Theoretical foundations of the pathology of miscarriage. Common miscarriage, causes, treatment, prevention, risk

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, very 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 a 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 for miscarriage (95) are represented by changes in the number of chromosomes, for example, monosomy, when one chromosome is lost, or trisomy, in which there is an extra chromosome, which is the result of errors in meiosis due to the influence of harmful factors(taking medications, radiation, chemical hazards, etc.). 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). 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 diagnosis(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 doubling, 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%, and the share birth defects development of 37% is due to a bicornuate uterus, 15% to a saddle uterus, 22% to a septum in the uterus, 11% to a double uterus and 4.4% to a 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 anamnesis contains indications of late miscarriages and premature birth, as well as pathology 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 makes it possible to identify 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 pregnancy and childbirth in the past, and then with repeated miscarriages and with uterine malformations surgical treatment has no 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, already from early dates 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 incompetence of the cervix, when it cannot be in a closed position, and as it progresses it shortens and opens, and cervical canal expands, which leads to prolapse of the fetal bladder, 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 the postoperative period, vaginal smears are monitored and, if necessary, the 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, body type are revealed. male type and an enlarged clitoris. 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 every other 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 are prescribed ( acetylsalicylic acid) together with vitamin D and calcium supplements, anticoagulants (enoxaparin, dalteparin sodium), small doses of glucocorticoid hormones (dexamethasone), 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;
• screening 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.

Miscarriage is one of the most important problems of modern obstetrics and has serious psychological consequences not only for the woman, but also for the entire family.

This is one of the most common complications of the gestational process with an incidence of 15% to 20% of all pregnancies, of which 5-10% are premature births. The threat of miscarriage complicates pregnancy in almost 40% of women. From 40% to 80% of spontaneous miscarriages occur in the first trimester of pregnancy, and almost every second woman does not even imagine that she had a pregnancy. As the duration of pregnancy increases (in the second and third trimesters), the frequency of spontaneous miscarriages decreases. Among stillborn children, over 50% are premature, and among those who died in the early neonatal period - 70-80%. .

Miscarriage is the spontaneous termination of pregnancy between conception and 37 weeks. A more serious pathology of miscarriage is recurrent miscarriage, in which spontaneous abortion occurs 2 times or more. In general, it accounts for 5% to 20% of the total number of miscarriages. The risk of pregnancy loss after the first miscarriage is 13-17%, while after two previous spontaneous abortions the risk of miscarriage is 36-38%.

There are several classifications of miscarriage. Let's look at the three taxonomies most commonly used in clinical diagnostics:

According to the timing at which the termination of pregnancy occurred;

According to the timing of termination of pregnancy, taking into account the weight of the fetus (WHO);

According to pathogenesis and clinical course.

The classification by timing of termination of pregnancy, which is used by Russian obstetricians, divides miscarriage into 4 categories:

• - early miscarriages - up to 12 weeks of gestation;
• - late miscarriages - 12-22 weeks of pregnancy;
• - termination of pregnancy at 22-27 weeks;
• - premature birth - from 28 weeks of pregnancy.

Let's look at the symptoms of premature birth. The incidence of premature birth is 7-10% of all births, of which 9-10% of children are born before 37 weeks, 6% before 36 weeks, 2-3% before 33 weeks.

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

With threatening premature birth, a woman complains of nagging, aching pain in the lower abdomen and lumbar region, a feeling of pressure, distension in the vagina, perineum and even rectum. This is all accompanied by individual contractions of the uterus. Increased uterine tone is determined by palpation. A vaginal examination shows a preserved cervix, its length is more than 1.5-2 cm, the external pharynx can be closed or slightly open, allowing the tip of the finger to pass through. The presenting part of the fetus is palpated in the upper or middle third of the vagina; it stretches the lower uterine segment. All the described signs indicate that premature labor is beginning.

Beginning premature labor begins with cramping pain in the lower abdomen and lower back, turning into regular contractions with an interval of 3-10 minutes. During vaginal examination, the cervix is ​​shortened to less than 1.5 cm or smoothed, and dilates. The most objective criterion for impending labor is the length of the cervix, determined by ultrasound. If the onset of premature labor cannot be stopped, then premature rupture of amniotic fluid may occur and the process progresses to the onset of premature labor.

If there is a threat of premature birth, bed rest, physical and sexual rest are strictly indicated for the pregnant woman. Along with drug therapy aimed at maturing the fetal lungs, herbal sedatives, such as motherwort and valerian decoction, are prescribed.

Rice. 1.1.

According to medical standards, the body weight of a premature newborn of less than 1000 g is considered extremely low, less than 1500 g is considered very low, and less than 2000 g is considered low. Experts note a relationship between the duration of an interrupted pregnancy and the frequency of perinatal morbidity and mortality: the shorter the duration, the more frequent the complications. Newborns weighing less than 1500 g are at risk for the development of paralysis, severe neurological disorders, blindness, deafness, functional and anatomical disorders of the respiratory, digestive, and genitourinary systems. This group has the highest mortality rate.

Children belonging to the low body weight group are successfully nursed in intensive care units for premature babies using special breathing equipment. In perinatal centers of the Russian Federation, the survival rate of newborns is:

• - 20% at 23 weeks;
• - 60% at 26 weeks;
• - 80% at 27-28 weeks
• - about 100% at 34-37 weeks.

The third classification of miscarriage shows the dependence of the condition of the fetus and its viability on the gestational age at which the termination of pregnancy occurred. Forecasts for the fetus depending on the timing of gestational termination are shown in Table 1.1.

The fourth classification of miscarriage based on pathogenesis and clinical course is based on two mechanisms of the initiation and development of the pathological process:

Contraction of the uterus with subsequent detachment of the ovum;

Detachment of the fertilized egg from the walls of the uterus, which is then accompanied by contraction of the uterine muscles. Sometimes these two processes have a common pathogenesis and act simultaneously.

