Examination of patients with habitual miscarriage

Examination of women outside pregnancy is necessary not only to understand the causes of embryo / fetal death, but also to assess the condition of the reproductive system of the spouses. The question of the time of examination is widely debated in the literature. It is generally accepted that the examination should begin after 3 spontaneous miscarriages. But the percentage of loss of the next pregnancy after 3 losses is much higher than after 2, and the possibilities to understand the cause of the interruption are the same as after 2, after 3, 4, etc. It is considered that it is necessary to examine after 2 miscarriages, and at the request of the spouses and taking into account the age, one can also be examined after one miscarriage.

The question is also debated whether it is necessary to examine a married couple if they lost their pregnancy due to the chromosomal abnormality of the embryo / fetus. It is well known that with the karyotyping of abortus, chromosomal pathology is found in 45-60% of abortus. It is believed that if the first pregnancy was interrupted due to the chromosomal pathology of the embryo, the second pregnancy has a 75% chance of being with a chromosomal pathology. In the event that the miscarriage was an embryo with a normal karyotype, then there is a 66% chance that the next pregnancy will be with the embryo also of a normal karyotype. In this connection, all the abortions are supposed to be karyotyped. In the event that the miscarriage was an embryo with a normal karyotype, then a couple is examined. In the event that the chromosomal pathology of the embryo was detected, the examination is not carried out despite the number of abnormal miscarriages. It is impossible to agree with this proposal. First, karyotype disorders most often occur de novo, in parents with a normal karyotype, and these disorders can occur under the influence of various causes: infectious, endocrine, disorders in the regulation of hormonal processes, which leads to the over-ripening of the egg, etc. Secondly, if the first embryo was karyotypically normal, there is no guarantee that the next one will also be normal.

Therefore, all couples should be examined after 2 losses, and women older than 35 years and at will, and after the first loss.

The evaluation of the reproductive system is also necessary for carrying out rehabilitation treatment and prophylactic measures with a view to preparing for a subsequent pregnancy. The examination should begin with a purposeful collection of anamnesis.

Heredity. It is necessary to find out the hereditary anamnesis of a married couple, diseases of parents, brothers, sisters. Particular attention should be paid to the presence in the family of thrombophilic disorders (heart attacks, strokes) at a young age. Find out the presence in the family of parents and relatives of miscarriages, stillbirths, the birth of children with developmental anomalies. Hereditary anamnesis is advisable to conduct by type of genealogical survey in the medical genetic consultation.

It is necessary to find out from the subject, in what family she was born, what kind of child she is, whether full or not, the age of her parents. Women born prematurely often suffer from reproductive harm, inheriting from the mother various endocrine disorders. It is advisable to find out whether the mother received any medications during pregnancy in order to assess their possible effect on the reproductive function of the subject. This is especially important for hormonal drugs. It is known the action of diethylstilbestrol, progesterone, dexamethasone, tranquilizers, etc. On the subsequent development of the organism, since the effect of many drugs affects after many years.

The nature of surgical interventions, blood transfusion in the anamnesis becomes clear.

Social living conditions of the family. Identify the age, the conditions of life and work of spouses, the presence of occupational hazards, bad habits (smoking, alcoholism, drugs), attitudes in the family, at work, combining work with study, the duration of the move from work to home. All this is necessary to know in order to understand the conditions in which the subject is, to study the psycho-emotional sphere of her life at home and at work.

Past illnesses. It is necessary to find out all the diseases transferred in childhood, and especially at pubertal age. With a high infectious index, it is possible to manifest genital infantilism, endocrine disorders. Particular attention should be paid to chronic infections (tonsillitis, pyelonephritis, rheumatism), thromboembolic complications, as well as other extragenital diseases.

Menstrual function. Clarification of the features of menstrual function is extremely important in assessing the endocrine status of women. It is necessary to establish the age of menarche, the duration of the cycle, the nature and duration of menstruation, soreness, the presence of bloody discharge before and after menstruation, in the middle of the cycle. It should pay attention to the delay of menstruation, often it is a manifestation of very early miscarriages. Long (more than 30 days), irregular cycle is typical for erased forms of adrenogenital syndrome, polycystic ovary syndrome. The time of the onset of menarche is of great importance. Women with infantilism, with malformations of the uterus may be later menarche (after 15-16 years). Painful, profuse menstruation can be noted in women with endometriosis, uterine myoma, inflammatory diseases of the genitals. Short, poor menstruation can be with intrauterine synechiae.

