The threat of termination of pregnancy in the early stages. Spontaneous abortion (miscarriage) Mkb 10 threatened miscarriage

Miscarriage, or spontaneous abortion - an unexpected spontaneous termination of pregnancy for up to 24 weeks. In most cases, there is abnormal vaginal bleeding and cramping pain in the lower abdomen.

A significant number of spontaneous abortions occur before 14 weeks, and sometimes the miscarriage occurs so early that the woman does not even suspect that she was pregnant.

More than 25% of all pregnancies end in miscarriage or loss of the fetus before the 24th week of pregnancy.

At-risk groups

Most often, spontaneous abortion occurs in women under the age of 16 or over 35 years. In some cases, it is a consequence of chromosomal or gene pathology of the fetus. Risk factors include smoking and alcohol or drug use during pregnancy. The risk group for late miscarriages also includes women with diabetes.

In about 6 out of 10 cases, the cause of spontaneous abortion is the presence of a genetic disease or pathology in the fetus.

Early miscarriage is typical for multiple pregnancies and can occur due to low levels of the hormone progesterone. The cause of late miscarriage (between the 14th and 24th weeks) may be cervical weakness or an acute infectious disease in the mother. The pathology of the shape of the uterus or a benign tumor in the wall of the uterus can also lead to spontaneous abortion.

Classification by type of flow

• Threatened abortion. The fetus is alive, the cervix is ​​closed. Although there may be vaginal bleeding, which is usually painless, such a pregnancy usually persists. The child develops all the due time, childbirth occurs at about the 40th week. However, in some cases, a threatened abortion can turn into an abortion in progress.
• Abortion is on the way. It is usually characterized by the death of the fetus and the opening of the cervix. In most cases, it is accompanied by pain caused by uterine contractions, with the help of which the fetus is expelled. Pain can range in severity from mild, similar to that experienced by a woman during her period, to severe, and there may be vaginal bleeding with clots. Such an abortion can be complete (all the contents of the uterus are expelled) or incomplete (parts of the fetal egg remain in the uterus).
• Failed abortion. The fetus dies, but there may be no bleeding or pain. The uterus does not contract, the cervix remains closed, and the dead fetus remains inside the uterus.

Diagnostics

If necessary, with the help of a vaginal dilator, the doctor will examine the cervix. If the cervix remains closed, there is still a chance for the pregnancy to continue. In order to make sure that the fetus has not died, patients are usually sent for ultrasound. If the cervix opens and the fetus dies, an ultrasound scan is performed to determine whether all the contents of the uterus have been expelled.

If a woman is diagnosed with a threatened abortion, bed rest will be recommended for several days until the bleeding stops. In addition, the doctor will prescribe treatment for any identified causes of the condition, such as an infectious disease.

In the event of a spontaneous abortion, the choice of treatment options will depend on whether the abortion was complete or incomplete. Usually, a course of drug treatment is carried out, which allows to achieve complete expulsion of the fetus from the uterus, in addition, in case of severe pain, it can be prescribed.

If an incomplete miscarriage occurs, the patient will need hospitalization. In order to prevent infection of the uterus in the hospital, the remaining tissues in the uterus will be surgically removed. The same procedure is performed in case of an early failed abortion. If the missed abortion occurred later in the pregnancy, labor may be artificially induced.

The loss of a child is always painful for a mother, and some time must pass before she can come to terms with what happened. If the patient has doubts about future pregnancies, they should be discussed with the doctor.

The threat of abortion is a condition in which the uterus begins to contract intensively, getting rid of the fetus in its cavity. The occurrence of this pathology is possible at any stage of bearing a baby and is a common problem in obstetrics and gynecology.

The likelihood of spontaneous abortion from the moment of conception to the 22nd week of pregnancy is considered to be a threat of early miscarriage, which is not uncommon. Threatening abortion at a later date is considered a pathology that occurs from 22 to 28 weeks of pregnancy. From 28 to 37 weeks, the appearance of uterine hypertonicity can lead to premature birth, which threatens with negative consequences for the health and development of the baby.

The appearance of a threatening state of pregnancy is dangerous for the health of a woman and the life of her unborn child - untimely detection of symptoms of this disease and delay in obtaining medical care lead to fatal pregnancy.

