Spontaneous abortion (miscarriage)

Spontaneous miscarriage is the spontaneous termination of pregnancy before the fetus reaches a viable gestational age.

According to the WHO definition, abortion is the spontaneous expulsion or extraction of an embryo or fetus weighing up to 500 g, which corresponds to a gestational age of up to 22 weeks of pregnancy.

Epidemiology

Overall, 10% to 20% of clinically diagnosed pregnancies end in early pregnancy loss.[ 1 ],[ 2 ] However, this statistic likely underestimates the true incidence of spontaneous miscarriage, as many miscarriages remain undiagnosed and the resulting bleeding is mistaken for heavy late menses. Studies that have monitored pregnancies using daily serum β-hCG measurements estimate a higher incidence of approximately 38%.[ 3 ] Additionally, 12% to 57% of pregnancies with first trimester bleeding end in miscarriage.[ 4 ]

The rate of early pregnancy loss in women aged 20 to 30 years is only 9–17%, whereas the rate of pregnancy loss at age 45 years is 75–80%. A history of pregnancy loss also increases the risk of recurrent pregnancy loss, with the risk increasing after each additional loss. For example, the risk of miscarriage in a future pregnancy is approximately 20% after one miscarriage, 28% after 2 consecutive miscarriages, and 43% after ≥3 consecutive miscarriages.[ 5 ] Additionally, vaginal bleeding in the first trimester of pregnancy, which occurs in 25% of pregnancies, is associated with a higher risk of pregnancy loss.[ 6 ],[ 7 ]

Causes miscarriage

About 50% of sporadic early miscarriages are caused by chromosomal defects; in the 8–11 week period, the proportion of chromosomal pathology is 41–50%, and in the 16–19 week period, it decreases to 30%.

The most common types of chromosomal pathology in early spontaneous miscarriages are autosomal trisomies (52%), monosomy X (19%), polyploidy (22%), other forms make up 7%. [ 8 ]

In 80% of cases, the ovum initially dies and then expulses. Among other causes of sporadic early miscarriages, anatomical, endocrine, infectious, and immune factors are distinguished, which are largely the causes of habitual miscarriages. [ 9 ], [ 10 ]

The causes of spontaneous miscarriages are extremely varied; often, not one but several causal factors lead to the termination of pregnancy. Despite all the conventionality, these factors can be grouped as follows:

• Abortion in the first trimester (less than 12 weeks of pregnancy) is usually caused by chromosomal abnormalities, most often Turner syndrome (45,X0 );
• uterine pathology;
• pathology of the fertilized egg (fetal sac without an embryo or yolk sac);
• immunological disorders; [ 11 ]
• endocrine pathology;
• infectious factor;
• somatic diseases (diabetes) and intoxication;
• mental factor.
• Abortion in the second trimester (12-20 weeks of pregnancy) is usually caused by organic lesions of the uterus (anomalies of the fusion of the Müllerian ducts, fibroids) or the cervix ( isthmic-cervical insufficiency ).

Uterine pathologies that contribute to spontaneous miscarriage include cervical anomalies ( septum, saddle-shaped, bicornuate uterus ), uterine cavity synechia ( Asherman's syndrome ), isthmic-cervical insufficiency, uterine hypoplasia, and fibroids.

Anomalies of the chromosomal apparatus, which most often lead to miscarriages in the early stages of pregnancy, are associated with structural disorders or quantitative aberrations of chromosomes.

In recent years, issues concerning the role of immune factors in miscarriage have been intensively developed. The literature data on this problem are contradictory, but there is no doubt that cellular and humoral immunity in women with habitual miscarriages is reduced. Many authors emphasize the role of histocompatibility antigens in the etiology of miscarriage. The coincidence of HLA antigens in the mother and father leads to an increase in the number of miscarriages. Pregnant women who do not have lymphocytotoxic antibodies to their husband's lymphocytes have more frequent miscarriages.

Endocrine pathology with profound changes in organ functions often leads to infertility. Spontaneous miscarriages usually occur in women with latent forms of hormonal disorders. First of all, this applies to ovarian hypofunction, usually expressed by luteal insufficiency, as well as androgenism of adrenal and ovarian genesis. In this case, spontaneous miscarriage can occur both with spontaneous pregnancy and with drug-induced pregnancy.

A common cause of miscarriages is infection of the mother's body. This group of etiological factors includes both general acute and chronic infectious diseases and local lesions of the reproductive system caused by bacterial flora, mycoplasma, chlamydia, toxoplasma, listeria, viruses, and fungi.

The role of a psychogenic factor, which often acts as a trigger against the background of other predisposing factors, cannot be ruled out.

Any of the above causes ultimately leads to increased contractile activity of the uterus, separation of the fertilized egg from the uterine wall and its expulsion. In the first and early second trimesters (before the placenta is fully formed), the fertilized egg separates and is released from the uterus without rupturing the amniotic sac. At a later stage, with the placenta formed, the termination of pregnancy occurs in the manner of a labor act: the cervix opens, the amniotic fluid is released, the fetus is born, and then the placenta.

