Detachment of the ovum in early pregnancy

One of the problems that occurs in early pregnancy is the detachment of the ovum. Consider the main causes of pathology, symptoms, methods of treatment.

The first trimester of pregnancy is an important period for both the mother and the unborn child. At this time, the key organs, systems of the baby are laid and a large number of spontaneous miscarriages occur. One of the reasons for termination of pregnancy is the detachment of the ovum.

The uterus  is a muscular organ that contracts periodically. During pregnancy, the ovum attaches to its walls and develops. At this moment, the placenta is formed, that is, the chorion. It is the villous shell of the embryo that covers the surface of the egg. Through the chorion, the fetus receives oxygen and all nutrients. The formation of a full-fledged placenta is observed at the end of the first month after conception. 

Fertile egg:

• This is an egg fertilized with the help of a sperm, which is attached to the walls of the uterus.
• It is the beginning of the embryonic development of the fetus and acts as the first structure determined by ultrasound.
• A month after conception, a yolk sac is determined in the egg, the presence of which indicates a healthy course of pregnancy.
• It has a round or oval shape, which gradually increases in size, which allows you to establish the exact period of gestation and identify possible violations.

Unlike the uterus, the chorion does not contract, therefore, with a strong contraction of the organ in the early stages, partial or complete detachment occurs. This problem occurs in 2% of all pregnancies and varies in severity and symptoms. [1]

The term detachment refers to two conditions: immediate detachment (early stages) and critical condition (mid or late pregnancy). In the first case, it is an alarming signal of a possible miscarriage.

Epidemiology

According to the International Classification of Diseases ICD-10, spontaneous miscarriage belongs to category XV Pregnancy, childbirth and the puerperium (O00-O99):

• O03 Spontaneous abortion.
• O02.1 Failed miscarriage.
• O20.0 Threatened abortion.

According to medical statistics, about 10-15% of all pregnancies end in early miscarriage. Moreover, more than 50% of sporadic (accidental) miscarriages are associated with genetic abnormalities of the fetus. [2]

Detachment of the ovum is closely related to the age of the pregnant woman, the older the woman, the higher the risk of abortion:

• Up to 35 years old - 15%
• 35-45 years old - 20-35%
• Over 45 years old - 50%
• History of miscarriages - 25%

Due to the action of certain factors, the embryo dies, and then the detachment of the ovum from the uterine walls begins. During this period, a woman has bloody discharge, since the exfoliated is removed from the uterine cavity. To confirm a spontaneous abortion, a quantitative determination of beta-hCG and ultrasound diagnostics are performed. [3], [4]

Causes of the detachments in early pregnancy

There are many factors that can trigger the passage of the ovum in the first trimester. Most often, the pathological condition is associated with the following reasons:

• Hormonal Disorders.
• History of abortion.
• Reproductive diseases.
• Neoplasms.
• Inflammatory pathologies of the pelvic organs.
• Genital anomalies in a woman.
• Viral and infectious diseases during pregnancy.
• STDs.
• Arterial hypertension.
• Increased physical activity.
• Hereditary pathologies.
• Rhesus conflict between mother and fetus.
• Disturbances in the development of the placenta, embryo.
• Bad habits of a woman: smoking, drug addiction, alcoholism.
• The negative impact of environmental factors.

The most common cause of detachment is progesterone deficiency. With this pathology, the female body does not produce enough progesterone, which is responsible for the normal bearing of a child. [5]

Risk factors

The risk of detachment of the ovum in the early stages of pregnancy increases significantly when the body is exposed to such factors:

• Stress and emotional experiences.
• Age over 35.
• Exhausting physical activity.
• Bad habits.
• Rhesus conflict.
• Tumor neoplasms.
• Progesterone deficiency.
• Diseases of a pregnant woman: venereal, infectious, viral, inflammatory.
• Taking certain medications.
• Hereditary pathologies and more.

Any of these factors can cause spontaneous abortion. A high risk of miscarriage is characteristic of the period when the placenta has not yet fully formed, that is, from the first days of fertilization to 16 weeks. During this period, a woman should protect herself as much as possible from the action of any pathological factors. [6]

Pathogenesis

The mechanism for the development of spontaneous miscarriage in the early stages of gestation is associated with many factors. The pathogenesis of detachment can be caused by such viruses in a woman: cytomegalovirus, herpes, parvovirus, rubella. Another possible cause of miscarriage is chromosomal or hereditary pathologies. 

Consider the etiopathogenesis of the main causes of detachment of the ovum:

1. Uterine pathologies - anomalies in the development of the Mullerian duct, synechia of the uterine shelf, hypoplasia of the uterus, organ damage due to abortion, isthmic-cervical insufficiency,
2. Endocrine diseases - ovarian hypofunction, luteal insufficiency, adrenal hyperandrogenism, hyperthyroidism, hypothyroidism, diabetes. Disorders in the work of the ovaries, adrenal glands and other endocrine glands. In this case, miscarriage can occur both with spontaneous conception and with drug-induced pregnancy.
3. Chromosomal abnormalities - structural abnormalities, quantitative chromosome aberrations. Violations of cellular and humoral immunity in women, isoserological incompatibility in blood group and Rh factor of mother and fetus.
4. Intoxication of the body - the greatest danger is poisoning with lead, mercury, gasoline, nicotine and other toxic substances. Early miscarriages are common among women exposed to ionizing radiation or working in the chemical industry.
5. Isoantigenic incompatibility of the blood of the fetal matter - with this anomaly, fetal antigens penetrate the placenta into the woman's body and provoke the formation of specific antibodies. Because of this, hemolytic disease, intrauterine fetal death and other pathologies can develop.
6. Diseases and abnormalities in the development of the genital organs. For example, with uterine myoma, implantation of the ovum can occur on the myomatous node, which is a thinned mucosa. Because of this, the embryo does not receive sufficient nutrition and cannot fully develop.
7. History of abortion - artificial termination of pregnancy causes disturbances in the nervous and endocrine systems. Against this background, the development of inflammatory diseases, chronic endometritis is possible. With instrumental removal of the fetus during the expansion of the cervix, damage to its muscle structures is possible. This entails insufficiency of the isthmic-cervical canal and miscarriage of all subsequent pregnancies.
8. Infectious diseases - miscarriage can provoke both chronic infections and local lesions of the genitals by bacterial flora, viruses, fungi and other pathogens. Inflammatory lesions of the genital organs lead to disruption of the structure and functions of the main layers of the endometrium and myometrium. Because of this, adhesions, tumor neoplasms in the small pelvis, fixed retroflection and other pathologies that disrupt the growth of the fetus appear.

