Tactics of managing pregnancy with the infectious genesis of miscarriage

At the onset of pregnancy in women with an infectious genesis of miscarriage, control of the activation of bacterial and viral infection is necessary.

The clinical course of pregnancy is evaluated, ultrasound is performed, in which it is necessary to pay attention to the contours of the fetal egg, the presence of a heartbeat, the location of the branching chorion, the state of the yolk sac.

Bacteriological, virological examination is carried out every 2 weeks due to frequent changes in microflora; definition of microcenosis of the vagina. It is necessary to control the hemostasiogram, with an exacerbation of infection, there are changes in the form of hypercoagulation, often a weakly positive lupus anticoagulant is observed, as a consequence of the infectious process.

It is necessary to exclude anemia, hypotension, which is typical for patients with miscarriage. The therapeutic measures in the first trimester are somewhat limited due to the danger of using certain medications during the embryogenesis period. Nevertheless, the use of immunoglobulin is intravenously drip in a dose of 25.0 ml every other day # 3. If there is a serious danger of exacerbation of a viral infection, then it is advisable to use octagrams 2.5 g intravenously after 2 days of number 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 the complexes of metabolic therapy. In case of changes on the haemostasiogram, correction is necessary, antiplatelet agents and / or anticoagulants may be prescribed.

From the first weeks of pregnancy, therapeutic and preventive measures are needed to prevent placental insufficiency, especially in those women who have low positioning or presentation of the branching chorion, partial detachment of the chorion. It may be recommended lymphocyte therapy of the lymphocytes of the husband, use of the drug actovegin in tablets 1 t 3 times a day or intravenously 5.0 ml in 200.0 ml of physiological solution № 5 every other day.

For a more successful course of 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 stress of the uterus, has a laxative effect, which is also important for pregnant women.

Due to the fact that many pregnant women have an inflammatory process of the uterine appendages, the pains in the first trimester are often due to the presence of an adhesion process, the taking of antispasmodics can be useful, in addition, all antispasmodics are antiaggregants, and this should also be taken into account.

If the uterus lags behind the gestation period, the low position of the branching chorion can be prescribed therapy with chorionic gonadotropin, Dufaston, Utrozhestan, dexamethasone may be taken according to indications.

In the trimester, antibiotic treatment is inappropriate, therefore, when we detect chlamydia, mycollasemia, ureaplasma, group B Streptococcus in the cervix of the uterus, we apply vaginal eubiotics and wait for 13-14 weeks when etiotropic therapy can be applied .It is possible to treat vaginosis in the I trimester vagina miramistinom, plivoseptom.Kandidozy use boroglicerin, treat the vagina with green.

In the II trimester of pregnancy, microbiological and virological monitoring, smear microscopy, continues. A distinctive feature of the II trimester is the control of the cervix, as itch-cervical insufficiency is possible. According to our data, ultrasound monitoring of the cervix is not enough. According to ultrasound, one can observe a shortening and widening of the cervix, if the patient is examined by the same doctor and if a good apparatus is used. But functional istrmico-cervical insufficiency is not visible by ultrasound. The neck becomes soft, but only then changes in length and width begin. Therefore, every 2 weeks (and if there is a suspicion, and after a week), when taking smears, a very careful glove examination of the cervix is performed with a sterile glove. If the cervix is soft, then surgical correction of ischemic-cervical insufficiency is necessary.

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

Levels of il-b in the contents of the cervical canal are a marker of the effectiveness of therapy for infectious complications. In those cases where the level of i-b remained high after treatment, premature birth and the birth of a child with intrauterine pneumonia subsequently occurred.

In the third trimester of pregnancy, with the threat of premature births, in the absence of the effect of bacterial therapy in the clinical manifestations of chorioamnionitis, the pregnancy was interrupted. 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 indicator of structural coagulation was the index of thrombotic potential (r = 0.92).

The development of the infectious process, as a rule, is accompanied by the development of hypercoagulation, which does not correspond to the term of gestation and the development of chronic two.

If necessary, surgical treatment of ischemic-cervical insufficiency, we perform additional PCR diagnostics (definition of herpes simplex virus, cytomegalovirus, chlamydia, mycoplasma, ureaplasma) in the mucus of the cervical canal. If there is no infection in the mucus of the cervical canal, smears are not treated with antibiotics. The cervix is examined and processed every day for 3-5 days and then we assign eubiotics. If there is a suspicion of an infectious process, we prescribe antibiotics taking into account the revealed flora. Imunofan 1.0 ml IM daily for a total of 5-10 injections.

Regardless of the presence of ischemic-cervical insufficiency and the presence or exacerbation at the moment of infection, we are conducting the 2nd course of preventing the activation of a viral infection. Immunoglobulin - intravenously drip 25.0 ml every other day 3 drops or octagam - 2.5 g 2-3 times intravenously drip. Rectal suppository with viferon - 2 suppositories per day for 10 days. In the second trimester, we monitor the fetus by dopplerometry of the placenta and utero-placental blood flow. At the same time, we are conducting a course of preventing placental insufficiency, assign actovegin 5.0 ml in 200.0 ml of physiological solution intravenously drip in alternation with instenon 2.0 ml in 200.0 ml of physiological solution (inject very slowly, there can be a severe headache) to 5 droppers. If it is not possible to conduct prevention courses by intravenous transfusions, one can recommend the tablet administration of actovegin, troxevasin for one month. In the course of the second trimester, it is also necessary to monitor the status of hemostasis, anemia, and correction of revealed disorders.

In the third trimester of pregnancy, a clinical assessment of pregnancy progression, hemostatic control, bacteriological and virological monitoring, smear microscopy, evaluation of the fetal status by ultrasound, dopplerometry of the placenta and utero-placental blood flow, cardiotocography.

Just like in the previous trimester of pregnancy, we recommend metabolic therapy, prevention of placental insufficiency. Before birth, 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 maintain immunity before delivery for the prevention of postpartum purulent-inflammatory complications and prevention of complications of the neonatal period.