Tactics of management of pregnancy with infectious genesis of miscarriage

When pregnancy occurs in women with infectious genesis of miscarriage, it is necessary to control the activation of bacterial and viral infections.

The clinical course of pregnancy is assessed, an ultrasound examination is performed, during which it is necessary to pay attention to the contours of the fertilized egg, the presence of a heartbeat, the location of the formation of the branched chorion, and the condition of the yolk sac.

Bacteriological and virological examination is carried out every 2 weeks due to frequent changes in microflora; determination of vaginal microcenosis. Hemostasiogram control is necessary; changes in the form of hypercoagulation are noted during exacerbation of infection; a weakly positive lupus anticoagulant is often noted as a consequence of the infectious process.

It is necessary to exclude anemia, hypotension, which is typical for patients with miscarriage. Therapeutic measures in the first trimester are somewhat limited due to the danger of using some medications during embryogenesis. However, it is recommended to use immunoglobulin intravenously by drip at a dose of 25.0 ml every other day No. 3. If there is a serious risk of exacerbation of a viral infection, it is advisable to use octagam 2.5 g intravenously every 2 days No. 2-3. This therapeutic and prophylactic measure should be carried out at 7-8 weeks of pregnancy. Treatment with immunoglobulin is extremely important for women receiving glucocorticoids due to hyperandrogenism or autoimmune disorders. It is advisable to continue metabolic therapy complexes. In case of changes in the hemostasiogram, correction is necessary, antiplatelet agents and/or anticoagulants can be prescribed.

From the first weeks of pregnancy, therapeutic and prophylactic measures are necessary to prevent placental insufficiency, especially in women with low location or presentation of the branched chorion, partial detachment of the chorion. Lymphocytotherapy with the husband's lymphocytes, the use of Actovegin in tablets of 1 tablet 3 times a day or intravenously 5.0 ml in 200.0 ml of physiological solution No. 5 every other day may be recommended.

For a more successful pregnancy, it is advisable to use the drug Magne-Vb. The drug is harmless to the embryo, has a good sedative effect, improves sleep, has an antispasmodic effect, relieves uterine tension, has a laxative effect, which is also important for pregnant women.

Since many pregnant women have a history of inflammatory processes in the uterine appendages, pain in the first trimester is often caused by the presence of adhesions, taking antispasmodics can be useful, in addition, all antispasmodics are antiplatelet agents, and this should also be taken into account.

If the uterus lags behind the pregnancy term, the branched chorion is located low, therapy with human chorionic gonadotropin may be prescribed, Duphaston, Utrozhestan, dexamethasone may be taken according to indications.

In the first trimester, it is not advisable to treat with antibiotics, therefore, if chlamydia, mycoplasma, ureaplasma, group B streptococcus are detected in the cervix, we use eubiotics vaginally and wait until 13-14 weeks, when it will be possible to use etiotropic therapy. If vaginosis is detected in the first trimester, the vagina can be treated with miramistin, plivosept. In case of candidiasis, use boroglycerin, treat the vagina with brilliant green.

In the second trimester of pregnancy, microbiological and virological monitoring, smear microscopy are continued. A distinctive feature of the second trimester is monitoring the condition of the cervix, since isthmic-cervical insufficiency is possible. According to our data, ultrasound monitoring of the cervix is not enough. According to ultrasound data, shortening and dilation of the cervix can be noticed if the patient is examined by the same doctor and if the equipment is good. But functional isthmic-cervical insufficiency is not visible with ultrasound. The cervix becomes soft, and only then changes in length and width begin. Therefore, every 2 weeks (and if there is a suspicion, then after a week) when taking smears, a very careful examination of the cervix is carried out with a sterile glove. If the cervix is soft, then surgical correction of isthmic-cervical insufficiency is necessary.

If isthmic-cervical insufficiency is suspected, it is advisable to conduct a study on the presence of proinflammatory cytokines (N-6 or fibronectin) in the cervical mucus or in the peripheral blood (TNFalpha, il-1), since they are convincing markers of intrauterine infection.

The levels of il-b in the contents of the cervical canal are a marker of the effectiveness of therapy for infectious complications. In those observations where the level of il-b remained high after treatment, premature births and the birth of a child with intrauterine pneumonia occurred later.

In the third trimester of pregnancy, with the threat of premature birth and the absence of the effect of bacterial therapy in the clinical manifestations of chorioamnionitis, the pregnancy was terminated. In these observations, the level of il-6 remained high. A direct correlation was found between the high level of il-6 in the mucus of the cervical canal, the structural coagulation indicator - the thrombus-forming potential index (r = 0.92).

The development of the infectious process is usually accompanied by the development of hypercoagulation that does not correspond to the gestational age and the development of chronic diarrhea.

If surgical treatment of isthmic-cervical insufficiency is necessary, we additionally perform PCR diagnostics (determination of herpes simplex viruses, cytomegalovirus, chlamydia, mycoplasma, ureaplasma) in the mucus of the cervical canal. In the absence of infection in the mucus of the cervical canal, favorable smears, we do not perform antibiotic treatment. We examine and treat the cervix daily for 3-5 days and then prescribe eubiotics. If there is a suspicion of an infectious process, we prescribe antibiotics taking into account the identified flora. Immunofan 1.0 ml intramuscularly daily for a total of 5-10 injections.

Regardless of the presence of isthmic-cervical insufficiency and the presence or exacerbation of infection at the moment, we carry out the 2nd course of prevention of activation of viral infection. Immunoglobulin - intravenous drip 25.0 ml every other day 3 droppers or octagam - 2.5 g 2-3 times intravenously drip. Rectal suppositories with viferon - 2 suppositories per day for 10 days. In the second trimester, we monitor the condition of the fetus by Doppler ultrasound of the fetoplacental and uteroplacental blood flow. At the same time, we carry out a course of prevention of placental insufficiency, we prescribe actovegin 5.0 ml in 200.0 ml of saline intravenously drip alternating with instenon 2.0 ml in 200.0 ml of saline (administer very slowly, there may be a severe headache) 5 droppers. If it is impossible to conduct courses of prophylaxis by intravenous transfusions, it is possible to recommend tablet intake of actovegin, troxevasin for one month. During the second trimester, it is also necessary to monitor the state of hemostasis, anemia, and correct the detected disorders.

In the third trimester of pregnancy, a clinical assessment of the course of pregnancy, hemostasis control, bacteriological and virological monitoring, smear microscopy, assessment of the condition of the fetus using ultrasound, Doppler ultrasound of the fetoplacental and uteroplacental blood flow, and cardiotocography are carried out.

As in the previous trimesters of pregnancy, we recommend courses of metabolic therapy, prevention of placental insufficiency. Before childbirth, it is advisable to conduct a third course of immunoglobulin 25.0 ml intravenously drip No. 3, it is advisable to use Viferon or Kipferon. This therapy allows you to support immunity before childbirth to prevent postpartum purulent-inflammatory complications and prevent complications of the neonatal period.