the uterine cavity - endometrium. This pathology can also prevent embryo implantation.
• Intrauterine synechiae are adhesions between the walls of the uterine cavity that prevent the fertilized egg from moving, implanting and developing. Synechia most often occurs as a result of mechanical trauma to the uterine cavity or inflammatory diseases.
• Uterine fibroids are benign tumor processes that arise in the muscular layer of the uterus - the myometrium. Myomas can cause miscarriage if the fertilized egg is implanted next to a myomatous node, which disrupts the tissue of the internal cavity of the uterus, “takes over” the blood flow and can grow towards the fertilized egg.
• Isthmic-cervical insufficiency. It is considered the most common cause of perinatal losses in the second trimester of pregnancy (13-20%). The cervix shortens and then dilates, which leads to pregnancy loss. Typically, isthmic-cervical insufficiency occurs in women whose cervix has been damaged previously (abortion, rupture during childbirth, etc.), has a congenital malformation, or cannot cope with the increased load during pregnancy (large fetus, polyhydramnios, multiple pregnancies, etc.). P.).

Some women have a congenital predisposition to thrombosis (blood thickening, the formation of blood clots in blood vessels), which complicates the implantation of the fertilized egg and prevents normal blood flow between the placenta, baby and mother.

The expectant mother often does not know at all about her pathology before pregnancy, since her hemostatic system coped well with its functions before pregnancy, i.e., without the “double” load that comes with the task of bearing 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 cause of recurrent miscarriage can also be normal chromosomes, which do not cause developmental problems in both partners, but are latent carriers of chromosomal abnormalities, which affect fetal development abnormalities. In such a situation, both parents should have their blood tested for karyotype in order to identify such chromosomal abnormalities (carriers of silent chromosomal abnormalities). With this examination, the results of karyotyping determine a probable assessment of the course of a subsequent pregnancy, and the examination cannot give a 100% guarantee of possible anomalies.

Chromosomal abnormalities are varied and can also cause pregnancy to fail to develop. In this case, only the membranes are formed, while the fetus itself may not exist. It is noted that the fertilized egg is either formed initially, or it has stopped its further development in the early stages. For this purpose, in the early stages it is typical to stop characteristic symptoms pregnancy, at the same time dark brown vaginal discharge often appears. An ultrasound can reliably determine the absence of a fertilized egg.

Miscarriage in the second trimester of pregnancy is mainly due to abnormalities in the structure of the uterus (such as an abnormal shape of the uterus, an additional horn of the uterus, a saddle-shaped uterus, the presence of a septum or a weakened continence of the cervix, the dilatation of which leads to premature labor). Wherein possible reasons Late miscarriage can result from infection of the mother (inflammatory diseases of the appendages and uterus) or chromosomal abnormalities of the fetus. According to statistics, the cause of miscarriage in the second trimester of pregnancy in 20% of cases is chromosomal abnormalities.

Symptoms and signs of primary miscarriage

A characteristic symptom of miscarriage is bleeding. Bloody vaginal discharge during spontaneous miscarriage usually begins suddenly. In some cases, a miscarriage is preceded by nagging pain in the lower abdomen, which is reminiscent of pain before menstruation. Along with the discharge of blood from the genital tract, when spontaneous miscarriage begins, the following symptoms are often observed: general weakness, malaise, increased body temperature, decreased nausea that was present before, and emotional tension.

But not all cases of occurrence bloody discharge in the early stages of pregnancy end in spontaneous miscarriage. If there is bleeding 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 the presence of cervical dilatation and select the necessary treatment aimed at maintaining the pregnancy.

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

The course of a full examination includes a certain set of examinations:

1. blood tests for chromosomal abnormalities in both parents (karyotype clarification) 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 if these tissues are available - either the woman saved them herself, 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 an image 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 mucosa, after which a hormonal examination of the tissue is performed.

Treatment and prevention of primary miscarriage

If a woman’s pregnancy is threatened by endocrine disorders, 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 adjustment of dosage and medications during pregnancy. In the case of using hormonal therapy, the condition of the expectant mother is always monitored and appropriate laboratory tests (tests) are performed.

If miscarriage is caused by uterine factors, then appropriate treatment is carried out several months before the baby is conceived, since it requires surgical intervention. During the operation, synechiae are dissected, polyps of the uterine cavity are eliminated, and fibroids that interfere with the course of pregnancy are removed. Infections that contribute to the development of endometritis are treated with medication before pregnancy. Isthmic-cervical insufficiency during pregnancy is corrected surgically. Most often, the doctor prescribes suturing the cervix (at 13-27 weeks) when insufficiency occurs - the cervix begins to shorten, become softer, and the internal or external pharynx opens. Stitches are removed at 37 weeks of pregnancy. A woman with a sutured cervix is ​​advised to have a gentle physical regimen and no psychological stress, since even on a sutured cervix, leakage of amniotic fluid is possible.

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

The doctor will offer you the most suitable method for each specific situation.

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

To prevent and treat problems associated with the hemostatic system of the expectant mother, the doctor will prescribe laboratory blood tests (mutations of the hemostatic system, coagulogram, D-dimer, etc.). Based on the published examination results, drug treatment (tablets, injections) that improves blood flow can be used. Expectant mothers with impaired venous blood flow are recommended to wear therapeutic compression hosiery.

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

It is very important that a woman with a history of miscarriage (three or more losses) be examined and receive medication preparation BEFORE the upcoming pregnancy to avoid this complication.