Also, psychogenic factors should not be excluded, the action of which increases the risk of miscarriage. Any of the above reasons leads to an increase in the contractile activity of the uterus and detachment of the ovum. If a miscarriage occurs at the beginning of the I-II trimester, then the ovum is separated from the uterus without opening the fetal bladder. [7]

Symptoms of the detachments in early pregnancy

The symptoms of spontaneous abortion are manifested by a deterioration in the woman's well-being. During this period, chorion detachment occurs, the vessels due to which it has penetrated into the uterus are ruptured and a hematoma is formed.

The main symptoms of a miscarriage include:

• Back pain similar to menstrual cramps.
• Cramping attacks in the lower abdomen.
• Bloody discharge with clots, indicating the removal of the exfoliated ovum from the uterine cavity.
• Reduction or complete absence of signs of pregnancy: nausea, chest pain, mood changes, and more.

In most cases, an early abortion begins with a spotting discharge that turns into bleeding. Such symptoms are the reason for urgent medical attention. 

First signs

Spontaneous miscarriage can occur at any stage of pregnancy, but most often it happens in the first months of gestation. In the first trimester, there is a high risk of retrochorial hematoma formation.

The first signs of detachment of fetal formation:

• Cramping pains in the lower abdomen.
• Drawing pains in the lower back.
• Bright red or dark vaginal discharge.
• Feeling of spasm of the uterus.
• Profuse bloody, clotted discharge.

If the hematoma does not begin to empty, then the discharge does not occur, the woman complains of pain and a general deterioration in well-being. The appearance of brown discharge indicates a decrease in hematoma and is the reason for consulting a gynecologist. In 30% of cases, miscarriage is asymptomatic and can only be diagnosed with the help of screening ultrasound. [8]

Stages

There are several stages of detachment of the ovum:

1. Threatened abortion - the woman feels pain, there is minor bleeding from the vagina. If you seek medical help in a timely manner, there are chances to maintain the pregnancy.
2. Incipient miscarriage - pain in combination with bloody discharge. There are still chances of maintaining the pregnancy.
3. Abortion on the go - sharp pains, profuse bloody discharge with clots. Pregnancy cannot be maintained.
4. Completed abortion - the ovum completely leaves the uterine cavity, the bleeding stops.

Fetal rejection before 12 weeks is called early miscarriage, and spontaneous abortion before 22 weeks is called late. [9]

Forms

Studies have shown that fetal membranes exfoliate in different ways. Therefore, there are several types of spontaneous abortion in the early stages, consider them:

1. Biochemical pregnancy - rejection occurred even before the delay in menstruation. The ultrasound does not detect the ovum, but in the analysis for hCG there are increased indicators. Most often, such detachment is associated with defects in the ovum or hormonal disorders in a woman.
2. Complete detachment - fetal membranes detached from the uterine walls, the embryo died. The uterus contracts and disposes of the fetus. The woman feels pulling pains in the lower abdomen, which radiate to the sacrum and lower back. Heavy bleeding is possible.
3. Incomplete abortion - when a part of the ovum leaves the uterus, tissues remain in the uterus that disrupt its contraction and hemostasis. Because of this, there is a risk of severe bleeding and hemorrhagic shock. Even if the bleeding is minor, the risk of its exacerbation remains due to the remaining parts of the ovum, infection or the formation of a placental polyp.
4. Failed miscarriage - the ovum stops developing, but is not rejected. It undergoes resorption and goes through several stages: bloody, fleshy, litoneedion (fossilization). This anomaly can occur at any time during gestation. Diagnosis is by bleeding from non-clotting blood. In anamnesis, such pregnant women may have angina pectoris.
5. Cervical pregnancy - the ovum develops in the cervical canal, that is, in the area of its isthmus. Rejection occurs at 4-6 weeks of gestation. The woman has profuse bleeding, which is life-threatening. For treatment, hysterectomy and blood replacement therapy are performed.
6. Septic (febrile) abortion is a serious condition caused by primary or secondary immunodeficiency. Detachment is associated with the penetration of superinfection with antibiotic-resistant flora into the vagina and uterus. The woman complains of general weakness, hyperthermia, tachycardia, acute pains in the lower abdomen, bloody and purulent discharge from their genital tract. The pregnant woman needs urgent medical attention and hospitalization.

Regardless of the type of spontaneous miscarriage, a woman needs medical and psychological help. 

Complications and consequences

The risk of developing complications after a miscarriage depends on many factors. First of all, this is the period at which the rejection of the ovum occurred, the woman's age, the type of spontaneous abortion, and more.

