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Spontaneous abortion (miscarriage): treatment

, medical expert
Last reviewed: 19.10.2021
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Treatment of spontaneous miscarriage should be carried out taking into account the period of pregnancy, the stage of clinical course and the cause of the disease. It is necessary to start therapy as early as possible, because it is easier to keep the pregnancy at the stage of a threatening miscarriage, it is more difficult - at the stage of started and impossible - at all subsequent. Assigning therapy and choosing the dosage of medications in the first trimester of pregnancy, you need to remember about the possible embryotoxic and teratogenic effects. Unfortunately, it is not always possible to identify the cause that caused the threat of abortion, but it is always necessary to strive for this in order to succeed with the least effort.

trusted-source[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

The goals of treatment of miscarriage (spontaneous abortion)

Relaxation of the uterus, stopping bleeding and maintaining pregnancy if there is a viable embryo or fetus in the uterus.

According to the recommendations adopted in our country, a threatening miscarriage is an indication for hospitalization in a hospital.

Medicinal treatment of miscarriage

Treatment of women with a threatening and started spontaneous miscarriage should be carried out only under stationary conditions. The complex of therapeutic measures includes:

  1. a full, balanced, vitamin-rich diet;
  2. bed rest;
  3. use of non-pharmacological methods of influence;
  4. the use of drugs that reduce psycho-emotional stress and relaxing the smooth muscles of the body.

As sedatives in the first trimester of pregnancy, it is better to limit the infusion of valerian root (Inf. Rad Valerianae 20.04-200.0) to 1 tablespoon 3 times a day or tincture of valerian (T-ha Valerianae 30.0) 30 drops also 3 times a day, or infusion of herb Leonurus (Inf. Haerbae Leonuri I5,0-j-200,0) and tincture of motherwort (T-hae Leonuri 30,0) in the same dosages. In the second trimester of pregnancy, you can use such tranquilizers as sibazon (diazepam, relanium) for 5 mg 2-3 times a day.

As spasmolytic agents, papaverine is used, in tablets (0.02-0.04 g), in suppositories (0.02 g), as injections (2 ml of a 2 % solution); but-shpu in tablets (0.04 g) or in the form of injections (2 ml of 2% solution); Metacin in tablets (0; 002 g) or as injections (1 ml of a 0.1 % solution); baralgin 1 tablet 3 times a day or intramuscularly 5 ml. Relaxation of the musculature of the uterus can be facilitated by intramuscular injection of a 25 % solution of magnesium sulfate in 10 ml at intervals of 12 hours.

The inhibitory effect on the contractile activity of the myometrium is exerted by some beta-adrenomimetics. In domestic obstetrics, the greatest use was found of partusisten (fenoterol, berotek) and ritodrin (yotopar). The tocolytic effect of these drugs is often used to prevent premature birth, but they can be successfully used to treat a threatening and started miscarriage in the II trimester of pregnancy. The available information on the embryotoxic effect of tocolytics in an animal experiment limits the possibility of using them in the early stages of pregnancy.

Partusisten is used orally in the form of tablets or intravenously. Tablets containing 5 mg of the drug are prescribed every 2-3-4 hours (the maximum daily dose is 40 mg). With the onset of miscarriage should begin treatment with intravenous administration; 0.5 ml of the drug is diluted in 250-500 ml of 5% glucose solution or 0.9% solution of sodium chloride and poured in at a speed of 5-8 to 15-20 drops per minute, seeking to suppress the contractile activity of the uterus. 30 minutes before the end of the drip introduction of the patient, the patient is given a partusisten tablet and then transfers it to the enteral route. When the persistent effect is achieved, the dosage of the drug is gradually reduced within a week. The duration of treatment is 2-3 weeks.

Ritodrin can be administered orally (5-10 mg 4-6 times a day), intramuscularly (10 mg every 4-6 hours) or intravenously (50 mg in 500 ml isotonic sodium chloride solution at a rate of 10-15 drops per minute) depending on the severity of the threat of termination of pregnancy. Course of treatment -2-4 weeks.