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

Most women do not require any treatment as such immediately after a spontaneous miscarriage in the early stages. The uterus gradually and completely cleanses itself, similar to what happens during menstruation. However, in some cases of incomplete miscarriage (partial remnants of the fertilized egg remain in the uterine cavity) and when the cervix is ​​bent, it becomes necessary to curettage the uterine cavity. Such manipulation is also required in case of intense and unstoppable bleeding, as well as in cases of threat of development of an infectious process or if, according to an ultrasound examination, remnants of membranes are detected in the uterus.

Anomalies in the structure of the uterus are one of the main causes of recurrent miscarriage (the cause in 10-15% of cases of recurrent miscarriage in both the first and second trimesters of pregnancy). Such structural anomalies include: irregular shape of the uterus, the presence of a septum in the uterine cavity, benign neoplasms that deform the uterine cavity (fibroids, fibroids, fibromyomas) or scars from previous surgical interventions (cesarean section, removal of fibroid 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 recurrent miscarriage is played by a certain weakness of the muscular ring of the cervix, and the most typical period for termination of pregnancy for this reason is 16-18 weeks of pregnancy. Initially, weakness of the muscular ring of the cervix can be congenital, and can also be the result of medical interventions - traumatic damage to the muscular ring of the cervix (as a result of abortion, cleansing, rupture of the cervix during childbirth) or certain types of hormonal disorders (in particular, increased levels of male sex hormones). The problem can be solved by placing a special suture around the cervix at the beginning of a subsequent pregnancy. The procedure is called “cervical cleavage.”

A significant cause of recurrent miscarriage is hormonal imbalance. Thus, ongoing studies have revealed that low levels of progesterone are extremely important in maintaining pregnancy in the early stages. It is the deficiency of this hormone that is the cause in 40% of cases. early interruption pregnancy. The modern pharmaceutical market has been significantly replenished with drugs similar to the hormone progesterone. They 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. Drugs of this kind are used in hormone replacement therapy in cases of corpus luteum insufficiency, although each of them has a certain range of disadvantages and side effects. Currently, only one drug can be named that is completely identical to natural progesterone - utrozhestan. The drug is very convenient 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 imitated. To maintain the luteal phase, micronized progesterone is prescribed in a dose of 2-3 capsules per day. If the pregnancy develops successfully while using utrozhestan, then its use continues, and the dose is increased to 10 capsules (as determined by the gynecologist). As pregnancy progresses, the dosage of the drug is gradually reduced. The drug is reasonably used until the 20th week of pregnancy.

Severe hormonal imbalance may 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 have not been sufficiently studied. Habitual miscarriage often becomes a consequence of immune disorders in the body of the mother and fetus. This is due to the specific ability of the body to produce antibodies to fight penetrating infections. However, the body can also produce antibodies against the body's own cells (autoantibodies), which can attack the body's own tissues, causing health problems as well as premature termination of pregnancy. These autoimmune disorders are the cause of 3-15% of cases of recurrent pregnancy loss. In such a situation, it is first necessary to measure the existing level of antibodies using special blood tests. Treatment involves the use of small doses of aspirin and blood thinners (heparin), which leads to the possibility of bearing a healthy baby.

Modern medicine is paying attention to a new genetic abnormality - the Leiden mutation of factor V, which affects blood clotting. This genetic trait may also play an important role in recurrent miscarriage. Treatment for this type of disorder has not yet been fully developed.

Asymptomatic infectious processes in the genitals occupy a special place among the causes of habitual pregnancy failure. It is possible to prevent premature termination of pregnancy by routinely screening partners for infections, including women, before a planned pregnancy. The main pathogens that cause recurrent miscarriage are mycoplasma and ureaplasma. Antibiotics are used to treat such infections: ofloxin, vibromycin, doxycycline. The treatment carried out must be carried out by both partners. A control examination for the presence of these pathogens is performed one month after the end of antibiotic therapy. In this case, it is extremely necessary to combine local and general treatment. Locally, it is better to use broad-spectrum drugs that act on several pathogens simultaneously.

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

It should be remembered that observation of a pregnant woman with recurrent 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 ultrasound data does not detect fetal cardiac activity, it is recommended to collect fetal tissue for karyotyping.

Once fetal cardiac activity is detected, additional blood tests are not necessary. However, in later pregnancy, evaluation of α-fetoprotein levels is advisable in addition to ultrasound. An increase in its level may indicate neural tube malformations, and low values ​​may indicate chromosomal abnormalities. Increased α-fetoprotein concentration without obvious reasons at 16-18 weeks of pregnancy may indicate the risk of spontaneous abortion in the second and third trimesters.

Evaluation of the fetal karyotype is of great importance. This study should be carried out not only for all pregnant women over 35 years of age, but also for women with recurrent miscarriage, which is associated with an increased likelihood of fetal malformations in subsequent pregnancies.

When treating recurrent miscarriage of unknown cause, IVF can be considered one of the alternatives. This method allows you to examine germ cells for the presence of chromosomal abnormalities even before artificial insemination in vitro. The combination of this technique with the use of a donor egg gives positive results in achieving the desired full pregnancy. According to statistics, full 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 various methods described for the treatment of recurrent miscarriage, it is necessary to note nonspecific, background therapy, the purpose of which is to relieve the increased tone of the muscular wall of the uterus. It is the increased tone of the uterus of various nature 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 drips of magnesium.

LECTURE 15

MARRIAGEPREGNANCY

Definition of post-term pregnancy.

Diagnostics.

Obstetric tactics.

Indications for CS surgery in post-term pregnancy.

Miscarriage consider spontaneous interruption of it in different deadlines from conception to 37 weeks, counting from the 1st day of the last menstrual period.