Risk factors for miscarriage

• Maternal age is one of the main risk factors for spontaneous miscarriage in healthy women. In women aged 20–30 years, it is 9–17%, 35 years – 20%, 40 years – 40%, 45 years – 80%. The data were obtained based on the analysis of the outcomes of 1 million pregnancies.
• Parity: Women with 2 or more previous pregnancies have a higher risk of miscarriage than women who have never given birth, and this risk is not dependent on age.
• History of spontaneous miscarriages. The risk of spontaneous miscarriage increases with the number of failures: in women with 1 spontaneous miscarriage in the history, the risk is 18-20%, after 2 miscarriages it reaches 30%, after 3 miscarriages - 43%. For comparison: the risk of miscarriage in women whose previous pregnancy ended successfully is 5%.
• Smoking. Smoking more than 10 cigarettes a day increases the risk of spontaneous abortion in the first trimester. These data are most indicative when analyzing spontaneous abortion with a normal chromosomal set.
• Use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the periconception period. There is evidence of a negative effect of prostaglandin synthesis inhibition on implantation success. With the use of nonsteroidal anti-inflammatory drugs in the periconception period and early pregnancy, the miscarriage rate was 25% compared with 15% in women not receiving NSAIDs. This trend was not confirmed with respect to acetaminophen.
• Fever (hyperthermia). An increase in temperature above 37.7°C leads to an increase in the frequency of early spontaneous miscarriages.
• Trauma, including invasive prenatal diagnostic techniques (with choriocentesis, amniocentesis, cordocentesis the risk is 3–5%).
• Caffeine consumption. With daily consumption of more than 100 mg of caffeine (4–5 cups of coffee), the risk of early miscarriages significantly increases, and this trend persists for fetuses with a normal karyotype. [ 12 ]

Other factors in the development of miscarriage

• Exposure to teratogens - infectious agents, toxic substances, drugs with a teratogenic effect.
• Folic acid deficiency - when the concentration of folic acid in the blood serum is less than 2.19 ng/ml (4.9 nmol/l), the risk of spontaneous miscarriage from 6 to 12 weeks of pregnancy significantly increases, which is associated with a higher frequency of formation of an abnormal karyotype of the fetus.
• Hormonal disorders and thrombophilic conditions are more likely to cause habitual rather than sporadic miscarriages. According to the American Society for the Prevention and Treatment of Diseases, assisted reproductive technologies do not increase the risk of spontaneous miscarriages.

Certain chronic medical conditions may predispose a pregnant woman to early pregnancy loss, including obesity, diabetes, hyperprolactinemia, celiac disease, thyroid disease, and autoimmune conditions, particularly antiphospholipid syndrome.[ 13 ] Additionally, certain infections are associated with an increased risk of early pregnancy loss, such as syphilis, parvovirus B19, Zika virus, and cytomegalovirus infection.[ 14 ] Structural uterine abnormalities (eg, congenital Müllerian anomalies, leiomyoma, and intrauterine adhesions) and intrauterine pregnancy with an intrauterine device also increase the risk of early pregnancy loss. Chronic stress secondary to social determinants of health (eg, racism, housing or food insecurity, or living with the threat of violence) is also associated with an increased risk of pregnancy loss. Finally, environmental pollutants, including arsenic, lead, and organic solvents, have also been linked to early pregnancy loss.

Symptoms miscarriage

Symptoms of spontaneous abortion (miscarriage) are expressed in the patient's complaints of bloody discharge from the genital tract, pain in the lower abdomen and lower back in the presence of a delay in menstruation.

Depending on the clinical symptoms, a distinction is made between threatened spontaneous abortion, abortion in progress (incomplete or complete), non-viable pregnancy, and infected abortion.

• Vaginal bleeding (light or heavy, constant or intermittent). It can be difficult to tell if bleeding is a sign of miscarriage, but if there is pain at the same time, the risk is higher.
• The appearance of pain in the lower abdomen, lower back or pelvic organs.
• Vaginal discharge of aborted tissue.

Symptoms of threatened abortion

Threatened abortion is manifested by nagging pains in the lower abdomen and lower back, sometimes scanty bloody discharge from the genital tract. The tone of the uterus is increased, the cervix is not shortened, the internal os is closed, the body of the uterus corresponds to the gestational age. The fetal heartbeat is recorded during ultrasound.

Symptoms of an abortion that has begun

When an abortion has begun, the pain and bloody discharge from the vagina are more pronounced, the cervical canal is slightly open. It is necessary to diagnose the following obstetric complications: detachment of the chorion (placenta) and its size, presentation or low location of the chorion (placenta), bleeding from the second horn of the uterus in case of its developmental defects, death of one ovum in case of multiple pregnancies.