Tokolitiki can cause tachycardia, lowering blood pressure, sweating, nausea, muscle weakness. Therefore, therapy with beta-adrenomimetics should be carried out only in a hospital setting, observing bed rest. To reduce the side effects of tocolytics, verapamil (isoptin, phinoptin), related to calcium ion antagonists, can be prescribed, especially since this drug itself has some inhibitory effect on the contractile activity of the uterus. To prevent side effects of beta-adrenomimetics, isoptin is used in the form of tablets at 0.04 g 3 times a day. To remove the expressed side effects, 2 ml of a 0.25 % solution of isoptn can be administered intravenously.

Patients with pathology of the cardiovascular system, therapy of the threat of interruption of pregnancy by tocolytes is contraindicated.

Hormonal therapy of a threatening and started miscarriage, according to modern ideas, does not belong to the basic, leading methods of treatment, however, with the proper choice of means and methods of administration, it can significantly contribute to the beneficial effect of treatment.

The gestagens are used in the first trimester of pregnancy in cases of previously diagnosed malnutrition of the yellow body. Preference is given to allylestrenol (turinal), which is prescribed for 1-2 tablets (5-10 mg) 3 times a day for 2 weeks. Individual dose is selected under the control of colpocytological study with calculating KPI. With increasing CPI, the dose of turinale increases. The drug should be withdrawn after a gradual decrease in dosage within 2-3 weeks. Turinal can be replaced with progesterone (1 ml of 1% solution intramuscularly every other day) or oxyprogesterone capronate (1 ml of 12.5% solution intramuscularly once a week).

Good results are obtained by treatment with a new domestic progestagen drug acetomepregenol. Acetomepregnol has a positive effect on the hormonal status of pregnant women and helps eliminate the threat of termination of pregnancy. The drug is started with 1 tablet (0.5 mg) per day. When the effect is achieved, the dose is reduced to 1 / 2-1 / 4 tablets. The course of treatment - 2-3 weeks.

In women with hypoplasia and malformations of the uterus, with pre-pregnancy hypofunction of the ovaries, with the appearance of bloody discharge gestagens should be combined with estrogens. As estrogenic drugs, you can use ethinyl estradiol (mikrofoltlin), folliculin or estradiol dipropionate. Depending on the KPI indices, ethinyl estradiol is prescribed by 1/2 - 1/4 tablets per day (0.0125-0.025 mg), folliculin by 2500-5000 units (0.5-1.0 ml of 0.05 % solution intramuscularly). Some doctors consider it advisable to begin treatment with a miscarriage of 5-10 weeks, starting with estrogenic hemostasis, intramuscularly 1 ml 0.1 % solution of estradiol dpropropionate on the 1st day after 8 hours, in the second after 12 hours, in 3-4-e - after 24 hours. Then it is possible to switch to combined therapy with microfollin and turinale.

In women with a potentially corrective ovarian hypofunction, a positive result results in the inclusion of a chorionic agent in the complex of medications: the drug is prescribed up to a 12-week period of 1000-5000 units 2 times a week, then up to a 16-week period - once a week. In parallel, the administration of estrogens and gestagens continues.

The use of gestagens is contraindicated in women with a threatening and started miscarriage, suffering from hyperandrogenism of the adrenal origin. In such situations, the use of corticosteroids-prednisolone or dexamethasone is pathogenetically justified. Treatment is carried out under the control of 17-CS excretion in a daily amount of urine. In the first trimester, this figure should not exceed 10 mg / day (34.7 μmol / day), in the second trimester -12 mg / day (41.6 μmol / day). Usually a sufficient dose of prednisolone is from 1/2 to 1/4 tablets (2.5-7.5 mg). The use of dexamethasone is more rational, since it does not cause retention of sodium and water in the body, i.e., does not lead to edema development even with prolonged use. Depending on the baseline level of 17-CS, the following doses of dexamethasone are recommended: with excretion of 17-CS, not exceeding 15 mg / day (52 μmol / day), an initial dose of 0.125 mg (1/2 tablet) is given; at 15-20 mg / day (52-69.3 μmol / day) - 0.25 mg (1/2 - tablets); at 20-25 mg / day (69.3-86.7 μmol / day) - 0.375 mg (3/4 tablets); if the level of 17-CS exceeds 25 mg / day (86.7 μmol / day) - 0.5 mg (1 tablet). In the future, the dosage of the drug is adjusted under the control of the 17-CS release. A compulsory study in such patients is the colpositogram with the KPI count. When CPI is below normal figures for this period of pregnancy, estrogen should be added to the complex of therapeutic agents (0.0 (25-0.025 mg of microfollin).) Estrogens are combined with glucocorticoid drugs and with the appearance of bloody discharge.