Table 1.1. Condition and viability of the fetus depending on gestational age Compiled by the author in accordance with

Termination of pregnancy	Number of premature births, %	Fetal condition
27 weeks and 6 days inclusive		Extreme prematurity with body weight up to 1000 g. Severe immaturity of the lungs, although in some cases prevention of respiratory distress syndrome (RDS) is effective. The prognosis is extremely unfavorable, mortality is high.
28 - 30 weeks and 6 days inclusive		Severe prematurity with body weight up to 1500 g. By administering glucocorticoids, it is possible to accelerate the maturation of the fetal lungs. The prognosis for childbirth is more favorable for the fetus.
31-33 weeks and 6 days inclusive		Moderate miscarriage
34 - 36 weeks and 6 days inclusive		Low degree of miscarriage, children with almost mature lungs. No glucocorticoid administration is required, and the level of infectious complications is low. The infectious morbidity rate of children born at this time is significantly lower than those born at an earlier date. Prolonging pregnancy has no effect on perinatal mortality

The pathogenesis of miscarriage is very diverse and has several types of clinical manifestations (Fig. 1.2)

Let's give brief description, indicated in Fig. 1.2, types of abortions.

With a threatened abortion, the contractile activity of the uterus increases while the connection between the fertilized egg and the uterine wall is maintained. The growth and development of the fertilized egg (embryo or fetus) is generally not impaired, but risk factors for miscarriage develop.

Fig.1.2.

The woman feels a slight nagging pain or a feeling of heaviness in the lower abdominal area, possibly in the sacrum area. Bloody discharge is practically absent or insignificant in the form of streaks of blood in the mucous discharge of the cervix. Bimanual and ultrasound examination shows a slight dilation in the area of ​​the external os, the internal os is closed, and the cervix is ​​preserved. The tone of the uterine myometrium is increased, the size of the uterus corresponds to the stage of pregnancy. The prognosis is favorable with conservation therapy.

When an abortion begins, the fertilized egg is detached from the wall of the uterus. The following appear simultaneously clinical manifestations: cramping pain in the lower abdomen is more pronounced than with a threatened miscarriage, the discharge becomes bloody, the cervix is ​​soft and preserved, the tone and excitability of the myometrium are increased. The cervical canal and cervical canal are slightly open.

An ultrasound examination shows deformation of the fertilized egg (embryo, fetus), its low location, discrepancy between the fertilized egg and the gestational age, and detachment of the chorionic membrane is visible. The growth and development of the fertilized egg is impaired, there are signs of incipient expulsion.

Pregnancy can be saved by carrying out appropriate anti-inflammatory therapy if there is no bleeding and the examination does not reveal disturbances in the development of the ovum that are incompatible with the further development of pregnancy.

An abortion in progress begins with cramping pain in the lower abdomen and severe uterine bleeding. In this case, the fertilized egg completely peels off from the wall of the uterus and descends into its lower sections to the cervical canal. The lower pole of the ovum can be found in the vagina. Abortion in progress can end in incomplete or complete abortion.

Incomplete abortion is characterized by detachment of the fertilized egg and its incomplete expulsion from the woman’s genital tract. The remaining elements of the fertilized egg (membrane and parts of the placenta) remain in the uterus or, partially, in the cervix. Bloody discharge from the genitals can be of varying intensity. A two-handed examination reveals a shortened cervix with a strongly open canal and an internal pharynx where a finger can easily pass. The size of the uterus is smaller than expected for this stage of pregnancy.

Conservation therapy is not carried out for incomplete abortion. Curettage of the uterus is performed instrumentally or vacuum aspiration, followed by anti-inflammatory treatment.

Complete abortion often occurs later in pregnancy. Against the background of bleeding, the fertilized egg is completely expelled from the uterine cavity. The uterus shortens, becomes smaller than it should be in the corresponding gestational period, and bleeding stops.

The occurrence of a complete abortion is possible only at 12-13 weeks of pregnancy, after the formation of the placenta. Before this period, there is no confidence in the complete emptying of the uterine cavity. Therefore, it is necessary to perform curettage of the internal cavity of the uterus with a small curette or vacuum aspiration to completely remove the contents of the uterine cavity. If a complete abortion occurs after 14 - 15 weeks of gestation and the doctor is confident in the integrity of the placenta, then there is no need to perform uterine curettage.

Thus, we see that the problem of miscarriage, in terms of its social significance, occupies one of the leading places in modern obstetrics. The pathogenesis of miscarriage is manifested by a threatened abortion, an ongoing abortion, an abortion in progress, or a failed abortion. Depending on the timing of termination of pregnancy, miscarriage is considered as early and late miscarriage, termination of pregnancy and premature birth. The condition and viability of the fetus also depends on the timing of miscarriage.

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 medical care allow you to avoid serious 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 abortion is chromosomal abnormalities 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 in early pregnancy are caused by abnormalities of somatic chromosomes in the fetus, with the majority of chromosomal abnormalities 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 his life. intrauterine development. If for some reason the body expectant mother begins to produce hormones incorrectly, then disturbances hormonal levels cause a risk 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. She is considered the most common cause 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 pregnancy and so on.).

Some women have a congenital predisposition to thrombosis (thickening of the blood, the formation of blood clots in the 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 appears 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 may also cause non-developing pregnancy. 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). In this case, possible causes of late miscarriage may be 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, miscarriage is preceded by pulling painful sensations in the lower abdomen, which resembles 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 spotting 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 during a vaginal examination, since the cervix 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 survey results, it can be applied drug treatment(tablets, injections) that improves blood flow. Expectant mothers with impaired venous blood flow are recommended to wear therapeutic compression stockings.

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 immediately after spontaneous miscarriage in the early stages, treatment as such is not required. 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 repeated miscarriage in both the first and second trimesters of pregnancy). Such structural anomalies include: irregular shape of the uterus, the presence of a septum in the uterine cavity, benign neoplasms that deform the uterine cavity (fibroids, fibroids, fibromyomas) or scars from previous surgical interventions ( caesarean section, removal of fibromatous nodes). As a result of such violations, problems arise for the growth and development of the fetus. The solution in such cases is to eliminate 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 routine examination 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.

In the event that the reasons for repeated pregnancy failure cannot be detected even after a comprehensive examination, the 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 (introduced into the rectum), intravenous drips of magnesium.

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Miscarriage

1 Etiology and pathogenesis

Miscarriage is one of the most important problems of modern obstetrics. The frequency of this pathology in the total number of births is more than 15%.

The causes of spontaneous miscarriages are varied; often there is a combination of these causes leading to this complication of pregnancy.

CLASSIFICATION (1975).