The main consequences of this pathology include:

• Incomplete abortion, in which part of the ovum and placenta remains in the uterus. It is dangerous with severe bleeding and infectious syndrome.
• Infectious and inflammatory diseases of the reproductive system.
• Hormonal Disorders.
• Difficulties with further conception and bearing of the fetus.
• Hematometer - a violation of the evacuation of blood from the uterine cavity. Due to poor contractility or spasms of the cervix, blood clots accumulate in it. The woman complains of sharp pains in the lower abdomen and a feeling of fullness, there is no spotting.
• Violation of the menstrual cycle.
• Isthmico-cervical insufficiency.
• Cervical erosion.
• Placental polyp - with incomplete detachment of the ovum, a part of the placenta remains in the uterus, which eventually grows with connective tissue and is tightly attached to the walls of the organ. The woman suffers from pain and occasional spotting, which can turn into profuse bleeding.
• Psychological problems, depression. [10]

In most cases, the consequences of detachment of the ovum in the early stages of gestation do not pose a danger to the life and health of a woman. For the prevention of possible complications, gynecologists recommend carrying out a mandatory curettage of the uterus and a control ultrasound examination after 2-3 weeks.

Diagnostics of the detachments in early pregnancy

To assess the patient's condition and diagnose spontaneous miscarriage, anamnesis, analysis of complaints, physical examination and a set of additional studies are carried out. The primary assessment of hemodynamic parameters is mandatory.

• Analysis of complaints and collection of anamnesis - features of the menstrual cycle, previous pregnancies and abortions, gynecological diseases, ultrasound results. The presence of symptoms of early pregnancy: bleeding from the vagina, pain in the lower abdomen and lower back, delayed menstruation. HCG urine test.
• Physical examination - temperature, blood pressure, heart rate. Examination and palpation of the abdomen (soreness, bloating, tension of the muscles of the anterior abdominal wall), vaginal examinations (examination with mirrors to determine the source and estimate the amount of bleeding). Bimanual assessment of the consistency and length of the cervix, the state of the cervical canal, soreness of the appendages and vaginal vaults.
• Instrumental examination of the pelvic organs (transvaginal or transabdominal ultrasound) and laboratory tests.

An integrated diagnostic approach makes it possible to detect detachment of the ovum in the early stages and, if possible, prevent a complete miscarriage. Also, timely seeking medical help avoids serious complications in case of incomplete discharge of the embryo. [11]

Analyzes

Laboratory tests in combination with the results of ultrasound can diagnose a miscarriage. The tests that need to be passed to the patient:

• Clinical blood test.
• Determination of the level of hCG.
• Determination of the blood group (at risk of blood loss).
• STD testing.
• Analysis for infectious diseases.
• Microscopic examination of the discharge of the cervix.

The analysis for human chorionic gonadotropin is a hormone formed after the implantation of an embryo into the uterine cavity. After a miscarriage, the level of hCG is increased, which makes it possible to diagnose a spontaneous abortion. Analysis for infectious diseases and other laboratory tests can determine what caused the miscarriage and, if possible, prevent the failure of future pregnancies. [12]

Instrumental diagnostics

With early loss of pregnancy, a transvaginal or transabdominal ultrasound is performed to detect signs of detachment of the ovum and the delay of its remnants in the uterus. The first ultrasound is a study through the vagina using an endovaginal probe, which allows you to examine the structure of the uterus and ovaries in maximum detail.

If a transvaginal examination cannot be carried out, then a transabdominal one is indicated. It is done with a full bladder. It allows you to study the state of the pelvic organs, uterus and appendages, to identify pathologies of the reproductive organs.

Possible research results:

• Complete abortion - the average inner diameter of the ovum> 20-25 mm, the embryo is not visualized. The thickness of the endometrium is less than 15 mm, the remaining products of conception were previously identified.
• Non-developing pregnancy - embryo> 7-8 mm, no palpitations are visualized.
• In case of incomplete miscarriage, tissue with a diameter of more than 15 mm is present in the uterus.
• Ectopic pregnancy - the uterine cavity is empty, but enlarged, like the appendages. There are signs of endometrial hyperplasia.
• Septic miscarriage - signs of complete or incomplete abortion, ascending infectious lesion of the uterine cavity and its appendages, peritoneum, pelvic abscess.

If a woman has a long or irregular menstrual cycle, then a second ultrasound is shown a week after the first.

Differential diagnosis

An obligatory component of examinations for rejection of fetal formation in early pregnancy is differential diagnosis.

Miscarriage is differentiated with the following pathologies:

• Neoplasms of the vagina and cervix. Abundant spotting may indicate ectropion, that is, eversion of the mucous membrane of the cervical canal. To identify the disease, an examination in the mirrors, colposcopy are carried out.
• Another possible cause of vaginal bleeding is the anovulatory cycle, in which menstruation is often delayed. For diagnosis, a hCG test (negative) and a bimanual examination of the uterus are performed.
• Differentiation is carried out with cystic drift. With this pathology, discharge appears in the form of bubbles, and the size of the uterus is greater than the expected period of gestation. An ultrasound scan is shown to confirm the diagnosis.
• With an ectopic pregnancy, bloody discharge, acute pain, a feeling of pressure on the bladder appear. HCG test is positive. With bimanual diagnosis, pain is determined when the cervix moves. The organ is smaller than it should be at the time of the expected pregnancy. On palpation of the fallopian tubes, thickening and swelling of the fornices is possible. On an ultrasound, the ovum is determined in the fallopian tube. When it ruptures, blood accumulates in the abdominal cavity.

