Examination of patients with habitual non-pregnancy

Examination of women outside pregnancy is necessary not only to understand the causes of embryo/fetus death, but also to assess the state of the reproductive system of the spouses. The question of the time of examination is widely discussed in the literature. The generally accepted point of view is that 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 of understanding the cause of the interruption are the same after 2, 3, 4, etc. It is generally accepted that it is necessary to examine after 2 miscarriages, and at the request of the spouses and taking into account their age, it is possible to examine after one miscarriage.

There is also a debate about whether a married couple should be examined if they lost a pregnancy due to a chromosomal abnormality of the embryo/fetus. It is well known that karyotyping of abortions reveals chromosomal abnormalities in 45-60% of abortions. It is believed that if the first pregnancy was interrupted due to a chromosomal abnormality of the embryo, the second pregnancy has a 75% chance of having a chromosomal abnormality. If the miscarriage was an embryo with a normal karyotype, there is a 66% chance that the next pregnancy will also have an embryo with a normal karyotype. In this regard, karyotyping of all abortions is suggested. If the miscarriage was an embryo with a normal karyotype, the married couple is examined. If a chromosomal abnormality of the embryo was detected, the examination is not carried out, regardless of the number of abnormal miscarriages. It is impossible to agree with this proposal. Firstly, 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 of the mechanisms of regulation of hormonal processes, which leads to over-maturity 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 married couples should be examined after 2 losses, and women over 35 years of age should be examined at their own discretion, even after the first loss.

An assessment of the reproductive system is also necessary for carrying out rehabilitation treatment and preventive measures in order to prepare for a subsequent pregnancy. The examination should begin with a targeted collection of anamnesis.

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

It is necessary to find out from the subject what family she was born in, what child in order, whether she was full-term or premature, and the age of her parents. Women born prematurely often suffer from reproductive dysfunction, inheriting various endocrine disorders from their mother. 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. The effect of diethylstilbestrol, progesterone, dexamethasone, tranquilizers, etc. on the subsequent development of the body is known, since the effect of many drugs is felt after many years.

The nature of surgical interventions and history of blood transfusions are determined.

Social conditions of family life. They identify the age, living and working conditions of the spouses, the presence of occupational hazards, bad habits (smoking, alcoholism, drugs), attitudes in the family, at work, combining work with study, the duration of travel from work to home. All this must be known in order to understand the conditions in which the subject is located, to study the psycho-emotional sphere of her life at home and at work.

Past illnesses. It is necessary to find out all illnesses suffered in childhood, and especially in puberty. With a high infection index, genital infantilism and endocrine disorders may manifest. Particular attention should be paid to chronic infections (tonsillitis, pyelonephritis, rheumatism), thromboembolic complications, and other extragenital diseases.

Menstrual function. Determining the characteristics of the menstrual function is extremely important when assessing the endocrine status of a woman. It is necessary to establish the age of menarche, the duration of the cycle, the nature and duration of menstruation, pain, the presence of bloody discharge before and after menstruation, in the middle of the cycle. It is necessary to pay attention to delays in menstruation, which often serves as a manifestation of very early miscarriages. A long (more than 30 days), irregular cycle is characteristic of latent forms of adrenogenital syndrome, polycystic ovary syndrome. The time of menarche is of great importance. Women with infantilism, with malformations of the uterus may have a later menarche (after 15-16 years). Painful, heavy menstruation may be observed in women with endometriosis, uterine fibroids, inflammatory diseases of the genitals. Short, scanty menstruation may be with intrauterine adhesions.

Of great importance in assessing the generative function is the identification of previous gynecological diseases, the presence of cervical ectopia, cervicitis, etc. It is necessary to clarify how the exacerbations of inflammatory diseases proceeded, what treatment was carried out.

In case of surgical interventions on the genitals, their scope should be clarified. In case of operations on the uterus, it is necessary to find out whether the uterine cavity was opened, how the postoperative period proceeded, whether there were any infectious complications. In case of treatment of the cervix, pay attention to the nature of the treatment: cryotherapy, laser therapy, chemotherapy. Find out whether there was surgical treatment of the cervix - amputation, plastic surgery.