There are several types of pathology:

• anembryony - the absence of an embryo in a fetal egg;
• chorionadenoma - pathological placental formation from the father's chromosomes;
• threatened miscarriage - the probability of detachment of the fetal egg from the wall of the uterus;
• a miscarriage that has begun is a partial rejection of the embryo;
• complete miscarriage - the fetal egg exfoliates completely and leaves the uterine cavity;
• incomplete miscarriage - when the embryo is rejected, particles of the fetus remain in the uterus;
• failed miscarriage - the fetal egg does not detach, but resolves.

According to the list of international classification of diseases (ICD-10), this diagnosis is presented as "Threatened abortion" and has the code O20.

With the threat of miscarriage early dates pregnancy is not always possible to maintain

Causes of threatened abortion in the early stages

There are several reasons that create a risk of miscarriage:

1. Hormonal disorders. With the onset of pregnancy in the blood of a woman, changes in hormone levels occur. If the norms necessary for the successful bearing of the fetus are violated, there is a threat of miscarriage. In many cases, this is due to a lack of progesterone, which can occur due to an excess of prolactin in the pregnant body. And also a threatening abortion is possible with an increase in the norms of the level of male hormones - this condition is called hyperandrogenism.
2. genetic failures. There are situations when, at the initial stages of pregnancy, chromosomal or gene mutations occur, the consequences of which are abnormal malformations of the fetus. With genetic failures incompatible with life, spontaneous abortion occurs in the first two months of pregnancy (up to the eighth week). If the pathology is not fatal (for example, with Down syndrome), then the pregnancy can be saved, but the risks of miscarriage will be high throughout its duration. Genetic failures can be due to heredity or the adverse effects of external factors such as poor ecology, chemicals in food, radiation, etc.
3. The presence of infectious or inflammatory processes in the pelvic organs. With the advent of pregnancy, the body's immunity decreases - at this time, the expectant mother is more exposed to the emergence of new and exacerbation of chronic diseases. When infections get in and inflammation occurs, the reproductive system of a woman “in position” weakens and ceases to function fully, which can contribute to a miscarriage.
4. The occurrence of Rhesus conflict (immunological cause). The body of a woman with negative Rh factor blood when carrying a child with a positive Rh, may perceive the fetus as a foreign formation in the body and will spontaneously try to get rid of it.
5. The presence of gynecological pathologies. The abnormal structure of the uterus (bicornuate or with a septum), endometriosis, fibroids - lead to impaired functioning of the genital organ, which is the cause of miscarriage.
6. Isthmic-cervical insufficiency. With this pathology, the cervix is ​​\u200b\u200bweakened and is not able to hold the fetus, which is constantly increasing in size. Miscarriage for this reason in most cases occurs at the beginning of the second trimester.
7. Exposure to stress and emotional upheaval. Regular exposure to stress or conflict situations and nervous strain can negatively affect the development of pregnancy, and in some cases cause its termination.
8. Getting injured. Injury to the abdominal area can threaten partial or complete detachment of the placenta, which will lead to fetal death and miscarriage.

The threat of spontaneous abortion can happen for any of the above reasons or a combination of several.

Symptoms of threatened abortion

Symptoms that occur when a miscarriage is threatened can be both obvious and mild:

• pains of a pulling or cramping character in the lower abdomen and in the lower back;
• discharge of bloody origin from the genital tract (even in small amounts);
• abundant clear or cloudy discharge - may be amniotic fluid (their leakage is possible from the beginning of the second trimester);
• uterine hypertonicity - a strong tension in the muscles of the reproductive organ, leading to a "petrification" of the abdomen.

If even one symptom appears, a pregnant woman needs immediate medical attention.

Diagnostics

If there is a suspicion of a threat of spontaneous abortion, a woman is first of all sent to gynecological examination to determine the condition of the cervix, as well as to exclude anomalies in the structure of this organ (if the pregnant woman has not yet been registered). During the examination, the doctor without fail takes a smear for sexually transmitted diseases or endocrine disorders.

The most effective way to diagnose a pregnancy problem is an ultrasound examination, as a result of which the doctor can determine the risk of interruption or its type and subsequently prescribe the necessary treatment.

To detect hormonal disorders, as well as infectious or inflammatory diseases, a pregnant woman is given referrals for blood and urine tests: general, biochemical, hormones.

Determination of genetic disorders or immunological problems is carried out using laboratory blood tests and ultrasound diagnostics.