Symptoms of abortion in progress

During an abortion, regular cramping contractions of the myometrium are determined, the size of the uterus is less than the expected gestational age, and in later stages of pregnancy, amniotic fluid may leak. The internal and external os are open, the elements of the ovum are in the cervical canal or in the vagina. Bloody discharge may be of varying intensity, often profuse.

Symptoms of incomplete abortion

Incomplete abortion is a condition associated with the retention of elements of the fertilized egg in the uterine cavity. The absence of a full contraction of the uterus and the closure of its cavity leads to ongoing bleeding, which in some cases can lead to significant blood loss and hypovolemic shock. It is more common after 12 weeks of pregnancy when the miscarriage begins with the discharge of amniotic fluid. During a bimanual examination, the uterus is smaller than the expected gestational age, bloody discharge from the cervical canal is abundant, during ultrasound, remnants of the fertilized egg are detected in the uterine cavity, in the second trimester - remnants of placental tissue.

Symptoms of an Infected Abortion

Infected abortion is a condition accompanied by fever, chills, malaise, lower abdominal pain, bloody, sometimes purulent discharge from the genital tract. Physical examination reveals tachycardia, tachypnea, defense of the muscles of the anterior abdominal wall, bimanual examination reveals a painful, soft uterus, and an enlarged cervix. The inflammatory process is most often caused by Staphylococcus aureus, Streptococcus, Gram-negative microorganisms, and Gram-positive cocci. If left untreated, infection may generalize into salpingitis, local or diffuse peritonitis, and septicemia.

Non-developing pregnancy (antenatal death of the fetus) is the death of an embryo or fetus before 20 weeks of pregnancy in the absence of expulsion of elements of the fertilized egg from the uterine cavity.

In the first trimester, a combination of pain symptoms and bloody discharge is typical for a miscarriage. In the second trimester, the initial manifestations of an abortion are cramping pains in the lower abdomen, bleeding occurs after the birth of the fetus. An exception is the termination of pregnancy against the background of placenta previa, when the leading symptom is bleeding, usually profuse.

Threatened miscarriage is manifested by minor pain in the lower abdomen. The miscarriage that has begun is accompanied by increased pain and possible appearance of scanty bloody discharge. Abortion "in progress" is characterized by a sharp increase in cramping pain and profuse bleeding. Incomplete abortion is characterized by a decrease in pain against the background of ongoing bleeding of varying severity. With complete abortion, the pain subsides and bleeding stops.

The peculiarities of the symptoms of spontaneous miscarriage may be determined by the etiologic factor that caused it. Thus, an abortion caused by isthmic-cervical insufficiency occurs in the second trimester of pregnancy, begins with the discharge of amniotic fluid and ends with the rapid birth of the fetus in the foyer of weak, slightly painful contractions. Genetic factors lead to miscarriage in the early stages of pregnancy. Abortions against the background of androgenism in the early stages begin with bloody discharge, then a pain symptom joins in, and often in such cases a frozen pregnancy is formed. Intrauterine death of the fetus is possible in the later stages. The death of the ovum with its subsequent expulsion from the uterus can be observed in the presence of chronic and acute infection, bleeding in this case is rarely profuse.

To clarify the diagnosis, it is necessary to conduct an examination of the cervix and vagina using speculums (if neoplasms of the cervix are suspected, a colposcopy and biopsy are performed), a careful bimanual examination, and determination of the level of human chorionic gonadotropin.

In developing tactics for managing pregnancy in case of bleeding in the first trimester of pregnancy, ultrasound plays a decisive role.

Unfavorable signs regarding the development of the fertilized egg during uterine pregnancy during ultrasound:

• absence of a heartbeat in an embryo with a crown-rump length of more than 5 mm;
• absence of an embryo with the size of the ovum being more than 25 mm in 3 orthogonal planes during transabdominal scanning and more than 18 mm during transvaginal scanning.

Additional ultrasound signs indicating an unfavorable pregnancy outcome include:

• an abnormal yolk sac, which may be larger than the gestational age, irregularly shaped, displaced to the periphery, or calcified;
• embryonic heart rate less than 100 beats per minute at a gestational age of 5–7 weeks of pregnancy;
• large size of retrochorial hematoma - more than 25% of the surface of the ovum.

Diagnostics miscarriage

Diagnosis of spontaneous miscarriages is usually straightforward. It consists of complaints presented by the patient; data from a general and gynecological examination; results of colposcopy, hormonal and ultrasound examination methods.

The general condition of the patient may be determined by both the pregnancy itself and the degree of blood loss associated with the form of spontaneous miscarriage. In the case of a threatened or incipient miscarriage, the condition of women is usually satisfactory, unless early toxicosis of pregnancy is superimposed and the miscarriage is not provoked by severe somatic pathology. In the case of an abortion "in progress", incomplete and complete abortion, the condition of the patient depends on the duration, intensity and degree of blood loss. Long-term, minor bleeding leads to anemia of the patient, the severity of which determines the condition of the woman. Acute blood loss can cause a state of shock.