In all cases of miscarriage that begins with bleeding, symptomatic drugs are not excluded: ascorutin for I tablet 3 times a day, etamzilate (dicinone) 1 tablet (0.25 g) 3 times a day.

In order to reduce the medical burden on the mother and developing fetus, it is recommended that physical factors be included in the complex of medical measures aimed at eliminating the threat of termination of pregnancy. In modern domestic obstetrical practice, the most widely used are physiotherapeutic procedures that have an effect on central or peripheral mechanisms regulating the contractile activity of the uterus:

  • endonasal galvanization;
  • magnesium electrophoresis by a sinusoidal modulated current;
  • induction of the renal region;
  • electrollation of the uterus by means of an alternating sinusoidal current.

To inhibit the contractile activity of the uterus, various methods of reflexotherapy, first and foremost acupuncture, are increasingly used.

With ischemic-cervical insufficiency, medical and physical methods of treatment are auxiliary. The main method of therapy in such cases is a surgical correction, which is advisable to be carried out at 13-18 weeks of pregnancy.

In case of a threatening miscarriage, a bed rest (physical and sexual rest), spasmolytic drugs (drotaverina hydrochloride, rectal suppository with papaverine hydrochloride, magnesium preparations), herbal sedatives (decollete decoction, valerian) are prescribed.

  • The preparation of folic acid is prescribed at 0.4 mg / day daily until 16 weeks gestation.
  • Drotaverina hydrochloride is prescribed with severe pain in the / m 40 mg (2 ml) 2-3 times a day, followed by a transition to oral intake of 3 to 6 tablets per day (40 mg in 1 tablet).
  • Suppositories with papaverine hydrochloride are used rectally for 20-40 mg twice a day.
  • Magnesium preparations (in 1 tablet: magnesium lactate 470 mg + pyridoxine hydrochloride 5 mg), with spasmolytic and sedative activity, appoint 2 tablets 2 times a day or 1 tablet in the morning, 1 tablet in the afternoon and 2 tablets a night, duration of intake 2 ned and more (according to indications).
  • With pronounced bloody discharge from the genital tract with a haemostatic purpose, etamzilate 250 mg in 1 ml is used - 2 ml / m 2 times a day with the transition to oral intake of 1 tablet (250 mg) 2-3 times a day; duration of treatment is set individually, depending on the intensity and duration of bloody discharge.

After clarifying the causes of the threat of termination of pregnancy, drugs that correct the violations are used.

Treatment for an undeveloped pregnancy

Surgical treatment of spontaneous abortion

Scraping the walls of the uterine cavity or vacuum aspiration is the method of choice for incomplete miscarriage and bleeding caused by it, as well as an infected miscarriage. Surgical treatment allows you to remove the remnants of chorial or placental tissue, stop bleeding, with an infected miscarriage - to evacuate tissues affected by the inflammatory process.

In the case of an undeveloped pregnancy, surgical treatment is also carried out in our country, vacuum-aspiration is the method of choice.

The most favorable results are given by operations that eliminate the inferiority of the internal pharynx of the cervix: various modifications of Shirodkar's method. A good effect is given by the operation closest to that of Shirodkar.