If necessary, the attending physician may prescribe an additional examination of the health of the pregnant woman by narrow specialists: a cardiologist, neurologist, surgeon, and others.

Treatment

With timely detection of the threat of spontaneous abortion, determining the causes and prescribing competent treatment, pregnancy can be saved.

Medical therapy

Treatment is carried out both on an outpatient basis and in a hospital - it depends on the degree of threat of interruption.

The main condition for a positive outcome of treatment is to ensure future mother physical and psychological peace, therefore, in some cases, first of all, a woman is prescribed sedatives. For example, Persen or Novopassit - these funds consist of natural ingredients and do not harm the fetus (in the absence of intolerance to the components of the drug).

With a hormonal imbalance, a woman is prescribed special hormonal drugs. With a lack of progesterone - Duphaston, Utrozhestan. At high level male hormones - Dexamethasone, Digostin, Cyproterone and others.

To eliminate uterine hypertonicity, medications are used that relax smooth muscles. The most common remedy is Magnesia (magnesium sulfate), injected into the body in doses determined by the doctor, using a dropper. And also papaverine suppositories are often used, which reduce uterine hypertonicity.

To relieve pain, pregnant women are prescribed antispasmodics: Drotaverine (shots), No-shpa (tablets).

In the event of a Rh-conflict situation between the mother and fetus, drugs are used that inhibit the production of antibodies - immunoglobulins. And also effective is the method of intrauterine blood transfusion to the fetus through the umbilical vein. This procedure is possible from the 22nd week of pregnancy.

When bleeding occurs, hemostatic drugs are used: Tranexam, Dicinon - are administered intravenously, by drip.

If the threat of miscarriage appears due to isthmic-cervical insufficiency, then to save the pregnancy, an obstetric pessary is placed on the uterus - a ring that supports the cervix. When using it, the period of gestation of the baby is extended until the due date of birth. In some similar cases, instead of using a pessary, sutures are applied to the cervix, due to which the uterine os does not open prematurely. The way to eliminate isthmic-cervical insufficiency is determined by the attending physician on an individual basis for each case.

Treatment of infectious and inflammatory processes, as well as chronic diseases in an acute form, is possible only as directed and under the supervision of the attending physician.

ethnoscience

Use of funds traditional medicine with the threat of termination of pregnancy is strictly prohibited without consulting a medical specialist. This method of eliminating the problem can harm health even more, which will lead to an irreversible negative outcome of the pregnancy.

Among folk remedies most popular:

1. Decoction of dandelion herb. One teaspoon of herbs should be poured into a glass of water and boiled for three minutes. Take in small sips one fourth cup of decoction 3 times a day.
2. A decoction of the bark of viburnum. One teaspoon of crushed young bark is poured into 250 ml of boiling water and boiled for 5 minutes. It is recommended to take 1-2 tablespoons three times a day.
3. Tincture of viburnum flowers. Two tablespoons of flowers are poured into 500 ml of boiling water and infused in a thermos for about two hours. Strained tincture is taken one quarter cup three times a day.
4. A decoction of the medicinal collection: licorice roots, cinquefoil and elecampane, blackcurrant berries, nettle grass. Two tablespoons of the collection should be 500 ml of boiling water and simmer for 15 minutes. Strain the resulting broth and cool, take half a glass three times a day.

The use of folk remedies without medication does not have a positive result, therefore, it cannot be used as the main treatment.

First aid for threatened miscarriage

If you experience symptoms that may indicate a threat of termination of pregnancy, you need to call an ambulance as soon as possible or consult a gynecologist yourself. Expect the arrival of an ambulance should be in a motionless position, preferably lying down.

After examination by a gynecologist, ultrasound diagnostics and the necessary blood tests are done - for the presence of diseases, for hormones, etc. All studies are aimed at establishing the causes that create the threat of spontaneous abortion, as well as in order to determine the level of danger of the complication that has begun.

If there is a chance of maintaining the pregnancy, the doctor most often places the woman in a hospital for treatment and close monitoring of the patient's health. Treatment at home is possible only if there are no pronounced symptoms of pregnancy pathology and strict adherence to all doctor's prescriptions.

The threat of spontaneous miscarriage cannot disappear on its own - the help of medical specialists is required to eliminate it. Otherwise, the woman risks losing her unborn child.