Gynecological examination data in case of threatened miscarriage indicate that the size of the uterus corresponds to the period of delay of menstruation. The uterus responds to palpation by contraction. There are no structural changes in the cervix. In case of the beginning of miscarriage, the cervix may be somewhat shortened with a slightly gaping external os. The spasmodic body of the uterus corresponding to the gestational age, the lower pole of the ovum easily reached through the cervical canal indicate an abortion "in progress". In case of incomplete abortion, the size of the uterus is less than the gestational age, and the cervical canal or external os is slightly open.

There is no need to resort to additional diagnostic methods for spontaneous miscarriages in all cases of the disease. Abortion is "in use" and, as a rule, incomplete abortion does not require the use of additional diagnostic methods. Only in some cases is ultrasound examination used to help differentiate incomplete abortion from one that has begun.

Laboratory and hardware methods are used for early diagnosis and dynamic monitoring of the initial stages of termination of pregnancy.

Colpocytological studies help to identify the threat of termination of pregnancy long before the appearance of clinical symptoms. It is known that the karyopyknotic index (KPI) in the first 12 weeks of pregnancy should not exceed 10%, in 13-16 weeks it is 3-9%, in later periods the KPI is within 5%. An increase in the KPI indicates a threat of termination of pregnancy and requires hormonal correction.

However, it should be remembered that in the case of pregnancy against the background of androgenism, a decrease in the CPI is an unfavorable sign, dictating the need to use estrogen drugs.

Determination of choriogonin, estradiol and progesterone in blood plasma has prognostic value. Termination of pregnancy in the first trimester becomes quite real if the choriogonin level is below 10,000 mIU/ml, progesterone is below 10 ng/ml, estradiol is below 300 pg/ml.

In women with androgenism, the determination of the 17-KS level in the daily urine volume has great diagnostic and prognostic value. If the amount of 17-KS exceeds 42 μmol/l, or 12 mg/day, then the threat of spontaneous abortion becomes real.

The value of laboratory methods for diagnosing the threat of miscarriage increases if an ultrasound examination is performed simultaneously. Echographic signs of a threatened miscarriage in the early stages of pregnancy are the location of the ovum in the lower parts of the uterus, the appearance of unclear contours, deformations, and constrictions of the ovum. From the end of the first trimester of pregnancy, with the threat of its termination, it is possible to identify areas of placental abruption and measure the diameter of the isthmus.

[ 15 ], [ 16 ], [ 17 ], [ 18 ], [ 19 ], [ 20 ], [ 21 ], [ 22 ], [ 23 ]

Differential diagnosis

Differential diagnostics are carried out with ectopic pregnancy, hydatidiform mole, menstrual cycle disorders (oligomenorrhea), benign and malignant diseases of the cervix, body of the uterus and vagina.

[ 24 ]

Treatment miscarriage

Treatment of spontaneous miscarriage should be carried out taking into account the gestational age, the stage of the clinical course and the cause of the disease. It is necessary to start therapy as early as possible, because it is easier to save a pregnancy at the stage of a threatened miscarriage, more difficult at the stage of an incipient miscarriage and impossible at all subsequent stages. When prescribing therapy and selecting dosages of medications in the first trimester of pregnancy, it is necessary to remember the possible embryotoxic and teratogenic effects. Unfortunately, it is not always possible to identify the cause that caused the threat of termination of pregnancy, but it is always necessary to strive for this in order to achieve success with the least effort. [ 25 ]

There is no way to stop a miscarriage. If there is no significant blood loss, fever, weakness or other signs of inflammation, the miscarriage will happen on its own. This may take several days. If you have a negative Rh factor, you should get a Rh antibody shot to prevent future miscarriages.

Most miscarriages do not require medical intervention, except in rare cases. If you have a miscarriage, you need to work with your doctor to prevent problems from developing. If the uterus cannot clear quickly, there is a lot of blood loss and inflammation develops. In such cases, curettage of the uterine cavity is performed. Miscarriage does not happen quickly. It takes time, and the symptoms vary from case to case. In case of miscarriage, use the following recommendations.

• Use pads (not tampons) during bleeding, which will last a week or more. The flow will be heavier than usual. Tampons can be used during your next cycle, which will begin in 3 to 6 weeks.
• Take acetaminophen (Tylenol) for pain that may last for a few days after the miscarriage. Read the package directions carefully.
• Eat a balanced diet, eat foods rich in iron and vitamin C, as bleeding can cause anemia. Foods rich in iron include meat, shellfish, eggs, legumes, and green vegetables. Vitamin C is found in citrus fruits, tomatoes, and broccoli. Talk to your doctor about taking iron tablets and multivitamins.
• Discuss your plans for future pregnancy with your doctor. Experts agree that you can try to get pregnant after one normal cycle. If you do not want to have a child yet, consult your doctor about contraception.