Maternal infectious diseases

complications associated with pregnancy

traumatic injuries

isoserological incompatibility of maternal and fetal blood

developmental anomalies of the female genital area

neuroendocrine pathology

various non-communicable diseases of the mother

chromosomal abnormalities

1. Infectious diseases of the mother. They occupy an important place among the causes of miscarriage. Chronic latent infections: chronic tonsillitis, chronic appendicitis, urinary tract infection. The mechanism of action of the infection is different: many toxins penetrate the placental barrier, therefore, with general infectious diseases Bacteria and viruses and their toxins can become pathogenic factors. In acute febrile illnesses, hyperthermia can also lead to miscarriage. This termination of pregnancy can occur as a result of intrauterine damage to the fetus, membranes and due to premature contractions of the uterus.

For example: influenza, malaria, syphilis, toxoplasmosis, chlamydia, mycoplasmosis, rubella. Their recognition is carried out on the basis of the clinic and various studies: bacterioscopy, bacteriological, biological, pathomorphological.

Infections directly affecting the genital organs: uterus, ovaries, etc. after inflammatory processes of the internal genital organs, there may be changes in the position of the uterus, etc. Local inflammatory processes account for up to 34% of the cause of miscarriage.

2. Toxicosis of the first and second half of pregnancy. Premature rupture of water, polyhydramnios, abnormal position of the placenta, abnormal position of the fetus, multiple births.

Polyhydramnios is a pathology of pregnancy; as a rule, it is infectious (infection of the membranes, placenta) and is often combined with fetal deformity.

Premature rupture of water. If POV is observed in the early stages of pregnancy from 15 to 20 weeks, it is often associated with so-called cervical insufficiency (isthmic-cervical insufficiency).

3. Traumatic injuries: trauma, both physical and mental. More often, injuries to the uterus itself (as the main receptacle for the fetus). The main cause of these injuries is surgery induced abortion. During an abortion, the cervix is ​​injured; abortion can cause isthmic-cervical insufficiency: the cervix is ​​shortened and has a funnel-shaped shape, and the external and internal os gape - the cervix is ​​actually open. Isthmic-cervical insufficiency can be of organic (structural or traumatic) origin:

during gynecological operations

after complicated childbirth (cervical rupture)

diathermocoagulation

uterine malformations (5-10%)

with an open cervix, the fetal bladder prolapses and can become infected, and then there is a combination of reasons. In addition to trauma to the cervix during abortion, trauma to the uterine cavity itself is also observed, and even after an abortion without complications, dystrophic changes in the myometrium can occur, and after traumatic abortions, the uterine cavity becomes infected. If the infection is complete, then the woman suffers from infertility.

Other types of surgical trauma: removal of benign tumors, operations for ectopic pregnancy(excision of the tubular angle).

4. Isoserological incompatibility due to Rh factor or others. Sometimes there is one cause of miscarriage, usually combined with other causes.

5. From 4 to 11%. Uterine anomalies are difficult to diagnose and diagnose after termination of pregnancy. Hysterography, hysterosalpingography.

Saddle uterus. During the process of embryogenesis, the uterus consists of two primordia; therefore, in case of anomalies, a kind of bifurcation occurs.

Double reproductive apparatus: 2 vaginas, 2 cervixes, 2 uteruses are usually underdeveloped. If pregnancy occurs, it ends in miscarriage. There may be several pregnancies in the anamnesis, the timing of which increases with each pregnancy. The fetal sac develops.

Double uterus.

6. Neuroendocrine pathology.

Diabetes, if not compensated in the early stages. Diabetes mellitus is often accompanied by polyhydramnios and a large fetus.

Hypo- and hyperthyroidism is a pathology of the ovaries: an unsteady cycle, an underdeveloped reproductive system, painful menstruation, hormonal deficiency in the form of a decrease in progesterone, gonadotropin, estrogens. In case of insufficiency of ovarian function: the mucosa is underdeveloped, the egg develops poorly in this mucosa, the placenta is underdeveloped, and functional cervical insufficiency develops.

Dysfunction of the adrenal cortex: phenomena of hyperandrogenism.

7. Estragenal pathology not associated with inflammatory processes: ischemic heart disease, anemia, various intoxications (benzene, nicotine).

8. Chromosomal abnormalities. In older parents, when using contraceptives, pregnancy is accidental. Use of antidiabetic drugs. Radiation exposure, etc. diseases during pregnancy: rubella, influenza, hepatitis.

2 The examinationWomen suffering from miscarriage

The examination should, if possible, be outside of pregnancy; it is necessary to exclude all types of pathology, and treat several possible causes. First, it is necessary to exclude infectious causes, since it is impossible and impossible to treat infections during pregnancy. Secondly, exclude genetic pathology.

Functional diagnostics to exclude neuroendocrine pathology.

Hysterosalpingography to exclude uterine malformations.

To exclude changes in adrenal function - urine analysis for corticosteroids, hormonal tests.

PREPARATION FOR PREGNANCY.

Treatment of all infections of the woman and her husband.

Hormone therapy. For adrenal hyperandrogenism, treat with prednisolone (1 tablet 4 times a day for 10 days, reduce to 1-2 tablets per day until the first half of pregnancy.

If there is a threat of miscarriage, the options are limited:

mandatory hospitalization

normalization of the neuropsychic state: conversations, psychotropic drugs.

Eliminating the cause of miscarriage

symptomatic therapy.

During pregnancy, penicillin and ampicillin can be prescribed in early pregnancy. For hormonal disorders, progesterone, vitamin E, estrogens, human chorionic gonadotropin, sigetin with glucose, antispasmodics: metacin, no-spa, intramuscular magnesium are prescribed, and in the later stages - tocolytes - adrenergic agonists.

In case of cervical insufficiency, a circular suture is placed on the cervix after 12 weeks with lavsan until 36 weeks. If a fistula forms in the cervix, childbirth can pass through it.

3 Classication of spontaneous miscarriages

Miscarriage - termination of pregnancy before 28 weeks, after 28 weeks - premature birth, up to 1 kg - fetus, more than 1 kg - child.

From 5 to 14-16 weeks - early miscarriage, from 16 to 27 weeks - late miscarriage.

DEVELOPMENTAL CLASSIFICATION.

Threatening miscarriage. There is a threat. Characterized by unexpressed, nagging pain in the lower abdomen, tone may be increased, and sometimes spotting. When examined with the help of mirrors: the cervix - there are no structural changes, that is, the cervix is ​​intact, the external os is closed. For treatment see above.

The beginning of a miscarriage - detachment of the ovum, spotting, constant pain in the lower abdomen, which can take on a cramping nature, increased tone of the uterus, the presence of moderate spotting. When examined in mirrors, there are practically no structural changes in the cervix: the cervix is ​​intact. The external pharynx is closed, there is always slight bleeding. You can continue your pregnancy. Treatment see above + hormones for hormonal deficiency.