Reproductive function. Reproductive function is one of the most important sections when collecting anamnesis. It is necessary to establish how many years after the onset of sexual activity, pregnancy occurred, what was the duration of infertility before pregnancy. Infertility in the intervals between miscarriages may indicate the endocrine nature of miscarriage.

It is necessary to find out the period of termination of pregnancy, as well as how the miscarriage proceeded, what treatment was carried out in order to preserve the pregnancy, and what complications were observed after the spontaneous miscarriage. These data often help to understand the reasons for the termination of pregnancy and outline a plan for examination.

Miscarriages at very early stages may be due to genetic reasons. It is important to find out whether the abortuses were karyotyped. If a normal female karyotype was determined, this should be treated with caution, since it is possible that the mother's tissue was taken for the study. Thus, according to research data, with careful separation of abortus tissues from decidua under a microscope, 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 ovum for karyotyping under ultrasound control before evacuation of the deceased pregnancy.

Termination of pregnancy in the first trimester is typical for endocrine, autoimmune and alloimmune disorders. In these types of pathology, termination occurs as a non-developing pregnancy. In this case, it is advisable to find out whether an ultrasound was performed before the miscarriage and whether the fetal heartbeat was recorded. In auto- and alloimmune disorders, miscarriage often begins due to chorion detachment, bleeding, and pain and contractions appear later.

In case of infectious etiology of miscarriage, the following are typical: fever, inflammatory complications after miscarriage in the form of endometritis of varying severity or exacerbation of the inflammatory process of the genitals.

With isthmic-cervical insufficiency, miscarriages occur mainly in the second trimester and often begin with premature rupture of water, proceed quickly, with minor pain.

In cases where spontaneous miscarriages were preceded by medical abortions, the reason for the termination of pregnancy, the timing of the abortion and the course of the post-abortion period should be clarified.

If the patient has been using contraception for a long time, it is advisable to clarify the method of contraception and the time of its discontinuation before conception. Pregnancy is less complicated if at least three normal menstrual cycles have passed from the time of discontinuation of hormonal contraception or removal of the IUD to conception. It is very important to find out what studies were conducted between miscarriages and what types of therapy the woman received outside of and during pregnancy. Often, women suffering from spontaneous miscarriages are not subjected to proper examination, they are only advised not to become pregnant for 1-2 years. Sometimes anti-inflammatory treatment is prescribed without examination, without individual selection of antibiotics, spa treatment without specifying the pathogenesis of the termination of pregnancy, which can cause harm, rather than the expected therapeutic effect.

If therapy was administered, it is necessary to evaluate the effectiveness of the treatment. A very important section of the anamnesis is to clarify the features of the pregnancy and the therapy administered. It is necessary to clarify what hormonal drugs the woman received. Unfortunately, in practice, progesterone treatment is very often prescribed in the early stages of pregnancy without examination. At the same time, women with hyperandrogenism experience increased hirsutism, and obesity is often observed. It is necessary to clarify whether the correction of isthmic-cervical insufficiency was performed, by what method, at what stages of pregnancy, whether the woman received antibiotics or other drugs and what is the reaction to the treatment.

When collecting anamnesis, special attention should be paid to the characteristics of the course of labor, including premature labor, if any, and to clarify the gestational age, the body weight of the newborn, its compliance with the gestational age, and also to establish whether there were any manifestations of intrauterine growth retardation and what neonatal complications were observed in the newborn. If the child died, it is necessary to familiarize yourself with the results of the pathological report.

The anamnesis should include information about the husband, his age, family history, previous illnesses. Professional hazards, bad habits (smoking, alcoholism, drugs).

Thus, anamnesis data are very necessary for assessing the effectiveness of all previously conducted treatment and preventive measures in order to outline the most appropriate examination paths to determine the state of the reproductive system and select pathogenetically justified rehabilitation therapy.

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