At the border of the cervix and anterior vaginal foramen a cross section of the mucosa is made. The wall of the vagina with the bladder moves upward. At the border of the cervix and the posterior vaginal vault, a second incision of the mucosa is made, parallel to the first. The wall of the vagina is also cut off posteriorly. With the help of Deshana's needle, a thick silk, lavsan or other thread is carried under the remaining intact jumper of the mucosa of the lateral vault of the vagina. The second end of the thread is carried under the mucosa of the opposite side. It turns out a circular seam, located close to the inner throat of the cervix. Ligature is tied in the anterior arch. The sections of the mucous membrane are sewn with separate catgut sutures.

A simpler technical modification is the McDonald modification, which achieves narrowing of the cervical canal below the internal seam area. The essence of this operation is that at the border of the transition of the mucous membrane of the vaginal vaults to the cervix, a suture of lavsan, silk or chrome catgut is superimposed.

A simple and effective method for correcting ischemic-cervical insufficiency is the method of AI Lyubimova and NM Mamedalieva (1981).

On the cervix at the level of the transition of the mucous membrane of the fornix of the vagina, the U-shaped seams are applied. Leaving 0.5 cm from the center line to the right, the lavsan thread is passed through the entire thickness of the neck, producing a pin on its back wall. Then with a needle with the same thread pierce the mucous membrane and part of the neck on the left side, a pin is produced in the anterior arch. The second thread is carried out in a similar way, making the first injection 0.5 cm to the left of the middle line and the second one - in the thick of the side wall to the right. Both seams are tied in the area of the anterior arch.

Operations that strengthen the outer cervical cervix are currently rarely used.

Vaginal operations, correcting istrmico-cervical insufficiency, can not be performed with excessively deformed, shortened or partially absent cervix of the uterus. In recent years, in such cases, a transabdominal suture of the cervix is performed successfully at the level of the internal pharynx.

Summing up the discussion of methods of treatment of a threatening or started spontaneous abortion, we once again emphasize that the success of treatment depends on the timeliness and adequacy of the choice of means. Hospitalization of patients should be carried out with the first, even minimal symptoms of the disease; treatment from the first minutes of stay in the hospital should be carried out in the most necessary amount, and only when the effect is achieved can gradually reduce the dosage of medications and reduce the range of means and methods of treatment.

In the absence of the effect of treatment or in the late treatment of a patient for medical care, there is a loss of connection between the fetal egg and the fetus, accompanied by increased bleeding. Preservation of pregnancy becomes impossible.

If an abortion is "under way" or an incomplete abortion is diagnosed in the first trimester of pregnancy, then urgent help consists in emptying the uterine cavity with a curette, thereby achieving rapid stopping of bleeding.

In the second trimester of pregnancy (especially after the 16th week), often the outpouring of amniotic fluid occurs, and the expulsion of the fetus and the afterbirth is delayed. In such cases, it is necessary to prescribe funds that stimulate the contractile activity of the uterus. You can use various modifications of the Stein-Kurdinovsky scheme. For example, after creating an estrogenic background by intramuscular injection of 3 ml of a 0.1% solution of folliculin or 1 ml of a 0.1% solution of estradiol dipropionate, the patient should drink 40-50 ml of castor oil, and after 1/2 hour put a cleansing enema. After evacuation of the intestine, the second part of the scheme is performed in the form of quinine and pituitrin (oxytocin) in divided doses. Usually, quinine hydrochloride is used at 0.05 g after 30 minutes (in a total of 8 powders); after intake of each two quinine powders, 0.25 ml of pituitrin or oxytocin is injected subcutaneously.

Fast ejection of the fetal egg can be achieved by intravenous drip of oxytocin (5 units of oxytocin per 500 ml of 5% glucose solution) or prostaglandin F2a (5 mg of the drug is diluted in 500 ml of 5/6 glucose solution or isotonic sodium chloride solution). Infusion begins with 10-15 drops in 1 minute, then every 10 minutes the rate of administration is increased by 4-5 drops per minute before the onset of contractions, however, the number of drops should not exceed 40 per 1 minute. After the birth of the fetal egg, even in the absence of visible defects of placental tissue or membranes, scraping of the walls of the uterine cavity with a large blunt curette is shown. If there is a delay in separation and separation of the afterbirth, an instrumental emptying of the uterus is performed with the help of an abortion and a curette.