Abortion is in progress. Almost the entire fertilized egg has already detached - strong frequent contractions in the lower abdomen, the cervix opens, frequent strong cramping pains, profuse spotting, profuse bleeding. The condition is serious, there may be post-hemorrhagic shock, anemia. On internal examination, the cervix is ​​shortened, the canal is open, allowing 1-2 fingers to pass through, the uterus corresponds to the gestational age, and there is profuse bleeding. The pregnancy cannot be saved. Stop bleeding, replenish blood loss. Stopping bleeding is done by curettage of the uterine cavity. A contraindication is infection (the fertilized egg is removed with an abortionist).

Incomplete abortion - decrease in pain in the lower abdomen, bleeding continues. The condition can be severe. The pregnancy cannot be saved. The neck is shortened, 2 fingers pass through, the size is less than the gestational age. The tactics are the same as in point 3.

Complete abortion: no complaints - no pain, no bleeding. Abortion according to medical history. There should not be any bleeding; if there is, it is an incomplete abortion. It is rare, the uterus is dense, the cervix is ​​shortened, the canal is passable, which indicates that a miscarriage has occurred. There is practically no need for help. This is how abortion often occurs with isthmic-cervical insufficiency. Hormonal examination no earlier than six months later.

Failed miscarriage (frozen pregnancy). Detachment occurred, but the fertilized egg remained in the uterus. The fetus dies and the uterus stops growing.

Previously, they waited for an independent miscarriage until the development of a generic dominant, in which case the fetus became mummified. This is fraught with bleeding in the postpartum period. Frozen pregnancy often leads to blood clotting pathology (DIC syndrome).

Simultaneous curettage, stimulation with oxytocin. Often there is afibrinogenemia - bleeding that is very difficult to stop.

4 Bleeding in the postpartum and early labor period

Previously, people died from these bleedings.

The normal afterbirth period lasts 2 hours (within 2 hours the afterbirth should separate from the walls of the uterus). The placenta is normally located along the posterior wall of the uterus with a transition to the side (or bottom). Separation of the placenta occurs in the first 2-3 contractions after the birth of the fetus, although it can separate from the walls during the birth of the fetus.

In order for the placenta to separate, the contractility of the uterus must be high (that is, equal to that in the 1st period).

The placenta is separated due to the fact that there is a discrepancy between the volume of the uterine cavity and the placental site. Separation most often occurs in the first 10-15 minutes after the birth of the fetus (in classical obstetrics, the placenta can separate within 2 hours after birth).

The mechanism of hemostasis in the uterus.

Myometrial retraction - the most important factor is the contractility of the uterus.

Hemocoagulation factor - processes of thrombosis of blood vessels of the placental site (they do not apply to other organ systems). Provide thrombosis processes:

plasma factors

blood cells

biologically active substances

Childbirth is always accompanied by blood loss since there is a hematochorial type of placenta structure.

Tissue factors

Vascular factors.

Prof. Sustapak believes that part of the placenta, amniotic fluid and other elements of the fetal egg are also involved in the process of thrombus formation.

These assumptions are correct because violations occur when:

antenatal fetal death (birth dead fetus) if the fetus is born more than 10 days after death, disseminated intravascular coagulation may develop. Therefore, in case of antenatal death, they strive to end the birth as quickly as possible.

Amniotic fluid embolism (mortality rate 80%) also leads to disseminated intravascular coagulation.

Disturbances in any part of hemostasis can lead to bleeding in the afterbirth and early postpartum period.

Normal blood loss is no more than 400 ml, anything higher is pathology (no more than 0.5% of body weight).

Separation of the placenta occurs from the center (formation of a retroplacental hematoma) or from the edge, hence the clinical difference during the period:

if the placenta separates from the center, the blood will be in the membranes and there will be no bleeding until the placenta is born.

If the edge is separated, then when signs of placenta separation appear, bleeding appears.

Risk groups for the development of bleeding (in general).

I. If we assume that muscle retraction is the main mechanism of hemostasis, then we can distinguish 3 risk groups:

violation of uterine contractility before the onset of labor:

abnormalities of the uterus

uterine tumors (fibroids)

if there were inflammatory diseases of the uterus (endometritis, metroendometritis).

Dystrophic disorders.

Women who have hyperstretched myometrium:

large fruit

polyhydramnios

multiple births

Women who have somatic and endocrine pathologies.

Risk group II.

Women whose contractility of the uterus is impaired during childbirth.

Childbirth complicated by anomalies labor activity(excessive labor, weakness of labor).

With excessive use of antispasmodic drugs.

Women with traumatic injuries (uterus, cervix, vagina).

III risk group. These are women who have disrupted processes of attachment and separation of the placenta and abnormalities in the location of the placenta:

placenta previa complete and incomplete

PONRP develops during childbirth

firm placenta attachment and true placenta accreta

retention of parts of the placenta in the uterine cavity

spasm of the internal os with separated placenta.

That is, risk groups are women with extragenital pathology, with complications of pregnancy, with complications of childbirth.

Bleeding in the afterbirth period.

Caused by disruption of the processes of separation of the placenta and discharge of the placenta.

There are 2 phases during the period:

separation of the placenta

discharge of placenta

Violation of the process of separation of the placenta:

in women with weak labor

with tight attachment and true increment

Tight attachment of the placenta is when the chorionic villi do not extend beyond the compact layer of the decidua. It can be complete or incomplete depending on the length.

True accretion - villi penetrate the muscular lining of the uterus up to the serosa and sometimes cause uterine rupture. Occurs in 1/10,000 births. It can be complete or incomplete depending on the length.

If there is complete true accretion and complete tight attachment, then there will never be bleeding, that is, when the entire placental area adjoins or grows into the muscle wall.

With true partial accreta, part of the placenta separates and bleeding occurs in the afterbirth period.

Bleeding in the placenta can develop when parts of the placenta are retained, when part of the placenta is separated and released, but a few lobules remain or a piece of the membrane remains and interferes with the contraction of the uterus.

Impaired discharge of placenta.

Violation when:

hypotonicity of the uterus

spasm of the internal pharynx

Spasm can occur if contractile agents are used incorrectly in the afterbirth period.

Tactics for managing the afterbirth period.

Principle: hands off the uterus!

Before checking contact signs, you need to check non-contact signs: look at the umbilical cord, which is lengthening (positive Alfeld sign). The uterus deviates to the right, upwards and flattens (Schroeder's sign), the umbilical cord retracts with a deep breath (Dovzhenko's sign).