Habitual miscarriage(synonym for “habitual pregnancy loss”) - spontaneous termination of pregnancy 2 times or more in a row.

Prematurity - spontaneous termination of pregnancy between 28 and 37 weeks (less than 259 days).

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

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

Perinatal period begins at 28 weeks of pregnancy, includes the period of childbirth and ends after 7 full days of the newborn’s life. The death of a fetus or newborn during these periods of pregnancy and the newborn period constitutes perinatal mortality. According to WHO recommendations, perinatal mortality is taken into account from 22 weeks of pregnancy when the fetal weight is 500 g or more.

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

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

Newborns born with a body weight of up to 2500 g are considered low birth weight, up to 1500 g are considered very low birth weight, and up to 1000 g are considered extremely low birth weight. Children of the last two groups most often die in the neonatal period.

Etiology of miscarriage is diverse, and miscarriage can be caused by various factors or even combinations thereof.

I trimester timing:

chromosomal abnormalities of the embryo;

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

hyperandrogenism in a pregnant woman;

uterine hypoplasia and/or uterine developmental abnormalities;

diabetes;

hypo- and hyperthyroidism;

acute viral hepatitis;

glomerulonephritis.

Etiology of miscarriage in II trimester pregnancy:

placental insufficiency;

isthmic-cervical insufficiency (ICI);

antiphospholipid syndrome;

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

Etiology of miscarriage in III trimester pregnancy:

• abnormalities in the location of the placenta;

premature abruption of the normally located placenta (PONRP);

polyhydramnios and/or multiple births;

incorrect position of the fetus;

rupture of membranes and chorioamnionitis.

Pregnancy can be terminated at any timedue to the following reasons:

genital infection;

abnormalities of the uterus and uterine fibroids;

diabetes mellitus;

• occupational hazards;

  immunological disorders;

  any reason leading to fetal hypoxia.

Pathogenesis of miscarriage

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

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

On days 7-10 after fertilization, nidation of the blastocyst into the endometrium occurs due to the release of chorionic gonadotropin (CG) by the primary chorion by the dividing egg. The immersion process lasts 48 hours. HCG supports the function of the corpus luteum and transfers it to a new mode of operation, like the corpus luteum of pregnancy (CLP).

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

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

Due to the increase in hormone levels, intensive synthesis of pregnancy proteins begins. At the same time it is braked the immune system mothers (production of antibodies to foreign proteins). As a result, the risk of infectious diseases increases and chronic infections worsen.

Mechanismthe threat of interruption pregnancy in later stages is as follows: in each organ only 30% of the vessels function, the rest turn on only under load, these are reserve vessels. There are a huge number of reserve vessels in the uterus. Blood flow increases 17 times during pregnancy. If blood flow decreases by half (trophic deficiency), the child experiences hypoxia. Under-oxidized products of hemoglobin metabolism - myoglobin - appear in the fetal urine. The latter, entering the amniotic fluid of the fetus, is a powerful stimulator of prostaglandin synthesis. Labor at any stage of pregnancy is triggered by prostaglandins; they are produced by the decidua and aqueous membranes of the fertilized egg. Any reason leading to fetal hypoxia can provoke the development of labor. During childbirth, uteroplacental blood flow decreases as a result of powerful contraction of the uterine muscle, myoglobin synthesis increases with the increase of labor.

Once labor has started, it is impossible to stop it. Pain during contractions is caused by ischemia of the uterine muscle. Therefore, therapy for threatened miscarriage should be aimed at mobilizing reserve vessels (bed rest, antispasmodics, drugs that relieve uterine contractions).

Terminology and classification

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

According to the nature of its occurrence, abortion can be spontaneous or artificial. Induced abortions, in turn, are divided into medical and criminal (performed outside a medical institution).

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

According to the clinical course, they are distinguished:

Threatened abortion. A threat of miscarriage is indicated by: a history of miscarriages, a feeling of heaviness in the lower abdomen or slight nagging pain in the absence of bleeding, the size of the uterus corresponds to the duration of pregnancy, the external os is closed. Ultrasound reveals hypertonicity of the uterine muscle.

An abortion has begun. It is characterized by cramping pain in the lower abdomen and slight bleeding (associated with detachment of the fertilized egg from the walls of the uterus). The size of the uterus corresponds to the duration of pregnancy. The uterine os may be slightly open.

The prognosis for pregnancy with an ongoing abortion is worse than with a threatened abortion, but maintaining the pregnancy is possible.

Abortion is in progress. The fertilized egg, detached from the walls of the uterus, is pushed out through the dilated cervical canal, which is accompanied by significant bleeding. Continuing the pregnancy is impossible. The fertilized egg is removed with a curette as a matter of urgency.

Incomplete abortion characterized by retention of parts of the fertilized egg in the uterine cavity, accompanied by bleeding, which can be moderate or heavy. The cervical canal is slightly open, the size of the uterus is less than the expected gestational age.

Infected(feverish) abortion. With spontaneous abortion (beginning, beginning or incomplete), microflora may penetrate the uterus and infect the membranes of the fertilized egg (amnionitis, chorioamnionitis), and the uterus itself (endometrium). Infection occurs especially often during artificial termination of pregnancy outside a medical institution (criminal abortion).

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

Delayed(failed) abortion. In case of a failed abortion, the embryo dies. In this case, there may be no complaints and subjective sensations of “pregnancy loss”; there may be no clinical signs of a threatening or incipient miscarriage. During an ultrasound examination: either the absence of an embryo (anembryony), or visualization of an embryo with no recording of its cardiac activity (the size of the embryo, CTE - often less than the normative values ​​for the expected gestational age).