With continued bleeding after emptying the uterus, additional administration of uterine contractions (1 ml 0.02% methylergometrine, 1 ml 0.05 % ergotal, or 1 ml 0.05 % ergotamine hydrotartrate) is necessary . These drugs can be administered under the skin, intramuscularly, slowly into a vein or into the cervix. In parallel with the stoppage of bleeding, all measures aimed at correcting blood loss, preventing or treating possible infectious complications of spontaneous miscarriage are carried out.

Special caution should be exercised when the fetus is delayed in the uterus over 4-5 weeks. Instrumental emptying of the uterus in such cases can be complicated by bleeding, not only in connection with the loss of tonus of the uterine musculature, but also due to the development of the internal combustion engine. Usually, these complications occur during pregnancy 16 or more. Particularly careful monitoring of patients should be carried out within the first 6 hours after emptying the uterus, for, as clinical practice shows, bleeding caused by the DIC syndrome of blood, almost in half of cases occurs within 2-4 hours after emptying the uterus against the background of apparent well-being at well-contracted uterus. Therapeutic measures should be aimed at eliminating the violations of the blood coagulation system, and if the therapy is ineffective, it should not hesitate to start removing the uterus.

Conservative management of the patient

Tactics adopted in European countries with undeveloped pregnancy in the first trimester include a conservative approach consisting in expecting spontaneous evacuation of the contents of the uterine cavity in the absence of intense bleeding and signs of infection.

The most common spontaneous miscarriage occurs 2 weeks after the development of the fetal egg has stopped. When there is intense bleeding, incomplete abortion, the appearance of signs of infection produce vacuum aspiration or scraping. Such expectant management is dictated by an increased risk of cervical injury, perforation of the uterus, the formation of synechia, the development of inflammatory diseases of the pelvic organs, side effects of anesthesia during surgical treatment.

In our country, with an undeveloped pregnancy, preference is given to the surgical method.

Surgical treatment is not performed in case of complete spontaneous miscarriage. With complete evacuation of the fetal egg from the uterine cavity, the cervix is closed, there is no bleeding, spotting is scanty, the uterus has shrunk well, dense. Obligatory ultrasound to exclude delays in the uterine cavity of the elements of the fetal egg.

trusted-source[11], [12], [13], [14], [15], [16], [17]

Medicinal treatment of spontaneous abortion

In recent years, discuss an alternative way of management with an undeveloped pregnancy - the introduction of analogues of prostaglandins. With vaginal use of the prostaglandin E1 - misoprostol analogue at a dose of 80 mg, a total spontaneous abortion occurred in 83% of cases for 5 days.

Misoprostol is contraindicated in bronchial asthma and glaucoma and is not approved for use in the US.

In our country, drug treatment with undeveloped pregnancy is not carried out, preference is given to the surgical method.

Management of the postoperative period

Recommended preventive antibacterial therapy of 100 mg doxycycline orally on the day of vacuum aspiration or curettage of the uterine cavity.

In patients with a history of inflammatory diseases of the pelvic organs (endometritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvioperitonitis), antibacterial treatment should be continued for 5-7 days.

In Rhesus-negative women (during pregnancy from a Rh-positive partner) during the first 72 hours after vacuum aspiration or scraping during gestation more than 7 weeks in the absence of Rh antibodies, prophylaxis of Rh-immunization by the introduction of anti-Rh0 (D) -immunoglobulin in a dose of 300 μg IM.

Training patient

Patients should be informed of the need to see a doctor during pregnancy when there is pain in the lower abdomen, in the lower back, when there is bloody discharge from the genital tract.

Further management of a patient with spontaneous abortion

After scraping the walls of the uterine cavity or vacuum aspiration, it is recommended not to use tampons and refrain from sex for 2 weeks.

The onset of the next pregnancy is recommended no earlier than 3 months, and therefore recommendations are given about contraception for 3 menstrual cycles.

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