You need to start separating the placenta as soon as signs of separation appear.

Or physiologically (pushing)

external techniques (Abuladze, Genter, Crede-Lazarevich) - these techniques can only separate the separated placenta.

If bleeding occurs in the afterbirth period, the first task of the obstetrician is to determine whether there are signs of placental separation.

There are signs of placenta separation.	There are no signs of placental separation.
Immediately remove the afterbirth using external methods estimate blood loss administer or continue administration of uterotonics put ice and weight on your stomach to clarify the condition of the woman in labor and the amount of blood loss examine the afterbirth and the integrity of its tissues	Assess the general condition of the woman in labor and the amount of blood loss Give intravenous anesthesia and begin or continue the administration of uterotonics after first performing an external massage of the uterus Proceed with the operation of manual separation of the placenta and release of the placenta.
If blood loss is normal, then you need to: monitor the woman's condition administer uterotonics for another 30-40 minutes.
If the blood loss is pathological, then you need to do: Determine the woman's condition Compensate for blood loss: for blood loss of 400-500 ml - gelatinol + saline solution + oxytocin intravenously. If blood loss is more than 500 ml, then hemodynamic disturbances occur and blood transfusion is necessary.

The operation of manual separation of the placenta and discharge of the placenta.

The hand is inserted into the uterine cavity.

Professor Akinints proposed a method - a sterile sleeve is put on the hand and the fingers are covered when inserted into the vagina; the assistants pull the sleeve towards themselves and thus reduce infection.

The hand must get between the wall of the uterus and the fetal membranes, so that with sawing movements they reach the placental area, separate it from the wall and release the afterbirth.

Reassess blood loss. If blood loss before surgery is 300-400, then during surgery it increases due to traumatic injuries.

Compensate for blood loss.

Continue intravenous administration of uterotonics.

With complete true growth and complete tight attachment, there is no bleeding (according to classical laws, wait 2 hours). In modern conditions, the rule is to separate the placenta 30 minutes after the birth of the fetus, if there are no signs of placental separation and no bleeding. Performed: operation of manual separation of the placenta and release of the placenta.

Further tactics depend on the result of the operation:

If the bleeding has stopped as a result of the operation, then you need to:

estimate blood loss

If bleeding continues due to placenta accreta, attachment, etc. then this bleeding progresses into the early postpartum period.

Before the operation of manual separation of the placenta, no data can be used to make a differential diagnosis of dense attachment or true placenta accreta. Differential diagnosis is only during surgery.

If the attachment is tight, the hand can separate the decidula from the underlying muscle tissue; with true accretion, this is impossible. Do not overdo it, as very heavy bleeding may develop.

In case of true accreta, the uterus must be removed - amputation, extirpation, depending on the location of the placenta, obstetric history, etc. this is the only way to stop the bleeding.

Bleeding in the early postpartum period.

Most often it is a continuation of complications in all stages of labor.

The main reason is the hypotonic state of the uterus.

Risk group.

Women with weakness of labor.

Delivery of a large fetus.

Polyhydramnios.

Multiple births.

Pathogenesis. Impaired thrombus formation due to exclusion of the muscle factor from the mechanisms of hemostasis.

Also causes of bleeding in the early postpartum period may be:

injuries of the uterus, cervix, vagina

blood diseases

Variants of hypotonic bleeding.

Bleeding immediately and profusely. In a few minutes you can lose 1 liter of blood.

After taking measures to increase the contractility of the uterus: the uterus contracts, bleeding stops after a few minutes - a small portion of blood - the uterus contracts, etc. and so gradually, in small portions, blood loss increases and hemorrhagic shock occurs. With this option, the vigilance of personnel is reduced and they often lead to death since there is no timely compensation for blood loss.

The main operation that is performed for bleeding in the early postpartum period is called MANUAL EXAMINATION OF THE UTERINE CAVITY.

Objectives of the ROPM operation:

determine whether there are any retained parts of the placenta left in the uterine cavity and remove them.

Determine the contractile potential of the uterus.

Determine the integrity of the uterine walls - whether there is a uterine rupture (clinically difficult to diagnose sometimes).

Determine whether there is a malformation of the uterus or a tumor of the uterus (a fibromatous node is often the cause of bleeding).

The sequence of performing the operation of manual examination of the uterine cavity.

Determine the amount of blood loss and the general condition of the woman.

Treat hands and external genitalia.

Give intravenous anesthesia and begin (continue) the administration of uterotonics.

Empty the uterine cavity of blood clots and retained parts of the placenta (if any).

Determine the tone of the uterus and the integrity of the uterine walls.

Examine the soft birth canal and suturing the damage, if any.

Re-evaluate the woman’s condition for blood loss and compensate for blood loss.

SEQUENCE OF ACTIONS IN STOPING HYPOTONIC BLEEDING.

Assess the general condition and volume of blood loss.

Intravenous anesthesia, start (continue) administration of uterotonics.

Proceed with manual examination of the uterine cavity.

Remove clots and retained parts of the placenta.

Determine the integrity of the uterus and its tone.

Inspect the soft birth canal and suture the damage.

Against the background of ongoing intravenous administration of oxytocin, simultaneously inject 1 ml of methylergometrine intravenously and 1 ml of oxytocin can be injected into the cervix.

Insertion of tampons with ether into the posterior fornix.

Re-assessment of blood loss and general condition.

Reimbursement for blood loss.

Obstetricians also distinguish atonic bleeding (bleeding in the complete absence of contractility - Couveler's uterus). They differ from hypotonic bleeding in that the uterus is completely inactive and does not respond to the administration of uterotonics.

If hypotonic bleeding does not stop with ROPM, then further tactics are as follows:

apply a suture to the posterior lip of the cervix with a thick catgut ligature - according to Lositskaya. Mechanism of hemostasis: reflex contraction of the uterus, since a huge number of interoreceptors are located in this lip.

The same mechanism occurs when introducing a tampon with ether.

Applying clamps to the cervix. Two fenestrated clamps are inserted into the vagina, one open branch is located in the uterine cavity, and the other in the lateral fornix of the vagina. The uterine artery departs from the iliac artery in the area of ​​the internal os and is divided into descending and ascending parts. These clamps compress the uterine artery.

These methods sometimes help stop bleeding, and sometimes are steps in preparation for surgery (as they reduce bleeding).