Medical tactics are instrumental removal of the fertilized egg.

Examination of women with miscarriage

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

Examination before planning pregnancy:

Examinations by specialists:

obstetrician-gynecologist;

therapist;

immunologist;

andrologist - urologist;

psychotherapist;

genetics (with recurrent miscarriage).

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

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

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

Study of reproductive function - the period of time from the onset of sexual activity to pregnancy is specified.

The nature of all previous pregnancies and births is assessed. If pregnancy was terminated in the past, the peculiarities of the clinical course (bleeding, pain, contractions, fever).

General examination: pay attention to height and weight, body type, severity of secondary sexual characteristics, presence and nature of obesity, hirsutism.

Examination of the mammary glands is mandatory (a well-protruding erectile nipple indicates normal hormonal function of the ovaries).

Gynecological examination: assessment of the vaginal part of the cervix, the presence of ruptures, deformities.

The nature of cervical mucus and its quantity, taking into account the day of the menstrual cycle. Size, shape, consistency, position and mobility of the uterus, the ratio of the length of the body of the uterus to the length of the cervix.

Size of the ovaries, mobility, sensitivity, presence of adhesions.

Hysterosalpingography is performed to exclude ICI and uterine malformations.

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

It is advisable to carry out functional diagnostic tests: (colpocytology, basal temperature, pupil symptom, fern symptom), study of blood hormones (depending on the phase of the menstrual cycle - FSH, LH, prolactin are determined on the 5th day of the cycle; on the 12th day estradiol, FSH, LH; on day 21 progesterone) and urine analysis for 17-ketosteroids in 24-hour urine to exclude hyperandrogenism.

Hemostasiogram once a month for autoimmune miscarriage.

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

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

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

Fetal CTG.

Doppler measurements from 16 weeks of pregnancy.

Determination of the content of hormones of the fetoplacental complex.

Placental hormones:

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

Chorionic gonadotropin (CG) appears in a woman’s body exclusively during pregnancy. Diagnosis of pregnancy is based on its definition. Its synthesis in the placenta begins from the moment of implantation on days 8-10. Its level increases rapidly, reaching a maximum by 7 weeks of pregnancy, after which it quickly decreases and remains at a low level throughout the remaining period of pregnancy. Disappears from the body in the first week after birth. Reduces the release of gonadotropins by the mother's pituitary gland, stimulates the formation of progesterone by the corpus luteum. Early or late appearance of the hCG peak indicates a dysfunction of the trophoblast and corpus luteum - this is an early indicator of the threat of miscarriage.

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

Fetal hormones:

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

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

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

Cytology of vaginal smears indicates the saturation of the body with estrogen. Karyopyknotic index is the ratio of cells with pyknotic nuclei to the total number of superficial cells. KPI in the first trimester - no more than 10%; in the second trimester - 5%, in the third trimester - 3%. If there is a threat of miscarriage, the CPI increases to 20 - 50%.

Basal temperature in uncomplicated pregnancy it is 37.2 - 37.4°C. If there is a threat of miscarriage, a decrease in basal temperature to 37°C indicates a lack of progesterone.

Pupil symptom. During an uncomplicated pregnancy, the mucus content in the cervical canal is minimal.

When there is a threat of miscarriage, a pronounced “pupil symptom” appears.

Treatment of miscarriage

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

Contraindications to pregnancy:

insulin-dependent diabetes mellitus with ketoacidosis;

diabetes mellitus + tuberculosis;

hypertension II, III;

heart defects with circulatory disorders;

epilepsy with personality degradation;

severe blood diseases.

Treatment of threatened miscarriage inItrimester:

Bed rest.

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

Antispasmodics (papaverine, no-spa).

Hormonal therapy.

Prevention of FPN

Metabolic therapy.

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

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

b) utrozhestan: threatened abortion or for the purpose of preventing habitual abortions that occur due to progesterone deficiency: 2-4 capsules daily in two doses up to 12 weeks of pregnancy (vaginally).

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

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

Treatment of threatened miscarriage during pregnancyIIAndIIItrimesters:

Bed rest and psycho-emotional rest.

Prescription of b-adrenergic agonists (tocolytics), which cause relaxation of the smooth muscles of the uterus (partusisten, ginipral, ritodrine). Treatment begins with intravenous drip administration of 0.5 mg of partusisten, diluted in 400 ml of NaCl 0.9%, starting with 6-8 drops per minute, but not more than 20 drops.

The dose is increased until the contractile activity of the uterus ceases. Before the end of the infusion, oral administration of the drug is started at 0.5 mg every 6-8 hours.

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

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

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

Prevention of fetal hypoxia.

Prevention of placental insufficiency.

If there is a threat of premature birth at 28-33 weeks, respiratory distress syndrome in newborns is prevented by prescribing glucocorticoid drugs (dexamethasone) 8-12 mg per course or lasolvan, ambroxol, ambrobene 800-1000 mg per day for 5 days intravenously.

Antispasmodics.

Sedatives.

For hyperandrogenism termination of pregnancy is caused by the antiestrogenic effect of androgens. Threatened miscarriage is treated with corticosteroids. It is based on the suppression of ACTH secretion, which leads, according to the feedback principle, to a decrease in the biosynthesis of androgens by the adrenal glands. Treatment is prescribed for a persistent increase in 17-KS with dexamethasone in an individually selected dose until 17-KS levels normalize. Hormonal treatment should be discontinued at 32-33 weeks of pregnancy so as not to suppress fetal adrenal function.