Goals of treatment for 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 threatened miscarriage is an indication for hospitalization.

Medical treatment of miscarriage

Treatment of women with threatened and incipient spontaneous miscarriage should be carried out only in hospital conditions. The complex of treatment measures includes:

1. a complete, balanced diet rich in vitamins;
2. bed rest;
3. use of non-drug methods of influence;
4. the use of drugs that reduce psychoemotional stress and relax the smooth muscles of the uterine body.

As sedatives in the first trimester of pregnancy, it is better to limit yourself to valerian root infusion (Inf. rad. Valerianae 20.04-200.0) 1 tablespoon 3 times a day or valerian tincture (T-rae Valerianae 30.0) 20-30 drops also 3 times a day, or motherwort herb infusion (Inf. haerbae Leonuri 15.0-200.0) and motherwort tincture (T-rae Leonuri 30.0) in the same dosages. In the second trimester of pregnancy, tranquilizers such as sibazon (diazepam, relanium) can be used at 5 mg 2-3 times a day.

The following are used as antispasmodics: papaverine, in tablets (0.02-0.04 g), in suppositories (0.02 g), in the form of injections (2 ml of 2% solution); no-shpa in tablets (0.04 g) or in the form of injections (2 ml of 2% solution); metacin in tablets (0.002 g) or in the form of injections (1 ml of 0.1% solution); baralgin, 1 tablet 3 times a day or intramuscularly, 5 ml. Relaxation of the uterine muscles can be facilitated by intramuscular administration of 25% magnesium sulfate solution, 10 ml at intervals of 12 hours.

Some beta-adrenergic agonists have an inhibitory effect on the contractile activity of the myometrium. In domestic obstetrics, the most widely used are partusisten (fenoterol, berotek) and ritodrine (utopar). The tocolytic effect of these drugs is often used to prevent premature birth, but they can be successfully used to treat threatened and incipient miscarriage in the second trimester of pregnancy. Available information on the embryotoxic effect of tocolytics in animal experiments limits the possibility of using them in early pregnancy.

Partusisten is administered 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). If a miscarriage has begun, treatment should be started with intravenous administration; 0.5 ml of the drug is diluted in 250-500 ml of a 5% glucose solution or 0.9% sodium chloride solution and infused drop by drop at a rate of 5-8 to 15-20 drops per minute, achieving suppression of uterine contractions. 30 minutes before the end of the drip administration of the drug, the patient is given a tablet of Partusisten and then transferred to the enteral route of drug administration. Upon achieving a stable effect, the dosage of the drug is gradually reduced over the course of a week. The duration of the course of treatment is 2-3 weeks.

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

Tocolytics can cause tachycardia, decreased blood pressure, sweating, nausea, muscle weakness. Therefore, beta-adrenergic therapy should be carried out only in a hospital setting, with bed rest. To reduce the side effects of tocolytics, verapamil (isoptin, finoptin), which is a calcium ion antagonist, can be prescribed, especially since this drug itself has some inhibitory effect on uterine contractility. To prevent side effects of beta-adrenergic agonists, isoptin is used in the form of tablets of 0.04 g 3 times a day. To relieve severe side effects, 2 ml of a 0.25% isoptin solution can be administered intravenously.

For patients with cardiovascular pathology, therapy of threatened miscarriage with tocolytics is contraindicated.

Hormonal therapy for threatened and incipient miscarriage, according to modern concepts, does not belong to the main, leading methods of treatment, however, with the correct choice of means and methods of administration, it can significantly contribute to the favorable effect of treatment.

Gestagens are used in the first trimester of pregnancy in cases of previously diagnosed corpus luteum insufficiency. Preference is given to allylestrenol (turinal), which is prescribed 1-2 tablets (5-10 mg) 3 times a day for 2 weeks. An individual dose is selected under the control of a colpocytological study with calculation of the CPI. With an increase in the CPI, the dose of turinal is increased. The drug should be discontinued after a gradual, over 2-3 weeks, reduction in dosage. Turinal can be replaced with progesterone (1 ml of a 1% solution intramuscularly every other day) or oxyprogesterone capronate (1 ml of a 12.5% solution intramuscularly once a week).

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

In women with hypoplasia and malformations of the uterus, with ovarian hypofunction established before pregnancy, if bloody discharge occurs, gestagens should be combined with estrogens. Ethinyl estradiol (microfollin), folliculin or estradiol dipropionate can be used as estrogenic drugs. Depending on the KPI indicators, ethinyl estradiol is prescribed at 1/2 - 1/4 tablet per day (0.0125-0.025 mg), folliculin at 2500-5000 U (0.5-1.0 ml of 0.05% solution intramuscularly). Some doctors consider it advisable to begin treatment with estrogenic hemostasis when a miscarriage begins at 5-10 weeks, prescribing 1 ml of a 0.1% solution of estradiol dnpropionate intramuscularly on the first day after 8 hours, on the second - after 12 hours, on the third-fourth - after 24 hours. Then you can switch to combined therapy with microfollin and turinal.