Massive blood loss is considered to be blood loss during childbirth of 1200 - 1500 ml. Such blood loss dictates the need for surgical treatment - removal of the uterus.

When starting the hysterectomy operation, you can try another reflex method to stop bleeding:

ligation of vessels according to Tsitsishvili. Vessels passing through the round ligaments, the ligament proper of the ovary, the uterine tube, and the uterine arteries are ligated. The uterine artery runs along the rib of the uterus. If it doesn’t help, then these clamps and vessels will be preparatory for removal.

Electrical stimulation of the uterus (now they are moving away from it). Electrodes are placed on the abdominal wall or directly on the uterus and a shock is delivered.

Acupuncture

Along with stopping bleeding, blood loss is compensated.

Prevention of bleeding.

Bleeding can and should be predicted based on risk groups:

extragenital pathology

pregnancy complications

gestosis (chronic stage of disseminated intravascular coagulation)

multiparous

large fetus, polyhydramnios, multiple births

weakness of labor during childbirth

This requires examination of the woman during pregnancy:

blood platelet test

blood coagulation potential

skilled labor management

Prevention of bleeding in the afterbirth and early postpartum period:

Administration of uterotonics depending on the risk group.

Minimum risk group: women with no medical history. Bleeding may occur because childbirth is a stressful situation, and the body’s reaction may be different. Administration of uterotonics intramuscularly after the birth of the placenta: oxytocin, pituitrin, hyfotocin 3-5 units (1 unit = 0.2 ml) higher risk group. Intravenous drip of oxytocin, which begins in the second stage of labor and ends within 30-40 minutes after birth. Or according to the scheme: methylergometrine 1 mg in 20 ml of physiological solution (5% glucose solution) intravenously in a stream at the moment of eruption of the head.

In a high-risk group, a combination of intravenous drip administration of oxytocin + simultaneous administration of methylergometrine.

Violation of hemostasis during childbirth is identified as follows:

Lee-White test (blood is taken from a vein into a test tube and seen when the blood clots).

You can determine the coagulation potential on a glass slide using the Folia method: 2-3 drops from your finger and determine how many minutes the blood will clot.

The first stage of labor is 3-5 minutes.

The second stage of labor is 1-3 minutes.

Third period 1-3 minutes.

NORM ACCORDING TO LEE-WHITE.

The first period is 6-7 minutes.

Third period 5 minutes.

Early postpartum period 4 minutes.

A woman at risk should be provided with blood substitutes and blood before going into labor.

Bibliography

To prepare this work, materials from the site http://referat.med-lib.ru were used

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Miscarriage is one of the serious problems of modern obstetrics, the frequency of which is 10-25% of all pregnancies. About 25% of cases of miscarriage are recurrent miscarriages, the frequency of premature births is 4-10% of the total number of all births.

Classification

According to the timing of occurrence, they are distinguished:

1) spontaneous (sporadic):

up to 11 weeks + 6 days - early abortion;

12-21 weeks + 6 days - late abortion (fetal weight up to 500 g);

2) premature birth:

22-27 weeks + 6 days of pregnancy - early premature birth (fetal body weight - 500-1000 g);

28-36 weeks + 6 days - premature birth (fetal body weight - over 1000 g).

Spontaneous abortion - expulsion of the embryo before 22 weeks of pregnancy. or with a body weight of up to 500 g, regardless of the presence of signs of fetal life.

The following types of abortions are distinguished by stages:

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

Also distinguished:

• - failed abortion;
• - infected abortion.

In the case of two consecutive spontaneously terminated pregnancies, they speak of recurrent miscarriage, which requires treatment outside of pregnancy.

Causes

The causes of miscarriage are extremely varied. Violations are usually caused by a combination of a number of reasons. Significant difficulties arise in determining the leading etiological factor of abortion.

Factors from the pregnant woman:

• endocrine - ovarian, adrenal, hypothalamic-pituitary and their combinations;
• anatomical and functional - isthmic-cervical insufficiency, muscular synechiae, infantile uterus, uterine developmental anomalies.

Incompatibility between mother and fetus:

• genetic;
• immunological.

Complications of pregnancy:

• placenta previa;
• multiple pregnancy;
• polyhydramnios;
• malposition;
• premature rupture of membranes;
• premature placental abruption.

Extragenital pathology:

• infections - viral, bacterial, protozoal (acute and chronic);
• diseases of the cardiovascular, urinary and hepatobiliary systems;
• disturbances in the plasma and vascular-platelet components of hemostasis (thrombophilic causes);
• surgical diseases of the abdominal organs.

Environmental factors:

• occupational hazards;
• social, including bad habits - smoking, drinking alcohol.

Infectious factor. Among the causes of fetal death, many consider infection as the leading etiological factor. Persistent infection, viral and bacterial, is one of the main causes of miscarriage. In most cases (more than 80%), the infection is mixed.

Endocrine factors. In 64-74% of cases of miscarriage, the leading role belongs to hormonal disorders, primarily hormonal insufficiency of the ovaries and placenta against the background of sexual infantilism (70-75%). The main component of hormonal insufficiency of the ovaries and placenta is estrogen deficiency, which in 60-80% of cases is combined with progesterone deficiency. In other cases, it is observed in isolation. In 50-60% of cases, insufficient production of human chorionic gonadotropin is noted. Hormonal deficiency of female hormones, often together with pathology of other endocrine components, primarily the adrenal glands and thyroid gland, is the most common cause of miscarriage.

Genital defects and anatomical defects. The causes of reproductive dysfunction are seen in isthmic-cervical insufficiency (incompetence of the internal os), anatomical and functional inferiority of the uterus, and hypoplasia. Isthmic-cervical insufficiency is one of the main causes of abortion from 15-16 to 28 weeks of gestation. The frequency of this cervical pathology in patients with miscarriage is 18.7-34%. With this pathology, spontaneous smoothing and dilatation of the cervix occurs, not caused by its contractile activity and leading to repeated termination of pregnancy. Failure may be functional in nature, depending on endocrine disorders, in particular ovarian hypofunction. However, more often it is acquired (organic in nature) due to injury to the internal os during artificial interruption pregnancy (up to 42%), less often - with the application of obstetric forceps, fetal extraction, delivery of a large fetus, unrepaired cervical ruptures. In cases of miscarriage, the following types of uterine anomalies often occur: intrauterine septum, bicornuate uterus, saddle uterus, unicornuate and rarely double uterus. Anatomical factors also include uterine fibroids, intrauterine adhesions and scars that deform its cavity, the consequences of abortions and interventions in the uterine cavity (diagnostic curettage, intrauterine infusions).