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

In case of miscarriage due to immunoconflict pregnancy minorities by erythrocyte antigens (the formation of erythrocyte antigens begins from 5 weeks of pregnancy) for all women with O(I) blood group with A(II) or B(III) blood group of the husband, as well as for Rh negative blood of the pregnant woman, check the blood for group and Rh antibodies. Treatment is carried out with allogeneic lymphocytes.

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

Organic ICI develops as a result of traumatic injuries to the isthmic part of the cervix during induced abortion, delivery of a large fetus, or surgical delivery (obstetric forceps).

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

ICN diagnostics:

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

When examined in the speculum: a gaping external os with flaccid edges, prolapse of the amniotic sac.

3. During vaginal examination: shortening of the cervix, the cervical canal passes the finger past the area of ​​the internal os.

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

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

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

Management of premature birth with a whole fetusbubble:

Gestational age 22 - 27 weeks (fetal weight 500-1000g): you should try to relieve labor by prescribing b-adrenergic agonists in the absence of contraindications to pregnancy. If there is an ICN, place a suture on the neck. Conduct courses of metabolic therapy. If possible, identify the cause of miscarriage and adjust therapy based on the examination data obtained.

Gestational age 28- 33 weeks (fetal weight 1000-1800 g): the therapy is the same, except for suturing the cervix. While preventing RDS in the fetus, monitor the degree of maturity of its lungs. The outcome for the fetus is more favorable than in the previous group.

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

Management of preterm birth during antenatal irritationamniotic fluid:

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

Expectant management is preferable, since with an increase in the water-free interval, accelerated maturation of the fetal lung surfactant is observed and, accordingly, a decrease in the incidence of hyaline membrane disease in the newborn.

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

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

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

Update: October 2018

Today, miscarriage is considered one of the most important problems in obstetrics, given the variety of causes and the ever-increasing percentage of perinatal losses. According to statistics, the number of recorded cases of miscarriage is 10 - 25%, 20% of which are recurrent miscarriages, and 4 - 10% are premature births (relative to the total number of births).

What does this term mean?

• The duration of pregnancy is 280 days or 40 weeks (10 obstetric months).
• Full-term births are those births that occur between 38 and 41 weeks.
• Miscarriage is the spontaneous termination of pregnancy that occurs between fertilization (conception) and 37 weeks.

Recurrent miscarriage includes cases of spontaneous abortion that occurred twice or more times in a row (including frozen pregnancy and antenatal fetal death). The frequency of recurrent miscarriage in relation to the total number of all pregnancies reaches 1%.

The risks of miscarriage are directly proportional to the number of previous spontaneous abortions in history. Thus, it has been proven that the risk of interruption new pregnancy after the first spontaneous abortion it is 13–17%, after two miscarriages/premature births it reaches 36–38%, and after three spontaneous abortions it is 40–45%.

Therefore, every married couple who has had 2 spontaneous abortions should be carefully examined and treated at the stage of pregnancy planning.

In addition, it has been proven that a woman’s age has a direct relationship with the risk of spontaneous abortion in the early stages. If for women in the age category from 20 to 29 years the possibility of spontaneous abortion is 10%, then at the age of 45 and after it reaches 50%. The risk of miscarriage with increasing maternal age is associated with the “aging” of eggs and an increase in the number of chromosomal abnormalities in the embryo.

Classification

The classification of miscarriage includes several points:

Depending on the period of occurrence

• spontaneous (spontaneous or sporadic) abortion is divided into early (up to 12 weeks of gestation) and late from 12 to 22 weeks. Spontaneous miscarriages include all cases of termination of pregnancy that occurred before 22 weeks or with a fetal body weight of less than 500 grams, regardless of the presence/absence of signs of its life.;
• premature births, which are distinguished by timing (according to WHO): from 22 to 27 weeks, ultra-early premature births, births that occurred from 28 to 33 weeks are called early preterm births, and from 34 to 37 weeks - premature births.

Depending on the stage, abortions and premature births are divided into:

• spontaneous abortion: threatened abortion, abortion in progress, incomplete abortion (with remnants of the fertilized egg in the uterus) and complete abortion;
• premature birth, in turn, is classified as: threatening, beginning (at these stages, labor can still be slowed down) and beginning.

Separately, there are infected (septic) abortion, which can be criminal, and failed abortion (frozen or non-developing pregnancy).

Causes of miscarriage

The list of causes of miscarriage is very numerous. It can be divided into two groups. The first group includes social and biological factors, which include:

To the second group These include medical reasons that are due to either the condition of the embryo/fetus or the health of the mother/father.

Genetic causes of miscarriage

Genetic miscarriage is observed in 3–6% of cases of pregnancy loss, and for this reason, about half of pregnancies are terminated only in the first trimester, which is associated with natural selection. When examining spouses (karyotype study), approximately 7% of failed parents are found to have balanced chromosomal rearrangements that do not in any way affect the health of the husband or wife, but with meiosis, difficulties arise in the processes of pairing and separation of chromosomes. As a result, unbalanced chromosomal rearrangements are formed in the embryo, and it either becomes unviable and the pregnancy is terminated, or is a carrier of severe chromosomal abnormality. The possibility of having a child with severe chromosomal pathology in parents who have balanced chromosomal rearrangements is 1–15%.

But in many cases, genetic factors of miscarriage (95) are represented by a change in the set of chromosomes, for example, monosomy, when one chromosome is lost, or trisomy, in which there is an additional chromosome, which is the result of errors in meiosis due to the influence of harmful factors (medication, radiation, chemical hazards and others). Genetic factors also include polyploidy, when the chromosomal composition increases by 23 chromosomes or the full haploid set.