The results of the differential diagnosis make it possible to make a definitive diagnosis of spontaneous abortion in the early stages. [13]

Treatment of the detachments in early pregnancy

If the suspicion of detachment of the ovum is confirmed, then the woman is sent to the hospital. A pregnancy that can be saved requires inpatient treatment and medical supervision, so the patient is hospitalized. The main goal of treatment is to relax the uterus, stop bleeding and prolong gestation, provided that the embryo / fetus is viable.

At this stage, the woman should be provided with complete peace, both physical and emotional. Even too active intestinal peristalsis is dangerous, therefore, dietary food is recommended with the rejection of foods that weaken or provoke flatulence. Sexual contacts are also prohibited. [14]

An obligatory component of therapy is medications that stop bleeding, reduce the tone of the uterus and relieve pain. But when using drugs in the first trimester, the risk of their teratogenic and embryotoxic effects should be taken into account. [15]

Medicines

In most cases, detachment of the ovum in the early stages of gestation requires drug treatment. Medicines are selected by the doctor, focusing on the condition of the pregnant woman, the type of rejection, the duration and general state of health.

• With a threatening or incipient miscarriage, hormone therapy is very often performed. In case of previously diagnosed insufficiency of the function of the corpus luteum, gestagens are used: Allylestrenol, Turinal. But such drugs are contraindicated for women with adrenal hyperandrogenism, so they are prescribed corticosteroids: Prednisolone, Dexamethasone. 
• Progesterone drugs have a positive effect on the hormonal status of a pregnant woman and eliminate the threat of miscarriage. Most often, patients are prescribed Acetomepregenol.
• For women with anomalies in the development of the uterus, hypoplasia, ovarian hypofunction, in addition to gestagens, estrogens are prescribed: Ethinylestradiol, Microfollin, Folliculin, Estradiol dipropionate.
• For patients with corrected ovarian hypofunction, the drug Choriogonin is used against the background of progestogen and estrogen therapy.
• When detachment begins with bleeding, Ascorutin, Ditsinon, Etamzilat are used.
• In case of incomplete abortion, intravenous drip of Oxytocin or Prostaglandin F2 can be used to remove the ovum.
• With prolonged bleeding after emptying the uterus, it is indicated by the use of drugs that contribute to the contraction of the organ: Methylergometrine, Ergotal, Ergotamine hydrotartrate. These funds are injected subcutaneously, intramuscularly, slowly into a vein or cervix.

Let us consider in more detail the main groups of drugs used for rejection of the ovum in the first trimester:

1. Antispasmodic drugs
   1. Papaverine

Myotropic antispasmodic agent. Reduces tone and contractility of smooth muscles. It has vasodilating and antispasmodic properties.

• Indications for use: spasms of smooth muscles of the abdominal organs, spasms of the urinary tract and cerebral vessels, spasms of peripheral vessels.
• Method of application: subcutaneously, intramuscularly and intravenously. The dosage and duration of therapy is determined by the attending physician.
• Contraindications: intolerance to the components of the drug, arterial hypotension, coma, respiratory depression, glaucoma, renal failure, broncho-obstructive syndrome.
• Adverse reactions: headaches and dizziness, drowsiness, temporary decrease in visual acuity, nausea, impaired stool, dry mouth, increased activity of liver enzymes. Arrhythmia, palpitations, allergic skin reactions, apnea. An overdose has similar symptoms. There is no specific antidote, the treatment is symptomatic.

Release form: ampoules of 2 ml, 10 pieces per pack.

2. No-shpa

The drug with the active ingredient is drotaverine. It has a strong and long-term antispasmodic effect on the body. Expands blood vessels and normalizes intestinal motility. Does not penetrate the blood-brain barrier and does not adversely affect the central nervous system.

• Indications for use: spasms of smooth muscle muscles of various etiology and localization, headaches and stress, algomenorrhea, colitis, gastritis.
• Method of application: 120-240 mg per day, divided into 2-3 doses. The duration of therapy depends on the severity of the painful condition.
• Side effects: headaches, dizziness, central nervous system disorders, difficulty in defecation, nausea and vomiting, tachycardia, hypotension, allergic reactions.
• Contraindications: hypersensitivity to the components of the drug, renal / hepatic failure, lactose intolerance, lactation, heart failure,
• Overdose: violation of the rhythm and conduction of the heart muscle. Treatment is aimed at maintaining the normal functioning of the body.

Release form: tablets of 10 pieces in a blister, 2 blisters in a package.

3. Metacin

M-anticholinergic agent used in diseases with smooth muscle spasms. It is prescribed for gastrointestinal ulcers, gastritis, renal and hepatic colic. In anesthesiology to reduce the secretion of the salivary and bronchial glands.

Method of application: orally, 20-40 mg 2-3 times a day, parenterally, 0.5-2 ml of a 0.1% solution. Side effects and symptoms of overdose are manifested by difficulty urinating, dry mouth, constipation. Metacin is contraindicated in case of increased intraocular pressure, prostatic hypertrophy. The drug has two forms of release: tablets of 20 mg, 10 pieces per pack, ampoules of 1 ml of 0.1% solution, 10 pieces per pack.

4. Baralgin

It has pronounced antispasmodic and analgesic properties. It is used for spasms of smooth muscles: spasms of the ureters, spastic dysmenorrhea, spasms of the stomach and intestines, tenesmus of the bladder and other pathologies.