In women with potentially correctable ovarian hypofunction, a positive result is achieved by including choriogonin in the complex of therapeutic agents: the drug is prescribed up to the 12-week period at 1000-5000 IU 2 times a week, then up to the 16-week period - 1 time per week. In parallel, the intake of estrogens and gestagens is continued.

The use of gestagens is contraindicated in women with threatened or started miscarriage, suffering from hyperandrogenism of adrenal genesis. In such situations, the administration of corticosteroids - prednisolone or dexamethasone is pathogenetically justified. Treatment is carried out under the control of excretion of 17-KS in the daily amount of urine. In the first trimester, this indicator 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 of a tablet (2.5-7.5 mg). The use of dexamethasone is more rational, since it does not cause sodium and water retention in the body, i.e. does not lead to the development of edema even with prolonged use. Depending on the initial level of 17-KS, the following doses of dexamethasone are recommended: if 17-KS excretion does not exceed 15 mg/day (52 μmol/day), an initial dose of 0.125 mg (1/2 tablet) is prescribed; at 15-20 mg/day (52-69.3 μmol/day) - 0.25 mg (1/2 tablet); at 20-25 mg/day (69.3-86.7 μmol/day) - 0.375 mg (3/4 tablet); if the 17-KS level exceeds 25 mg/day (86.7 μmol/day) - 0.5 mg (1 tablet). The dosage of the drug is subsequently adjusted under the control of 17-KS excretion. A mandatory examination in such patients is a colpocytogram with CPI calculation. If the CPI is below normal values for a given gestational age, it is necessary to add estrogens (0.0 (25-0.025 mg microfollin) to the treatment complex. Estrogens are combined with glucocorticoid drugs and if bloody discharge occurs.

In all cases of a miscarriage that has begun and is accompanied by bleeding, the use of symptomatic medications is not excluded: askorutin, 1 tablet 3 times a day, etamsylate (dicynone), 1 tablet (0.25 g) 3 times a day.

In order to reduce the drug load on the mother's body and the developing fetus, it is recommended to include physical factors in the complex of treatment measures aimed at eliminating the threat of termination of pregnancy. In modern domestic obstetric practice, the most widespread are physiotherapeutic procedures that affect the central or peripheral mechanisms regulating the contractile activity of the uterus:

• endonasal galvanization;
• electrophoresis of magnesium with sinusoidal modulated current;
• inductothermy of the kidney area;
• Electrorelaxation of the uterus using alternating sinusoidal current.

To inhibit the contractile activity of the uterus, various methods of reflexology, primarily acupuncture, are increasingly being used.

In case of isthmic-cervical insufficiency, medicinal and physical methods of treatment are auxiliary. The main method of therapy in such cases is recognized as surgical correction, which is advisable to carry out in 13-18 weeks of pregnancy.

In case of threatened miscarriage, bed rest (physical and sexual rest), antispasmodic drugs (drotaverine hydrochloride, rectal suppositories with papaverine hydrochloride, magnesium preparations), herbal sedatives (decoction of motherwort, valerian) are prescribed.

• Folic acid is prescribed at 0.4 mg/day daily until 16 weeks of pregnancy.
• Drotaverine hydrochloride is prescribed for severe pain, intramuscularly at 40 mg (2 ml) 2-3 times a day, followed by a transition to oral administration of 3 to 6 tablets per day (40 mg in 1 tablet).
• Suppositories with papaverine hydrochloride are used rectally at 20–40 mg 2 times a day.
• Magnesium preparations (in 1 tablet: magnesium lactate 470 mg + pyridoxine hydrochloride 5 mg), which have antispasmodic and sedative activity, are prescribed 2 tablets 2 times a day or 1 tablet in the morning, 1 tablet during the day and 2 tablets at night, the duration of administration is 2 weeks or more (as indicated).
• In case of pronounced bloody discharge from the genital tract, etamsylate is used for hemostatic purposes at 250 mg in 1 ml - 2 ml intramuscularly 2 times a day with a transition to oral administration of 1 tablet (250 mg) 2-3 times a day; the duration of treatment is determined individually depending on the intensity and duration of bloody discharge.

After clarifying the reasons for the threat of termination of pregnancy, drugs are used to correct the identified disorders.

Treatment for non-viable pregnancy

Surgical treatment of spontaneous abortion

Scraping of the uterine cavity walls or vacuum aspiration is the method of choice for incomplete miscarriage and the resulting bleeding, as well as infected miscarriage. Surgical treatment allows for the removal of residual chorionic or placental tissue, stopping bleeding, and, in the case of an infected miscarriage, evacuating tissue affected by the inflammatory process.