Diagnostics

Diagnosis of genetic factors for recurrent miscarriage begins with collecting anamnesis from both parents and their close relatives: are there any hereditary diseases in the family, are there any relatives with congenital anomalies, were/are there children with a delay mental development in spouses, whether the spouses or their relatives had infertility or miscarriage of unknown origin, as well as cases of idiopathic (unspecified) perinatal mortality.

Of the special examination methods, a mandatory study of the karyotype of the spouses is indicated (especially at the birth of a child with congenital malformations and in the presence of recurrent miscarriage in the early stages). A cytogenetic study of abortion (karyotype determination) is also indicated in cases of stillbirth, miscarriage and infant mortality.

If changes are detected in the karyotype of one of the parents, a consultation with a geneticist is indicated, who will assess the risk of having a sick child or, if necessary, recommend the use of a donor egg or sperm.

Pregnancy management

In the event of pregnancy, mandatory prenatal diagnostics are carried out (chorionic villus biopsy, cordocentesis or amniocentesis) in order to identify gross chromosomal pathology of the embryo/fetus and possible termination of pregnancy.

Anatomical causes of miscarriage

The list of anatomical causes of miscarriage includes:

• congenital malformations (formation) of the uterus, which include its duplication, bicornuate and saddle-shaped uterus, uterus with one horn, intrauterine septum complete or partial;
• anatomical defects that appeared during life (intrauterine synechiae, submucosal myoma, endometrial polyp)
• isthmic-cervical insufficiency (cervical incompetence).

Habitual miscarriage due to anatomical reasons is 10–16%, with the share of congenital malformations accounting for 37% of the bicornuate uterus, 15% for the saddle uterus, 22% for the septum in the uterus, 11% for the double uterus and 4.4% for the uterus with one horn.

Miscarriage with anatomical uterine abnormalities is caused either by unsuccessful implantation of a fertilized egg (directly on the septum or next to the myomatous node) or by insufficient blood supply to the uterine mucosa, hormonal disorders or chronic endometritis. Isthmic-cervical insufficiency is highlighted in a separate line.

Diagnostics

The history contains indications of late miscarriages and premature birth, as well as pathology of the urinary tract, which often accompanies malformations of the uterus and features of the formation of the menstrual cycle (there was a hematometra, for example, with a rudimentary uterine horn).

Additional examination methods

Additional methods for miscarriage caused by anatomical changes include:

• metrosalpingography, which allows you to determine the shape of the uterine cavity, identify existing submucosal myomatous nodes and endometrial polyps, as well as determine the presence of synechiae (adhesions), intrauterine septum and tubal patency (carried out in phase 2 of the cycle);
• allows you to see with your eye the uterine cavity, the nature of the intrauterine anomaly, and, if necessary, dissect the synechiae, remove the submucosal node or endometrial polyps;
• Ultrasound of the uterus allows you to diagnose submucosal fibroids and intrauterine synechiae in the first phase, and in the second it reveals a septum in the uterus and a bicornuate uterus;
• In some difficult situations Magnetic resonance imaging of the pelvic organs is used, which allows identifying abnormalities in the development of the uterus with concomitant atypical localization of organs in the pelvis (especially in the presence of a rudimentary uterine horn).

Treatment

Treatment of recurrent miscarriage caused by anatomical pathology of the uterus consists of surgical excision of the uterine septum, intrauterine synechiae and submucosal myomatous nodes (preferably during hysteroscopy). The effectiveness of surgical treatment of this type of miscarriage reaches 70–80%. But in the case of women with a normal course of pregnancy and childbirth in the past, and then with repeated miscarriages and with uterine malformations, surgical treatment does not have an effect, which may be due to other causes of miscarriage.

After surgical treatment, in order to improve the growth of the uterine mucosa, combined oral contraceptives are recommended for 3 months. Physiotherapy (,) is also recommended.

Pregnancy management

Pregnancy against the background of a bicornuate uterus or with its doubling occurs with the threat of miscarriage at different times and with the development of placental insufficiency and delayed fetal development. Therefore, from an early stage, if bleeding occurs, bed rest, hemostatic agents (dicinone, tranexam), antispasmodics (magne-B6) and sedatives (motherwort, valerian) are recommended. It is also recommended to take gestagens (Utrozhestan, Duphaston) for up to 16 weeks.

Isthmic-cervical insufficiency

ICI is one of the most common factors for late pregnancy loss, mainly in the 2nd trimester. Isthmic-cervical insufficiency is regarded as failure of the cervix when it cannot be in a closed position, and as it progresses it shortens and opens, and the cervical canal expands, which leads to prolapse of the amniotic sac, its opening and discharge of water and ends in late miscarriage or premature birth . There are ICNs of a functional (hormonal imbalance) and organic (post-traumatic) nature. This cause of recurrent miscarriage occurs in 13–20% of cases.

Diagnostics

It is impossible to assess the risk of developing functional ICI before pregnancy. But in the presence of post-traumatic ICI, metrosalpingography is indicated at the end of phase 2 of the cycle. If an expansion of the internal os of more than 6–8 mm is diagnosed, the sign is regarded as unfavorable, and a woman with an ensuing pregnancy is included in the high-risk group for miscarriage.

During pregnancy, it is recommended to assess the condition of the cervix weekly (starting from 12 weeks) (inspection in mirrors, ultrasound scan of the cervix and determination of its length, as well as the condition of the internal os using transvaginal ultrasound).