Genetic abnormalities. Chromosomal imbalance caused by chromosome deficiency or duplication leads to spontaneous abortion. Approximately 70% of early spontaneous abortions are associated with chromosomal abnormalities in the fetus. In addition, chromosomal abnormalities are detected in 30% of cases in the 2nd trimester and in 3% of stillbirths.

Immunological disorders. 80% of miscarriages are based on immunological disorders. Alloimmune and autoimmune disorders are distinguished. In alloimmune disorders, the woman’s body’s response is directed against fetal antigens that are foreign to her body. An example of alloimmune disorders is hemolytic disease due to Rh or ABO sensitization. Autoimmune reactions are an abnormal immune response of the mother to her own proteins, that is, the woman rejects her own proteins by releasing autoantibodies that attack her own antigens. In the autoimmune aspects of miscarriage, one of the main places is occupied by antiphospholipid syndrome (APS), the frequency of detection of which in women with miscarriage is about 27%. The development of APS is based on the formation of autoantibodies to phospholipid complexes, which are found in large quantities in the vascular endothelium, platelets, lung and brain tissues.

Hemorrhagic defects. Miscarriage associated with hemorrhagic defects occurs due to disruption of normal fibrin formation at the site of egg implantation.

Other significant factors. The risk of repeated spontaneous abortion increases in the presence and cumulative impact of such unfavorable factors as trauma to the pregnant woman (physical or mental), extragenital pathology of the mother (diseases). of cardio-vascular system mother, kidney disease, liver), complications associated with pregnancy (preeclampsia, polyhydramnios, premature placental abruption, placental insufficiency), industrial, environmental and household hazards, husband’s health condition, pathological changes ejaculate.

Unexplained spontaneous abortion (idiopathic). For a significant proportion of women, the cause of spontaneous abortion remains unclear, despite all the research. The incidence of idiopathic miscarriage ranges from 27.5 to 63.7%. Psychological support is effective in such cases, while empirical drug therapy is not very effective.

Pathogenesis

In the pathogenesis of miscarriage, the leading role is played by violations of cortical and cortico-subcortical relationships that arise under the influence of many reasons, among which, in addition to the complex reflex connection between mother and fetus, numerous factors influencing the nature and intensity of reflex effects or changing them are of great importance.

Taking into account the listed etiological factors, we can distinguish 4 main pathogenetic variants of miscarriage:

1. disruption of immune and hormonal homeostasis in the fetoplacental complex. This combination of two factors is due to the common central mechanism of regulation of immunogenesis and hormonogenesis. These mechanisms of abortion are mainly characteristic of early pregnancy (up to 12 weeks);
2. the prevalence of the mechanisms of contractile activity of the uterus, as a result of which fetal rejection occurs according to the type of labor. This is typical for the second half of pregnancy, when significant morphological and functional changes develop in the uterus;
3. chromosomal mutations or genetic defects leading to the death of the embryo or fetus;
4. isthmic-cervical insufficiency.

Reproductive losses are combined into the so-called fetal loss syndrome. This syndrome includes:

• one miscarriage or more spontaneous abortions within 10 weeks. and more;
• history of stillbirth;
• neonatal death;
• three or more spontaneous abortions at the preembryonic or early embryonic stage.

Diagnostics

Based on the identification of two main groups of causes of miscarriage - genetic and non-genetic - it is necessary to conduct clinical and laboratory studies, taking into account their feasibility, including from an economic point of view.

The scope of examination for miscarriage is determined by the polyetiology of this pathology.

Traditional methods for diagnosing disorders of the anatomical structure of the reproductive organs are, according to indications, hysterosalpingography and hysteroscopy. Sometimes an MRI is required to clarify the diagnosis of miscarriage.

Determining the condition of the cervix is ​​necessary for diagnosing isthmic-cervical insufficiency. Its presence is indicated by: during vaginal examination - ectocervix defects, cervical dilation up to 2 cm or more in the 2nd trimester in the absence of uterine contractions and placental abruption, prolapse of the amniotic sac; with transvaginal ultrasound - the cervix is ​​shortened to 25 mm or more in 16-24 weeks, wedge-like transformation of the cervical canal by 40% of the entire length or more.

Diagnosis of persistent infection includes assessment of the antigen itself and the body's response to these antigens. Informative diagnostic methods are polymerase chain reaction, determination of IgG, IgM class antibodies, enzyme immunoassay method (determines the presence of a chronic or acute process), cultivation method, determination of the state of cellular and humoral immunity.

To clarify the function of the adrenal glands, the violation of which can seriously affect the preparation of the body for pregnancy, a study of 24-hour urine for 17-hydroxyketosteroids is carried out. A very important role is played by the diagnosis of thyroid function, a decrease in which causes an increase in the likelihood of spontaneous abortion and stillbirth. and in a newborn - to an increased likelihood of developmental delays.

Disturbances in the plasma and vascular-platelet components of hemostasis are determined by examining the hemostasis system and assessing blood clotting time, platelet count, prothrombin index, APTT, thrombin time, level of antithrombin 3, protein C, fibrinogen, fibrin and fibrinogen degradation products. Detection of deviations in these parameters may indicate thrombotic causes of miscarriage.

The final way to identify non-genetic causes of miscarriage is an immunological study, namely an immunogram and the detection of various autoantibodies.

To diagnose antiphospholipid syndrome as a cause of miscarriage, lupus anticoagulant and antiphospholipid antibodies are determined using standard tests. Positive result Testing antiphospholipid antibodies twice with an interval of a month at the level of medium and high titers serves as the basis for diagnosing antiphospholipid syndrome and carrying out treatment.

Thus, it is advisable to adhere to the following examination algorithm, which includes: karyotyping of all products of conception, karyotyping of blood cells of spouses, if karyotype abnormalities are detected - consultation of a clinical geneticist, ultrasound of the pelvic organs, examination for the presence of persistent infections, hormonal studies, immunogram and immunological tests, screening tests for antiphospholipid antibodies (lupus anticoagulant and anticardiolipids), examination of the hemostatic system.

Symptoms and treatment of miscarriage

Common clinical manifestations of spontaneous abortion are bloody discharge from the genitals of varying intensity and in the lower abdomen. However, each stage of abortion has its own clinical manifestations, diagnostic criteria and appropriate treatment tactics.