Forecasts

The course of pregnancy after the threat of miscarriage in the early stages depends on the reason why this happened, as well as on the effectiveness of the prescribed treatment.

With the normalization of hormone levels, the cure for infectious or inflammatory processes, the solution of the problem of isthmic-cervical insufficiency, pregnancy can develop in the future without pathology.

If the threat of abortion arose for an immunological reason, then the pregnancy will be under the close supervision of doctors, since the likelihood of its failure may arise again at any stage.

With genetic failures that are incompatible with life, the fetus is not preserved. But this is not a guarantee that with the onset of a new pregnancy the problem will recur.

In most cases, after the threat of spontaneous abortion at an early stage of bearing a baby, it is subsequently possible to safely give birth to a healthy child in due time.

Prevention

Preventive measures for the threat of miscarriage include:

1. Planning for pregnancy. At this stage, both parents are recommended to undergo a complete medical examination, to cure all existing diseases. Including it is necessary to visit the office of a geneticist, who will determine the compatibility of parents and the likelihood of an Rhesus conflict.
2. Right way of life. With the onset of pregnancy, you should give up bad habits, eat right, take regular walks in the fresh air, observe the correct daily routine - eat on time, do not overwork during the day, sleep at least 9 hours a day.
3. Favorable psychological environment. During the bearing of the baby, it is recommended to avoid stressful situations, to prevent nervous breakdowns and tantrums.

Compliance with preventive measures cannot give a 100% guarantee of eliminating the threat of spontaneous abortion. But a responsible attitude to one's health and a serious approach to pregnancy planning significantly reduce the risks of this pathology.

When undergoing a medical examination before the onset of pregnancy, the doctor can identify in advance possible problems after conception. In my case, the use of Duphaston was prescribed from 3 to 18 weeks of pregnancy. Thanks to supportive hormonal therapy, I managed to avoid the threat of spontaneous miscarriage.

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Threatened abortion (O20.0)

obstetrics and gynecology

general information

Short description

Approved by the Protocol of the meeting of the Expert Commission
on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 18 dated September 19, 2013

Spontaneous miscarriage- spontaneous abortion, which ends with the birth of an immature and non-viable fetus before the 22nd week of pregnancy, or the birth of a fetus weighing less than 500 grams (1)

habitual miscarriage- spontaneous termination of 3 or more pregnancies up to 22 weeks (WHO).
The risk of recurrent miscarriage is significantly higher in pregnant women with antiphospholipid antibodies or lupus anticoagulant (LA) (2, 3, 4, 5). Anticardiolipin (ALA) antibodies (the most commonly detected antiphospholipid antibodies) are present in less than 10% of normal pregnant women (2, 3, 6). Women with AL antibodies have a 3–9 times increased risk of fetal loss compared with those who do not have these antibodies (2, 3, 6). Antiphospholipid antibodies contribute to arterial and venous thrombosis.

Missed miscarriage(non-developing pregnancy, missedabortion) - The term "early antenatal fetal death" refers to situations where the fetus has already died, but the uterus has not yet begun to expel it. Previously, many terms were used to describe this condition, including "empty gestational sac", "missed miscarriage" and "missed pregnancy". In practice, in such situations, the fetus is dead, but the cervical canal remains closed. Diagnosis is based on ultrasonography after clinical findings such as vaginal bloody discharge, no fetal heartbeat on electronic auscultation (from 12 weeks), no fetal movement (from 16 weeks), or if the uterus is much smaller than expected (2).

At any time, the reasons for termination of pregnancy can be:
- genetic;
- immunological (APS, HLA antigens, histocompatibility);
- infectious;
- anatomical (congenital anomalies, genital infantilism, intrauterine synechia, isthmic-cervical insufficiency);
- endocrine (deficiency of progesterone).

I. INTRODUCTION

Protocol name: Spontaneous miscarriage
Protocol code:

ICD-10 code(s):
O03 - Spontaneous miscarriage
020.0 - Threatened miscarriage
O02.1 - Miscarriage

Abbreviations used in the protocol:
Ultrasound - ultrasonography
WHO - World Organization health care
NB - non-developing pregnancy
AFS - antiphospholipid syndrome
LA - lupus anticoagulant

Protocol development date: April 2013.

Protocol Users: obstetrician-gynecologists, general practitioners.