• The drug is taken orally 1-2 tablets 2-3 times a day. In especially severe cases, Baralgin is administered intramuscularly or intravenously.
• Contraindications: intolerance to the components of the drug, granulocytopenia, tachyarrhythmia, glaucoma, prostate hypertrophy, coronary circulation insufficiency.
• Side effects: allergic reactions. Overdose has similar symptoms, symptomatic treatment.

Release form: tablets of 20 pieces and ampoules of 5 ml, 5 pieces per package.

Also, intramuscular administration of a 25% solution of magnesium sulfate will help to relax the muscles of the uterus.

2. Hemostatic

1. Etamsilat

Increases the formation of mucopolysaccharides in the walls of the capillaries and increases their stability. It normalizes their permeability, improves microcirculation and has a hemostatic effect.

Stimulates the formation of blood coagulation factor III, normalizes the rate of platelet adhesion. Does not affect prothrombin time, does not cause increased blood clotting and does not contribute to the formation of blood clots.

• Indications for use: capillary bleeding in diabetic angiopathies. Surgical interventions in otorhinolaryngology and ophthalmology, dentistry, urology in surgical and gynecological practice. Emergency cases with intestinal and pulmonary bleeding and hemorrhagic diathesis.
• Method of application: intravenous, intramuscular, oral, subconjunctival, retrobulbar. The dosage and duration of therapy is determined by the attending physician.
• Contraindications: bleeding caused by anticoagulants. It is prescribed with caution for patients with a history of thrombosis and embolism. Overdose cases and adverse reactions were not identified.

Release form: solution of 12.5% in 2 ml ampoules, 10, 50 ampoules per package. Tablets 250 mg, 50 and 100 pieces per package.

2. Trenax

Antifibrinolytic drug, contains the active ingredient - tranexamic acid. It slows down the process of fibrinolysis, has a local and systemic hemostatic effect. It penetrates well into the synovial fluid, creating equal plasma concentrations. In the cerebral fluid, the level of active components is about 10%. Tranexamic acid does not bind to plasma albumin. It is excreted by the kidneys unchanged and in the form of metabolites.

• Indications for use: short-term therapy of hemorrhage for patients with increased total fibrinolysis, including malignant lesions of the pancreas and prostate, surgical interventions, postpartum hemorrhage. Nasal, uterine and gastrointestinal bleeding, hematuria, bleeding after conization of the cervix, prostatectomy. Hereditary angioedema and allergic skin diseases.
• Method of application: orally 1-1.5 g 2-3 times a day. The duration of treatment depends on the severity of the painful condition.
• Side effects: pain in the epigastric region, nausea, vomiting, stool disorders, headaches and dizziness, urticaria, itching, thrombosis, thromboembolism.
• Contraindications: individual intolerance to the components of the drug, severe renal dysfunction, thrombophlebitis, macroscopic hematuria, myocardial infarction, subarachnoid hemorrhages, high risk of thrombus formation.
• Overdose: pain in the epigastric region, nausea and vomiting, orthostatic hypotension. There is no specific antidote, the treatment is symptomatic.

Release form: 6 tablets in a strip, 2 strips in a package.

3. Ascorutin

Reduces capillary permeability, blocks the hyaluronidase enzyme. Prevents lipid peroxidation of cell membranes. It is used for increased vascular permeability, hypovitaminosis and avitaminosis R.

The drug is taken 1 tablet 2-3 times a day. Not used in case of intolerance to active ingredients. Overdose cases and adverse reactions were not identified. Ascorutin is available in the form of tablets of 10 and 50 pieces per pack.

4. Dicinon

Antihemorrhagic agent. Suppresses the breakdown of mucopolysaccharides of the vascular wall, normalizes its permeability in pathological processes. The drug acts hemostatically, increases the rate of formation of a primary thrombus. It has no effect on prothrombin time and does not have a hypercoagulable effect.

Shows activity after 5-10 minutes with injection and after 1-2 hours with oral administration. Keeps its effect for 4-8 hours. During the course of treatment, the therapeutic effect lasts 5-8 days.

• Indications for use: parenchymal and capillary bleeding during surgical interventions in otolaryngology, ophthalmology, dentistry, gynecology. Emergency surgery to stop acute bleeding, diseases of the blood system, hemorrhagic diathesis.
• Method of application: intravenous / intramuscular, oral. The dosage and duration of treatment is determined by the attending physician.
• Side effects: headaches and dizziness, impaired sensitivity of the lower extremities. Nausea, vomiting, heartburn, heaviness in the epigastric region. Decrease in blood pressure, hyperemia of the skin.
• Contraindications: hemorrhages and bleeding in case of anticoagulant overdose, porphyria, thromboembolism, thrombosis. Cases of acute overdose have not been recorded.

Release form: tablets of 50 and 500 mg, 5% and 12.5% solution for injection.

3. Sedatives
   1. Persen

Medication with a mild sedative effect on a herbal basis. Contains valerian and lemon balm extract. Soothes, relieves irritability and psycho-emotional stress, agitation. Improves falling asleep, but does not cause drowsiness during the day.

• Indications for use: neuroses, psychoemotional agitation, decreased attention, insomnia, anxiety, vascular dystonia. Psychosomatic disorders with stress factors. Withdrawal of potent sedatives.
• Method of application: orally 2-3 capsules 1-3 times a day. The duration of treatment is determined by the attending physician.
• Side effects: hypersensitivity reactions, tendency to constipation.
• Contraindications: intolerance to the constituents of the drug, pediatric practice.
• Overdose: weakness, headaches and dizziness, nausea, spastic pains in internal organs, tremors of the extremities, mydriasis. Painful symptoms go away on their own one day after administration.