Of great importance in the evaluation of the generative function is the clarification of the transferred gynecological diseases, the presence of ectopia of the cervix, cervicitis, etc. It is necessary to clarify how the exacerbations of inflammatory diseases have proceeded, what treatment has been performed.

At operative interventions on genitals it is necessary to specify their volume. When performing operations on the uterus, it is necessary to find out whether there was an opening of the uterine cavity, as the postoperative period was, whether there were infectious complications. When treating the cervix, pay attention to the nature of the treatment: cryotherapy, laser therapy, chemotherapy. Find out if there was a surgical treatment for the cervix - amputations, plastics.

Genital function. Genital function is one of the most important sections in the collection of anamnesis. It is necessary to establish, how many years after the onset of sexual activity, pregnancy has come, what is the duration of infertility before the onset of pregnancy. Infertility in the intervals between miscarriages can indicate the endocrine nature of miscarriage.

It is necessary to find out the term of termination of pregnancy, as well as how the miscarriage proceeded, what treatment was used to maintain the pregnancy, and what complications were observed after the spontaneous miscarriage. These data often help to understand the causes of abortion and outline a survey plan.

Miscarriages at a very early age can be due to genetic causes. It is important to find out whether there has been karyotyping of the abortus. If a normal female karyotype was determined, then this should be treated with caution, since it is possible that the mother's tissues were taken for the study. Thus, according to research, with a careful separation under the microscope of abortus tissues from decidua, the frequency of obtaining a normal female karyotype (46XX) decreased from 70 to 25%. In this regard, it is proposed to take transcervical tissues of the fetal egg for karyotyping before the evacuation of the lost pregnancy under the supervision of ultrasound.

Interruption of pregnancy in the first trimester is characteristic of endocrine, autoimmune and alloimmune disorders. In these types of pathology, interruption occurs as a type of undeveloped pregnancy. In this case, it is advisable to find out whether an ultrasound was performed before the onset of miscarriage and whether the fetal heartbeat was recorded. With auto- and alloimmune disorders, miscarriage often begins as a result of chorion detachment, bleeding, and pain and contraction appear later.

Infectious etiology of miscarriage is characterized by an increase in temperature, inflammatory complications after miscarriage in the form of endometritis, varying degrees of severity, or exacerbation of the inflammatory process of the genitals.

With ischemic-cervical insufficiency miscarriages occur mainly in the second trimester and often begin with a premature outflow of water, flow rapidly, with minor pain sensations.

In cases where spontaneous abortion was preceded by medical abortion, the cause of abortion, the period of abortion and the post-abortion period should be clarified.

If the patient has been prevented for a long time from pregnancy, it is advisable to specify the method of contraception and the time of cancellation before conception. Pregnancy is less complicated, if at least three normal menstrual cycles have passed since the termination of hormonal contraception or removal of the IUD before conception. It is very important to find out what studies were conducted in between miscarriages and what kinds of therapy the woman received outside and during pregnancy. Often, women who suffer from spontaneous abortions are not properly examined, they are only advised not to become pregnant within 1-2 years. Sometimes, without an examination, anti-inflammatory treatment is prescribed, without individual selection of antibiotics, sanatorium treatment without clarifying the pathogenesis of abortion, which can cause harm, rather than the expected therapeutic effect.

If therapy was performed, it is necessary to evaluate the effectiveness of the treatment. A very important section of the anamnesis is the elucidation of the peculiarities of the course of pregnancy and the therapy. It should be clarified what kind of hormonal drugs the woman received. Unfortunately, in practice, very often without a prescription, progesterone treatment is prescribed in the early stages of pregnancy. At the same time, women with hyperandrogenia have an increase in hirsutism, obesity is often observed. It is necessary to clarify whether correction of ischemic-cervical insufficiency was carried out, by what method, at what time of pregnancy, whether the woman received antibiotics or other medications and what response to treatment.

Particular attention should be paid to the peculiarities of the course of labor, including premature births, if any, and if the pregnancy period, the body weight of the newborn, its timing of pregnancy, and whether there were any manifestations of intrauterine growth retardation and what complications of the neonatal period were observed in the newborn. If the child has died, then it is necessary to get acquainted with the results of the pathoanatomical conclusion.

The history should include information about the husband, his age, family history, the transferred diseases. Professional harmfulness, bad habits (smoking, alcoholism, drugs).

Thus, the history data are very necessary for assessing the effectiveness of all previously conducted medical and prophylactic measures in order to outline the most expedient ways of examination for clarifying the state of the reproductive system and selecting pathogenetically based rehabilitation therapy.

[1], [2], [3], [4]