Treatment

Treatment of miscarriage before pregnancy consists of surgical intervention on the cervix (for post-traumatic insufficiency), which consists of cervical plastic surgery.

When pregnancy occurs, surgical correction of the cervix (suturing) is performed in the period from 13 to 27 weeks. Indications for surgical treatment are softening and shortening of the neck, expansion of the external pharynx and opening of the internal pharynx. IN postoperative period vaginal smears are monitored and, if necessary, vaginal microflora is corrected. In case of increased uterine tone, tocolytics (ginipral, partusisten) are prescribed. Subsequent pregnancy management includes inspection of cervical sutures every 2 weeks. Sutures are removed at 37 weeks or in the event of an emergency (leakage or rupture of water, the appearance of blood from the uterus, cutting of sutures, and in the event of the onset of regular contractions, regardless of gestational age).

Endocrine causes of miscarriage

Miscarriage due to hormonal reasons occurs in 8–20%. In the forefront are such pathologies as luteal phase deficiency, hyperandrogenism, hyperprolactinemia, thyroid dysfunction and diabetes mellitus. Among habitual miscarriages of endocrine origin, luteal phase insufficiency occurs in 20–60% and is caused by a number of factors:

• failure of the synthesis of FSH and LH in phase 1 of the cycle;
• early or late LH surge;
• hypoestrogenism, as a reflection of defective maturation of follicles, which is caused by hyperprolactinemia, excess androgens, etc.

Diagnostics

When studying the anamnesis, attention is paid to the late development of menstrual function and cycle irregularity, a sharp increase in body weight, existing infertility or habitual spontaneous abortions in the early stages. During the examination, the physique, height and weight, hirsutism, the severity of secondary sexual characteristics, the presence of “stretch marks” on the skin, and mammary glands are assessed to exclude/confirm galactorrhea. A graph of basal temperature over 3 cycles is also assessed.

Additional examination methods

• Determination of hormone levels

In phase 1, the content of FSH and LH, thyroid-stimulating hormone and testosterone, as well as 17-OP and DHES are examined. In phase 2, progesterone levels are determined.

Ultrasound monitoring is carried out. In phase 1, endometrial pathology and the presence/absence of polycystic ovaries are diagnosed, and in phase 2, the thickness of the endometrium is measured (normally 10 - 11 mm, which coincides with the level of progesterone).

• Endometrial biopsy

To confirm luteal phase deficiency, endometrial aspiration is performed on the eve of menstruation.

Treatment

If luteal phase deficiency is confirmed, its cause must be identified and eliminated. In case of NLF against the background of hyperprolactinemia, MRI of the brain or radiography of the skull is indicated (evaluate the sella turcica - exclude pituitary adenoma, which requires surgical intervention). If no pituitary pathology is detected, a diagnosis of functional hyperprolactinemia is made and bromocriptine therapy is prescribed. After pregnancy occurs, the drug is discontinued.

If hypothyroidism is diagnosed, treatment with sodium levothyroxine is prescribed, which is continued after pregnancy.

Direct therapy for NLF is carried out in one of the following ways:

• stimulation of ovulation with clomiphene from days 5 to 9 of the cycle (no more than 3 cycles in a row);
• replacement treatment with progesterone drugs (Utrozhestan, Duphaston), which supports full secretory transformation of the endometrium in case of continued ovulation (after pregnancy, therapy with progesterone drugs is continued).

After using any method of treating NLF and pregnancy occurs, treatment with progesterone drugs is continued for up to 16 weeks.

Adrenal hyperandrogenism or adrenogenital syndrome

This disease is hereditary and is caused by a violation of the production of hormones of the adrenal cortex.

Diagnostics

The history includes indications of late menarche and an extended cycle up to oligomenorrhea, spontaneous abortions in the early stages, and possible infertility. Upon examination, acne, hirsutism, a male body type and an enlarged clitoris are revealed. Based on basal temperature charts, anovulatory cycles are determined, alternating with ovulatory ones against the background of NLF. Hormonal status: high content of 17-OP and DHES. Ultrasound data: the ovaries are not changed.

Treatment

Therapy consists of prescribing glucocorticoids (dexamethasone), which suppress excess androgen production.

Pregnancy management

Treatment with dexamethasone is continued after pregnancy until delivery.

Ovarian hyperandrogenism

Another name for the disease is polycystic ovary syndrome. The history includes indications of late menarche and cycle disorders such as oligomenorrhea, rare pregnancies ending in early miscarriages, and long periods of infertility. On examination, increased hair growth, acne and stretch marks, and excess weight are noted. According to basal temperature charts, periods of anovulation alternate with ovulatory cycles against the background of NLF. Hormonal levels: high levels of testosterone, possibly increased FSH and LH, and ultrasound reveals polycystic ovaries.

Treatment

Therapy for ovarian hyperandrogenism consists of normalizing weight (diet, physical activity), stimulating ovulation with clomiphene and supporting phase 2 of the cycle with progestin drugs. According to indications, surgical intervention is performed (wedge excision of the ovaries or laser treatment).

Pregnancy management

When pregnancy occurs, progesterone medications are prescribed for up to 16 weeks and dexamethasone for up to 12–14 weeks. The condition of the cervix is ​​checked and if ICI develops, it is sutured.