Release form: enteric-coated tablets in blisters of 40 pieces, capsules of 20 pieces per package.

2. Novo-Passit

A combined product that includes guaifenesin and a complex of extracts of medicinal plants: hawthorn, hops, St. John's wort, lemon balm, passion flower, black elderberry, valerian. It has soothing and anti-anxiety properties. Eliminates mental stress and fear. Promotes relaxation of smooth muscles.

• Indications for use: irritability, mild forms of neurasthenia, anxiety, fear, fatigue, memory impairment, mental exhaustion. Sleep disorders, headaches, migraines, neuromuscular irritability. Dermatoses, functional gastrointestinal diseases, vegetative-vascular dystonia.
• Method of application: syrup and tablets are taken orally. The dosage and duration of therapy is determined by the doctor, individually for each patient.
• Side effects: headaches and dizziness, fatigue, decreased concentration, nausea, vomiting, heartburn, muscle weakness, itching, constipation.
• Contraindications: muscle weakness, hypersensitivity to drug components, severe gastrointestinal disorders, pediatric practice.

Release form: oral solution in bottles of 100 ml, tablets of 10 pieces in a blister.

As a sedative, you can use an infusion of valerian root or motherwort herb, 1 tablespoon three times a day. Teas and decoctions based on mint, lemon balm, chamomile will be useful.

4. Adrenomimetics, which have an inhibitory effect on the contractile activity of the myometrium.
   1. Partusisten

A tocolytic agent from the pharmacological group of beta2-adrenostimulants. Its mechanism of action is similar to Fenoterol.

• Indications for use: the threat of premature birth. Does not have a negative effect on the fetus and baby.
• Method of application: intravenous drip of 0.5 mg in 250-500 ml of 5% glucose solution. Orally 5 mg every 2-3 hours, the maximum daily dosage is 40 mg. Duration of treatment is 1-3 weeks.
• Side effects: tachycardia, tremors of the limbs, decreased blood pressure, sweating, nausea and vomiting, muscle weakness.
• Contraindications: cardiac arrhythmias, heart defects, thyrotoxicosis, glaucoma.

Release form: tablets of 0.5 mg and ampoules of 0.025 mg.

2. Fenoterol

Adrenomimetic agent, stimulates betagadrenergic receptors of the uterus and bronchi. It is used to relieve attacks of bronchial asthma, with pulmonary emphysema, spastic asthmoid bronchitis. The method of administration and dosage are individual for each patient, therefore they are selected by the attending physician.

Side effects are manifested by tremors of the limbs, tachycardia, increased anxiety, fatigue, sweating, headaches. Dosage reduction is indicated for treatment.

The medication is contraindicated in cardiac arrhythmias, severe atherosclerosis. Fenoterol is available in the form of 5 mg tablets, 0.5 mg ampoules for injections, and also in the form of a 15 ml aerosol can (300 single doses).

3. Rhythodrin

A drug that, in its mechanism of action, is similar to fenoterol, salbupartur and other beta2-adrenergic agonists. Relaxes the uterine muscles. It is used as a tocolytic agent for the threat of premature termination of pregnancy.

• Method of application: inside, 5-10 mg 3-6 times a day. Duration of treatment is 1-4 weeks. If you suspect a detachment of the ovum in the early stages, the drug is administered intravenously. 50 mg of the drug is diluted in 500 ml of isotonic sodium chloride solution and injected drip (10-15 drops per minute).
• Side effects: heart palpitations, tremors of the limbs, muscle weakness, excessive sweating, nausea and vomiting, lowering blood pressure. Painful symptoms are reduced by intravenous administration of 30 mg of Verapamil.
• Contraindications: cardiac arrhythmias, thyroid disease, heart defects, increased intraocular pressure.

Release form: ampoules of 10 mg and tablets of 5 mg.

5. Hormonal agents
   1. Utrozhestan

The drug with the active ingredient is natural micronized progesterone. When introduced into the body, it normalizes secretory transformations in the mucous membrane of the uterus. Promotes the transition of the endometrium from the proliferative phase to the secretory phase. During pregnancy, it reduces the contractility and excitability of the myometrium and fallopian tubes. Stimulates the transformation in the end elements of the mammary glands. [16]

• Indications for use: the drug is used orally for infertility due to insufficiency of the corpus luteum of the ovary, menstrual irregularities, mastopathy, premenstrual syndrome.
• Intravaginal administration of capsules is indicated to maintain the luteal phase of menstruation, as hormone replacement therapy in premature menopause. It is prescribed for infertility due to insufficiency of the corpus luteum of the ovary, for the prevention of uterine fibroids and endometriosis. The drug is effective for threatened abortion and for the treatment of recurrent pregnancy loss due to progesterone deficiency.
• Method of application: tablets are taken orally at 200-300 mg per day, divided into two doses. The capsules are inserted deep into the vagina with a dosage selected by the attending physician. For threatening abortion and for preventive treatment of recurrent miscarriage, 400-800 mg are used intravaginally.
• Side effects: intermenstrual bleeding, headaches and dizziness, drowsiness, hypersensitivity reactions. Overdose has similar symptoms, symptomatic treatment.
• Contraindications: bleeding from the genital tract, a tendency to thrombosis, incomplete abortion, malignant lesions of the reproductive organs and mammary glands, porphyria. It is not used for severe hepatic dysfunction, allergic reactions to the components of the medication. [17]

Release form: 100 mg tablets, 30 pieces in a blister, capsules for intravaginal administration 200 mg, 14 pieces per package.