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

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

A transverse incision of the mucous membrane is made at the border of the cervix and the anterior vaginal fornix. The vaginal wall together with the urinary bladder is moved upward. A second incision of the mucous membrane is made at the border of the cervix and the posterior vaginal fornix, parallel to the first. The vaginal wall is also separated posteriorly. Using a Deschamps needle, a thick silk, lavsan or other thread is passed under the remaining intact septum of the mucous membrane of the lateral vaginal fornix. The other end of the thread is passed under the mucous membrane of the opposite side. A circular suture is obtained, located close to the internal os of the cervix. The ligature is tied in the anterior fornix. The incisions of the mucous membrane are sutured with separate catgut sutures.

Technically simpler is the McDonald modification, which achieves a narrowing of the cervical canal below the area of the internal suture. The essence of this operation is that a purse-string suture made of lavsan, silk or chromic catgut is applied at the border of the transition of the mucous membrane of the vaginal vaults to the cervix.

A simple and effective method for correcting isthmic-cervical insufficiency is the method of A. I. Lyubimova and N. M. Mamedalieva (1981).

U-shaped sutures are applied to the cervix at the level of the transition of the mucous membrane of the anterior vaginal fornix. Stepping back 0.5 cm from the midline to the right, a lavsan thread is passed through the entire thickness of the cervix, making a puncture on its posterior wall. Then, with a needle and the same thread, the mucous membrane and part of the thickness of the cervix on the left side are pierced, the puncture is made in the anterior fornix. The second thread is passed in a similar manner, making the first puncture 0.5 cm to the left of the midline and the second - in the thickness of the lateral wall on the right. Both sutures are tied in the area of the anterior fornix.

Operations that strengthen the external os of the cervix are rarely used nowadays.

Vaginal operations correcting isthmic-cervical insufficiency cannot be performed with an excessively deformed, shortened or partially absent cervix. In recent years, transabdominal suturing of the cervix at the level of the internal os has been successfully performed in such cases.

Summing up the discussion of methods of treatment of threatened or started spontaneous miscarriage, we emphasize once again that the success of treatment depends on the timeliness and adequacy of the choice of means. Hospitalization of patients should be carried out at the first, even minimal symptoms of the disease; treatment from the first minutes of stay in the hospital should be carried out in the maximum necessary volume, and only when the effect is achieved can the dosage of medications be gradually reduced and the range of means and methods of treatment be narrowed.

If there is no effect from treatment or if the patient seeks medical help late, the connection between the fertilized egg and the fetal receptacle is lost, accompanied by increased bleeding. Maintaining the pregnancy becomes impossible.

If an abortion is in progress or an incomplete abortion is diagnosed in the first trimester of pregnancy, then emergency care consists of emptying the uterine cavity with a curette, which quickly stops the bleeding.

In the second trimester of pregnancy (especially after the 16th week), amniotic fluid often leaks out, while the expulsion of the fetus and placenta is delayed. In such cases, it is necessary to prescribe agents that stimulate uterine contractions. Various modifications of the Stein-Kurdinovsky scheme can be used. For example, after creating an estrogenic background by intramuscularly administering 3 ml of a 0.1% folliculin solution or 1 ml of a 0.1% estradiol dipropionate solution, the patient should drink 40-50 ml of castor oil, and after 1/2 hour, a cleansing enema is given. After emptying the bowels, the second part of the scheme is performed in the form of giving quinine and pituitrin (oxytocin) in fractional doses. Quinine hydrochloride is usually used at 0.05 g every 30 minutes (a total of 8 powders); After taking every two quinine powders, 0.25 ml of pituitrin or oxytocin is administered subcutaneously.

Rapid expulsion of the ovum can be achieved by intravenous drip administration of oxytocin (5 U 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). The infusion begins with 10-15 drops per 1 min, then every 10 minutes the rate of administration is increased by 4-5 drops per minute until contractions occur, but the number of drops should not exceed 40 per 1 min. After the birth of the ovum, even in the absence of visible defects in the placental tissue or membranes, scraping of the walls of the uterine cavity with a large blunt curette is indicated. If there is a delay in separation and discharge of the placenta, instrumental emptying of the uterus is performed using an abortion forceps and a curette.

If bleeding continues after emptying the uterus, additional administration of uterine contraction agents is necessary (1 ml of 0.02% methylergometrine, 1 ml of 0.05% ergotal, or 1 ml of 0.05% ergotamine hydrotartrate). These drugs can be administered subcutaneously, intramuscularly, slowly into a vein, or into the cervix. In parallel with stopping the bleeding, all measures are taken to correct blood loss, prevent or treat possible infectious complications of spontaneous abortion.