Threatened abortion

Women complain of nagging pain in the lower abdomen, which in the 2nd trimester can be cramping in nature; scanty bleeding. The size of the uterus corresponds to the term, it is easily excitable, its tone is increased. When examining the cervix in a speculum, the external os is closed. Ultrasound signs of a threatened abortion are: deformation of the contour of the fetal egg, depression due to the hypercone of the masha, the presence of an area of ​​chorion or placenta detachment. At this stage, with targeted treatment, pregnancy can be saved. Before starting treatment, it is necessary to determine the viability of the embryo and the prognosis of pregnancy. Prognostic criteria for pregnancy progression are used.

Unfavorable criteria for pregnancy progression include:

• history of spontaneous abortion;
• age over 34 years;
• absence of heart contractions with fetal CTE of 6 mm (by transvaginal ultrasound) and 10 mm (by transabdominal ultrasound);
• presence of bradycardia;
• an empty fertilized egg with a diameter of 15 mm at a gestation period of 7 weeks, 21 mm at a gestation period of 8 weeks;
• the size of the fertilized egg is 17-20 mm or more in the absence of an embryo or yolk sac in the egg;
• lack of growth of the fertilized egg for 10 days;
• discrepancy between the size of the embryo and the size of the fertilized egg;
• presence of subchorionic hematoma;
• hCG level is below normal or increases by less than 66% in 2 days;
• progesterone levels are below normal.

If unfavorable signs of pregnancy progression are detected, the ultrasound should be repeated after 7 days, if the pregnancy has not been terminated. If there are signs of threatened abortion before 8 weeks. and unfavorable signs of pregnancy progression, therapy to maintain pregnancy is not recommended.

Treatment for threatened miscarriage should be comprehensive. Medications should be prescribed according to strict indications, in minimal doses, combined with non-drug agents (electroanalgesia, acupuncture, electrorelaxation of the uterus, herbal aromatherapy). It should be remembered that due to the teratogenic effect during the period of organogenesis (18-55 days from the moment of conception), many medications are contraindicated.

Abortion in progress

The detached fertilized egg exits the uterine cavity through the dilated cervical canal. Pregnant women complain of cramping pain in the lower abdomen, bleeding, often profuse. During a vaginal examination, the opening of the cervical canal is determined, with parts of the fertilized egg in it. Ultrasound reveals complete (almost complete) detachment of the ovum (before 12 weeks), the presence of an area of ​​placental abruption (after 12 weeks). Management tactics depend on the stage of pregnancy. For gestational age up to 16 weeks. vacuum aspiration or curettage of the uterus is performed urgently. Examination of the removed tissue is mandatory. In pregnancy after 16 weeks. vacuum aspiration or curettage of the uterus is carried out after spontaneous expulsion of the fertilization product. In the case of bleeding under conditions, without waiting for the spontaneous expulsion of the embryo, the contents of the uterus are evacuated and hemodynamics are stabilized. In the absence of conditions for immediate evacuation of the contents of the uterus, with continued heavy bleeding, it is necessary to perform an abdominal termination of pregnancy.

Incomplete abortion

The fertilized egg does not completely leave the uterine cavity; parts of it remain. The patient is bothered by cramping pain and bloody discharge from the genitals of varying severity. In this case, the neck is shortened, the external os is open. The consistency of the uterus is soft, its size does not correspond to the gestational age. Ultrasound reveals: the uterine cavity is dilated by more than 15 mm, the cervix is ​​open, the fertilized egg is not visualized, tissues of a heterogeneous structure can be detected. In case of incomplete abortion, the uterus is freed from embryonic tissue with pathohistological examination. There are surgical and medicinal methods for freeing the uterine cavity from the fertilized egg.

The absolute indications for the surgical method of evacuation of the contents of the uterine cavity are:

• heavy bleeding;
• the uterine cavity is dilated >50 mm (according to ultrasound);
• temperature increase >37.5.

In the medical method of evacuation of the contents of the uterine cavity during incomplete abortion, large doses of prostaglandin E (800-1200 mg) are used.

The drug of choice is misoprostol, which in a dose of 800-1200 mg is administered intravaginally into the posterior fornix in a hospital setting. A few hours (usually 3-6 hours) after its administration, coloration of the uterus and expulsion of the fertilized egg begin. Usage this method effective for incomplete abortion within seventy days from the first day of the last menstruation. The advantage of using the medication method is a reduction in the incidence of pelvic infections. However, this method has a number of contraindications: adrenal insufficiency, long-term treatment with glucocorticoids, hemoglobinopathy, glaucoma, taking NSAIDs within the previous 48 hours, arterial hypertension, bronchial asthma. If significant bleeding occurs, symptoms of infection appear, evacuation fails after administration of prostaglandin E1 after 8 hours, or remains of the fertilized egg are detected in the uterus during an ultrasound, after 7 days the surgical evacuation method is started.

Complete abortion

The fertilized egg completely leaves the uterine cavity. It contracts, and the cervical canal closes. Women complain of nagging pain in the lower abdomen, minor bleeding, but there may be no complaints. On vaginal examination, the uterus is dense, its size is less than the gestational age, and the external os is closed. If there are no complaints, bleeding or tissue in the uterus (according to ultrasound results), instrumental inspection of the walls of the uterine cavity is not performed.

A failed abortion is the cessation of embryo development with retention of embryonic tissue in the uterus. IN in this case subjective signs of pregnancy disappear. Sometimes there is bleeding and increased body temperature. Ultrasound data: discrepancy between the size of the fertilized egg or embryo and the gestational age, absence of heartbeats (at 7-8 weeks) and embryo movements (at 9-12 weeks). If cyanosis of a failed abortion is confirmed, urgent evacuation of embryonic/fetal tissues from the uterus by surgery or medication is necessary, since the presence of a non-developing fertilized egg or embryo in the uterus for a month or more increases the risk of coagulopathic complications.

Treatment of isthmic-cervical insufficiency in case of miscarriage consists of suturing the cervix from the moment of diagnosis. A prophylactic suture is indicated for high-risk groups with a history of two or more spontaneous abortions or premature births in the 2nd trimester of pregnancy. Therapeutic suture is indicated for women at risk with ultrasound data confirming the diagnosis of isthmic-cervical insufficiency.

Antiphospholipid syndrome established by laboratory diagnostic methods in case of miscarriage requires treatment with anticoagulants and antiplatelet agents (aspirin, heparin).

The article was prepared and edited by: surgeon