2. Duphaston

The drug with the active ingredient is dydrogesterone (an analogue of natural progesterone). Does not have estrogenic, corticoid and androgenic effects. Does not interfere with thermogenesis and does not affect metabolic processes. Selectively affects the progestin receptors of the uterine mucosa. Does not affect ovulation of the follicle.

• Indications for use: endogenous progesterone deficiency, threatened abortion, habitual fetal loss, premenstrual syndrome. Hormone replacement therapy, menopausal syndrome.
• Method of application: for threatening abortion, take 40 mg once a day, then 10 mg every 8 hours for 1 week. In the future, the dosage is reduced, but with a new threat of abortion, the doses are restored. The medicine can be taken up to 12-20 weeks of gestation. For dysfunctional bleeding, take 10 mg twice a day in combination with ethinylestradiol 0.05 mg. When planning pregnancy or recurrent miscarriage - 10 mg twice a day from 11 to 25 days of the menstrual cycle.
• Side effects: in rare cases, bleeding develops. Development of hypersensitivity to the drug is possible.
• Contraindications: intolerance to dydrogesterone or other components of the drug, Rotor and Dabin-Johnson syndrome. Overdose cases were not recorded.

Release form: tablets for oral administration.

According to statistics, with timely access to medical care, about 80% of cases of rejection of fetal education ends with the patient's recovery without the development of complications. With late seeking medical care, maintaining pregnancy is impossible. With incomplete emptying of the uterine cavity, surgical scraping of the products of conception is performed. The duration of treatment is individual for each patient, but on average - at least 10-14 days.  [18]

Vitamins

Vitamin therapy is an indispensable component of the treatment of any disease or pathological condition. Vitamins are recommended in early pregnancy and with detachment of the ovum. Most often, women are prescribed the following beneficial substances:

1. Vitamin E

Tocopherol improves reproductive functions, therefore it is prescribed for successful conception. It has antioxidant properties, normalizes the nervous system, protects against stress. Promotes the normal development of the fetus in the first trimester and is responsible for the baby's central nervous system, protects against negative environmental factors. [19]

Take vitamin E after consulting your doctor. This is associated with the risk of developing allergic reactions and gastrointestinal disorders. Tocopherol comes in liquid form and capsules that are taken orally. In the early stages, the vitamin is taken at 200 mg per day, divided into two doses. The duration of treatment should not exceed 1 month. [20], [21]

2. Folic acid

Vitamin B9 belongs to the group of antianemic water-soluble substances. Stimulates hematopoiesis, participates in the formation of erythrocytes, leukocytes and platelets. Promotes the absorption of iron. Folic acid is involved in the synthesis of amino acids DNA and RNA, maintaining normal homocysteine levels and in the maturation of the egg. [22]

B9 stimulates the brain, improves memory and mood. Normalizes female hormonal levels. The use of the vitamin before conception and in the first trimester reduces the risk of developing pathologies in the fetus. [23]

Folic acid deficiency can cause placental abruption and miscarriage. Increases the likelihood of congenital malformations and abnormalities in the fetus, for example, a neural tube defect, cleft palate, and more. Folic acid is taken at 0.4 mg per day. An overdose of the drug causes increased excitability, gastrointestinal disorders, functional changes in the kidneys. [24]

3. Magne B6

Magnesium is involved in many biochemical processes in the body. The substance normalizes the functioning of the immune, nervous and muscular systems, accelerates metabolic processes, and also promotes the restoration of bone tissue. During the period of gestation, the body's need for this microelement increases 2-3 times. [25]

Magne B6 deficiency negatively affects women's health and fetal development. This can lead to malformations of the joints and the mitral valve of the heart. The risk of miscarriage and premature birth increases. The dosage of the vitamin and the duration of its use is determined by the attending physician, individually for each patient. 

Physiotherapy treatment

If there is a threat of detachment of the ovum in the early stages of gestation, a woman may be prescribed physiotherapy. Such treatment is aimed at eliminating the threat of termination of pregnancy and to reduce the drug load on the body.

Most often, patients are prescribed physiotherapy procedures that affect the contractility of the uterus, central or peripheral mechanisms.

Physiotherapy treatment is indicated in such cases:

• The risk of spontaneous abortion.
• Early toxicosis with nausea and vomiting.
• Gestosis.
• Fetal growth retardation.
• Postponing pregnancy.
• Divergence of the pubic bones.
• Lactostasis, postpartum endometritis.

With the threat of rejection of fetal education, the following physiotherapy procedures are used:

1. Endonasal galvanization.
2. Magnesium electrophoresis with sinusoidal modulated current.
3. Inductothermia of the kidney area.
4. Electric relaxation of the uterus using alternating sinusoidal current.

If the cause of the detachment is isthmic-cervical insufficiency, then drug therapy and physiotherapy are auxiliary methods. The main method of treatment is surgical correction.

Alternative treatment

Unconventional medical recipes for detachment of the ovum in most cases are ineffective and even dangerous. But some women still use alternative therapies. Consider the safest herbal-based methods:

• Pour a tablespoon of viburnum bark with 500 ml of boiling water and boil over low heat for 10 minutes. Refrigerate, strain. Take ½ cup 3 times a day.
• Grind and combine 100 g of dry herb of a millennium and 50 g of grass of a knotweed. Take ½ teaspoon herbal powder 3 times daily 30 minutes before meals.
• Take 5 grams of fresh dandelion leaves or roots. Pour boiling water over and boil for 5-7 minutes over medium heat. Take 50 ml 3 times a day.
• Mix equal proportions of fresh St. John's wort and calendula flowers. Pour 250 ml of boiling water and let it brew for 30-40 minutes. Strain and take 2 glasses a day, adding a spoonful of honey.