Particular caution is required if the dead fetus is retained in the uterus for more than 4-5 weeks. Instrumental evacuation of the uterus in such cases may be complicated by bleeding not only due to the loss of tone of the uterine muscles, but also due to the development of DIC syndrome. These complications usually occur with a pregnancy of 16 IU or more. Particularly careful observation of patients should be carried out during the first 6 hours after evacuation of the uterus, since, as clinical practice shows, bleeding caused by DIC syndrome in almost half of the cases occurs 2-4 hours after evacuation of the uterus against the background of apparent well-being with a well-contracted uterus. Treatment measures should be aimed at eliminating disorders of the blood coagulation system, and if therapy is ineffective, it is necessary to immediately proceed to removal of the uterus.

Conservative management of the patient

The tactics adopted in European countries for non-viable pregnancy in the first trimester include a conservative approach, which consists of waiting for spontaneous evacuation of the contents of the uterine cavity in the absence of intense bleeding and signs of infection.

Most often, spontaneous miscarriage occurs 2 weeks after the cessation of development of the ovum. In the event of intense bleeding, incomplete abortion, or signs of infection, vacuum aspiration or curettage is performed. Such a wait-and-see tactic is dictated by the increased risk of cervical trauma, uterine perforation, formation of adhesions, development of inflammatory diseases of the pelvic organs, and side effects from anesthesia during surgical treatment.

In our country, in case of non-developing pregnancy, preference is given to the surgical method.

Surgical treatment is not performed in case of complete spontaneous miscarriage. With complete evacuation of the fertilized egg from the uterine cavity, the cervix is closed, there is no bleeding, bloody discharge is scanty, the uterus has contracted well, is dense. Ultrasound control is mandatory to exclude retention of elements of the fertilized egg in the uterine cavity.

Drug treatment of spontaneous abortion

In recent years, an alternative way of managing a non-developing pregnancy has been discussed - the introduction of prostaglandin analogues. With the vaginal use of the prostaglandin E1 analogue - misoprostol at a dose of 80 mg once, a complete spontaneous miscarriage occurred in 83% of cases within 5 days.

Misoprostol is contraindicated in asthma and glaucoma and is not approved for use in the United States.

In our country, drug treatment for non-viable pregnancies is not carried out; preference is given to the surgical method.

Medications and Surgical Treatment for Miscarriage

It is not possible to prevent or stop a miscarriage with medication. The goal of treatment is to prevent inflammation and excessive blood loss. Such complications usually occur when the uterus is not completely cleared. For decades, incomplete miscarriages were usually treated with a curettage procedure. Women now have more options: non-surgical treatment is preferred for first-trimester miscarriages with no symptoms of complications (high fever and heavy bleeding).

• In many women, the body itself completes the process of cleansing the uterus, while the doctor only carefully monitors the patient's health.
• Surgical intervention is aimed at quickly cleaning the uterus, it is usually carried out in case of severe bleeding and symptoms of inflammation.
• Medicines are aimed at accelerating the process of uterine contraction and its cleansing. The drugs are taken longer and can cause pain and side effects, but in this case there is no need for anesthesia, which in itself is fraught with consequences.
• Non-surgical treatments do not always effectively cleanse the uterus, so if there is no positive result, the doctor will usually recommend curettage.

Postoperative management

Prophylactic antibacterial therapy with 100 mg doxycycline orally on the day of vacuum aspiration or curettage of the uterine cavity is recommended.

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

In Rh-negative women (in pregnancy from a Rh-positive partner) in the first 72 hours after vacuum aspiration or curettage at a pregnancy term of more than 7 weeks in the absence of Rh antibodies, prophylaxis of Rh immunization is carried out by administering anti-Rh0(D) immunoglobulin at a dose of 300 mcg intramuscularly.

Further management of the patient with spontaneous abortion

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

The onset of the next pregnancy is recommended no earlier than 3 months later, in connection with which recommendations are given on contraception for 3 menstrual cycles.

Patient education

Patients should be informed about the need to consult a doctor during pregnancy if they experience pain in the lower abdomen, lower back, or if they experience bloody discharge from the genital tract.

Prevention

There are no specific methods for preventing sporadic miscarriage.

To prevent neural tube defects, which can cause early spontaneous miscarriages, it is recommended to take folic acid 2-3 menstrual cycles before conception and during the first 12 weeks of pregnancy at a daily dose of 0.4 mg. If a woman has a history of neural tube defects in her fetus during previous pregnancies, the prophylactic dose should be increased to 4 mg/day.

Forecast

As a rule, spontaneous abortion has a favorable prognosis. After 1 spontaneous miscarriage, the risk of subsequent miscarriage increases slightly and reaches 18-20% compared to 15% in the absence of a history of miscarriages. In the presence of 2 consecutive spontaneous abortions, it is recommended to conduct an examination before the desired pregnancy to identify the causes of miscarriage in this couple.