Infectious causes of miscarriage

The question of the significance of the infectious factor as a cause of repeated pregnancy losses still remains open. In the case of primary infection, pregnancy ends in the early stages, due to damage to the embryo that is incompatible with life. However, in the majority of patients with recurrent miscarriage and existing chronic endometritis, several types of pathogenic microbes and viruses predominate in the endometrium. The histological picture of the endometrium in women with recurrent miscarriage in 45–70% of cases indicates the presence of chronic endometritis, and in 60–87% there is activation of opportunistic flora, which provokes the activity of immunopathological processes.

Diagnostics

In case of miscarriage of infectious origin, there is a history of late miscarriages and premature birth (for example, up to 80% of cases of premature rupture of water are a consequence of inflammation of the membranes). Additional examination (at the pregnancy planning stage) includes:

• smears from the vagina and cervical canal;
• tank. inoculation of the contents of the cervical canal and quantitative determination of the degree of contamination with pathogenic and opportunistic bacteria;
• detection of sexually transmitted infections using PCR (gonorrhea, chlamydia, trichomoniasis, herpes virus and cytomegalovirus);
• determination of immune status;
• determination of immunoglobulins for cytomegalovirus and herpes simplex virus in the blood;
• study of interferon status;
• determination of the level of anti-inflammatory cytokines in the blood;
• endometrial biopsy (curettage of the uterine cavity) in phase 1 of the cycle, followed by histological examination.

Treatment

Treatment of miscarriage of an infectious nature consists of prescribing active immunotherapy (plasmapheresis and gonovaccine), antibiotics after provocation, and antifungal and antiviral drugs. Treatment is selected individually.

Pregnancy management

When pregnancy occurs, the state of the vaginal microflora is monitored, and studies are also carried out for the presence of pathogenic bacteria and viruses. In the first trimester, immunoglobulin therapy is recommended (administration of human immunoglobulin three times a day) and prevention of fetoplacental insufficiency is carried out. In the 2nd and 3rd trimesters, courses of immunoglobulin therapy are repeated, to which the administration of interferon is added. If pathogenic flora is detected, antibiotics and simultaneous treatment of placental insufficiency are prescribed. If the threat of miscarriage develops, the woman is hospitalized.

Immunological causes of miscarriage

Today it is known that approximately 80% of all “unexplained” cases of repeated pregnancy terminations, when genetic, endocrine and anatomical causes have been excluded, are due to immunological disorders. All immunological disorders are divided into autoimmune and alloimmune, which lead to recurrent miscarriage. In the case of an autoimmune process, “hostility” of immunity to a woman’s own tissues occurs, that is, antibodies are produced against one’s own antigens (antiphospholipid, antithyroid, antinuclear autoantibodies). If the production of antibodies by a woman’s body is directed towards the antigens of the embryo/fetus that it received from the father, they speak of alloimmune disorders.

Antiphospholipid syndrome

The frequency of APS among the female population reaches 5%, and the cause of recurrent miscarriage is APS in 27–42%. The leading complication of this syndrome is thrombosis; the risk of thrombotic complications increases as pregnancy progresses and after childbirth.

Examination and medicinal correction of women with APS should begin at the stage of pregnancy planning. A test is carried out for lupus anticoagulant and the presence of antiphospholipid antibodies; if it is positive, the test is repeated after 6 - 8 weeks. If a positive result is obtained again, treatment should be started before pregnancy.

Treatment

APS therapy is prescribed individually (the severity of the activity of the autoimmune process is assessed). Antiplatelet agents (acetylsalicylic acid) are prescribed together with vitamin D and calcium supplements, anticoagulants (enoxaparin, dalteparin sodium), small doses of glucocorticoid hormones (dexamethasone), and plasmapheresis if indicated.

Pregnancy management

Starting from the first weeks of pregnancy, the activity of the autoimmune process is monitored (lupus anticoagulant, antiphospholipid antibody titer are determined, hemostasiograms are assessed) and an individual treatment regimen is selected. During treatment with anticoagulants, OAC and platelet count determination are prescribed in the first 3 weeks, and then platelet levels are monitored twice a month.

Fetal ultrasound is performed from 16 weeks and every 3 to 4 weeks (assessment of fetometric indicators - growth and development of the fetus and the amount of amniotic fluid). In the 2nd – 3rd trimesters, study of the functioning of the kidneys and liver (presence/absence of proteinuria, level of creatinine, urea and liver enzymes).

Dopplerography to exclude/confirm placental insufficiency, and from 33 weeks conducting CTG to assess the condition of the fetus and decide on the timing and method of delivery. During childbirth and the day before, the hemostasiogram is monitored, and in the postpartum period the course of glucocorticoids is continued for 2 weeks.

Prevention of miscarriage

Nonspecific preventive measures for miscarriage include giving up bad habits and abortions, maintaining a healthy lifestyle and a thorough examination of the couple and correction of identified chronic diseases when planning pregnancy.

If there is a history of spontaneous abortion and premature birth, the woman is included in the high-risk group for recurrent miscarriage, and the spouses are recommended to undergo the following examination:

• blood type and Rh factor of both spouses;
• consultation with a geneticist and karyotyping of spouses if there is a history of early miscarriages, antenatal fetal death, the birth of a child with intrauterine developmental anomalies and existing hereditary diseases;
• examination for sexually transmitted infections for both spouses, and for the woman for TORCH infections;
• determination of a woman’s hormonal status (FSH, LH, androgens, prolactin, thyroid-stimulating hormones);
• exclude diabetes mellitus in a woman;
• if anatomical causes of miscarriage are identified, perform surgical correction (removal of myomatous nodes, intrauterine synechiae, cervical plastic surgery, etc.);
• preconception treatment of identified infectious diseases and hormonal correction of endocrine disorders.