All of the above recipes are used when there is a threat of miscarriage in the first trimester. Before using alternative medicine methods, you should consult with your doctor and get his permission.

Herbal treatment

Medicinal herbs are another unconventional approach in the treatment of detachment of the ovum in the early stages of gestation.

Herbal recipes can be used to prevent miscarriage:

• Take 2 parts each rye, marigold flowers and angelica herb. Combine them with 1 part of stinging nettle leaves and erect cinquefoil rhizomes. Pour 500 ml of boiling water over two tablespoons of the collection and let it brew for 3 hours. Strain and take ½ cup 3 times a day 30 minutes before meals.
• Pour three tablespoons of calendula (leaves and inflorescences) with 1 liter of water and put on medium heat. The liquid should be boiled down in half. Filter the cooled broth and take 50 ml 2-3 times a day before meals.
• Take 3 parts licorice root and elecampane, add 2 parts black currant to them. Mix the herbs thoroughly and combine with 1 part Potentilla root and stinging nettle. Pour 2-3 spoons of the collection with 250-300 ml of boiling water, boil over medium heat for 20-30 minutes. Refrigerate, strain and take ½ cup 3 times daily before meals.

Before using the above recipes, you should consult with your doctor and make sure that there are no allergic reactions to the herbal ingredients of the recipes.

Homeopathy

An alternative treatment for spontaneous abortion in the first months of gestation is homeopathy. If there is a threat of miscarriage, then the following homeopathic medicines can be used:

• Aconite - the threat of abortion after a nervous experience, stress, an outbreak of anger.
• Arnica - rejection of the ovum after injury, severe bleeding.
• Belladonna - Drawing pains in the lower abdomen and in the back, profuse bloody discharge.
• Caulophyllum is a habitual miscarriage, pain in the back and abdomen. Contractions of the uterus with little bloody discharge.
• Chamomilla - abortion after intense nervous excitement.
• Cimicifuga - Acute pain in the lower abdomen.
• Sabina - Profuse bloody discharge. Back pain extending to the lower abdomen.
• Secale - risk of detachment, profuse bleeding, severe pain.
• Sepia - acute pain and weakness, muscle spasms.
• Viburnum - a history of miscarriages, pain in the abdomen, back and hips.

All medicines and their dosage are selected by the homeopathic physician, assessing the patient's condition.

Surgery

In case of incomplete miscarriage, septic abortion and in the case of massive bleeding, surgical treatment is indicated. Before the operation, an ultrasound examination is performed, which reveals the remnants of the ovum in the uterine cavity. Depending on the results of the ultrasound, the following types of cleaning can be prescribed:

1. Aspiration curettage - the remains of the embryo are small and can be sucked off with a vacuum. [26]
2. Curettage - the fetus died, but did not completely come out of the uterus.

Treatment is carried out under general or local anesthesia. For the operation, special instruments are used that open the cervix and remove the upper layer of the endometrium. The duration of the procedure takes about 15-25 minutes. After that, the patient spends a couple of hours under medical supervision and if there are no complications, then goes home.

After curettage, such complications may develop, some of which are normal:

• Moderate pain in the lower abdomen, similar to menstrual pain. They persist from a couple of hours to several days and do not require treatment.
• Profuse bleeding. Normally, they last no more than 10 days. If bleeding lasts longer, it may be a sign of cervical spasm and requires additional treatment.
• The risk of infection and the development of sepsis.
• Danger of incomplete extraction of fetal tissue residues. Causes severe blood loss and requires urgent surgical intervention.
• Risk of injury to the cervix or uterus during surgery. Improper actions of the surgeon can lead to perforation of the uterus or rupture of its tissues.

The tissues obtained as a result of the operation after a miscarriage are sent for histological examination. This is necessary to confirm uterine pregnancy, exclude ectopic pregnancy, trophoblastic disease. 

In order to minimize the risk of miscarriages in the future, you should undergo a comprehensive medical examination. This will allow you to determine the causes of rejection of fetal education and eliminate them.

Prevention

Specific methods for preventing detachment of the ovum in the first months of pregnancy have not been developed. To reduce the risk of developing neural tube defects in the fetus, which can cause miscarriages, folic acid supplementation is indicated during pregnancy planning and during the first trimester.

Conception planning is also important. In preparation for pregnancy and to reduce the threat of spontaneous abortion, future parents must undergo a medical examination and pass a number of tests:

• Analysis for STDs and infectious diseases.
• Genetic tests. 
• Reproductive system examination.
• Ultrasound of the pelvic organs in a woman.
• Determination of the biocompatibility of spouses and other analyzes.

Regular visits to the gynecologist and timely registration with the antenatal clinic are also a preventive method. Medical consultation and early screenings allow assessing the state of the ongoing pregnancy.

The expectant mother is shown good nutrition, moderate physical activity and a minimum of stress. You should also give up bad habits that negatively affect both the female body and the development of the fetus.

Forecast

Detachment of the ovum in early pregnancy has a favorable outcome. With one spontaneous abortion, the risk of disrupting the next pregnancy is about 20%. If a woman has two spontaneous miscarriages in a row, then a comprehensive examination is carried out to identify the causes of this anomaly. 

Do not forget about psychological rehabilitation. After a miscarriage, a woman faces severe stress and depression, so she needs restorative therapy. You can plan a new pregnancy no earlier than in 6-12 months. At the same time, it is very important to exclude all the factors that led to abortion in the past.