Classification

Clinical classification (WHO)

By gestational age:
- Early - spontaneous miscarriage before 12 weeks of pregnancy.
- Late - spontaneous miscarriage in terms of more than 12 weeks to 21 weeks of pregnancy.

According to clinical manifestations:
- threatening miscarriage;
- abortion in progress;
- incomplete miscarriage;
- complete miscarriage;
- missed miscarriage (non-developing pregnancy).

Abortion is in progress, incomplete and complete miscarriages are accompanied by bleeding (see protocol: "").

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of main diagnostic measures

Main:
1. The study of complaints, anamnesis (delayed menstruation for 1 month or more), special obstetric examination: external obstetric examination (height of the fundus of the uterus), examination of the cervix on the mirrors, vaginal examination.
2. Ultrasound examination is the main one in NB.
3. A short list of studies for hospitalization - not provided.

Diagnostic criteria

Complaints and anamnesis
Light spotting with a threatened miscarriage and in the presence of clinical manifestations of a missed miscarriage, sometimes accompanied by pain in the lower abdomen, with a delay in menstruation for 1 month or more, or with an established pregnancy. In the anamnesis there may be spontaneous miscarriages, infertility, menstrual dysfunction.

With a non-developing pregnancy, the subjective signs of pregnancy disappear, the mammary glands decrease in size and become soft. Menstruation does not return. In the expected period, no movement is noted. However, if fetal movements appear, they stop. Clinical signs non-developing pregnancy (pain, bleeding from the genital tract, lagging behind the size of the uterus from the expected gestational age) appear 2-6 weeks after the cessation of embryo development. The stages of NB interruption correspond to the stages of spontaneous abortion: threatened miscarriage, ongoing abortion, incomplete abortion.

A thorough study of the anamnesis is mandatory to determine the clinical criteria for the presence of APS in order to determine the scope of the examination and further management.

With a threatened miscarriage in women with recurrent miscarriage, if she was not examined before the onset of a real pregnancy; in women with a history of stillbirths, in women with a history of thromboembolic complications, examination should be carried out during the current pregnancy in order to prevent spontaneous miscarriage and / or premature birth. In a miscarriage that has not occurred, a thorough history of APS is necessary for further management after removal of the gestational sac.

Physical examination

BUTkusher examination
1. VSDM - corresponds to the gestational age with a threatened miscarriage, does not correspond with NB.
2. Examination of the cervix on the mirrors, vaginal examination:
- light bleeding;
- the cervix is ​​closed;
- the uterus corresponds to the expected gestational age with a threatened miscarriage and does not correspond with NB.

Laboratory research:
- determination of the concentration of hCG in the blood. The concentration of hCG corresponds to the gestational age with a threatened miscarriage, lower - with an undeveloped pregnancy;
- examination for suspected APS: lupus anticoagulant and the presence of antiphospholipid and anticardiolipid antibodies, AhTV, antithrombin 3, D-dimer, platelet aggregation;
- study of hemostasis parameters in case of miscarriage: blood clotting time, fibrinogen concentration, APT, INR, prothrombin time.

Instrumental Research

Ultrasound procedure:
- the presence of the fetus and its heartbeat, possibly the presence of a retroplacental hematoma;
- the absence of an embryo in the cavity of the fetal egg after 7 weeks of pregnancy or the absence of a heartbeat in a non-developing pregnancy.

Indications for expert advice:
- if APS is suspected, consultation with a therapist/hematologist with the results of a laboratory test;
- in case of a failed miscarriage with pronounced deviations of hemostasis - consultation of a hemostasiologist.

Differential Diagnosis

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Treatment

Treatment Goals: prolongation of pregnancy with threatening pregnancy and removal of the fetal egg in a failed abortion.

Treatment tactics

threatened miscarriage

Non-drug treatment (7):
- Medical treatment is usually not necessary.
- Advise the woman to refrain from strenuous activity and sexual intercourse, but bed rest is not necessary.
- If the bleeding has stopped, continue observation in the w / c. If bleeding recurs, reassess the woman's condition.
- If bleeding continues, evaluate fetal viability (pregnancy test/ultrasound) or possibility of ectopic pregnancy (ultrasound). Continued bleeding, especially if the uterus is larger than expected, may indicate twins or a mole.
- If ICI is suspected, determination of the length of the cervix by ultrasound with a vaginal probe at 18-24 weeks of gestation (A.8).

Medical treatment
A review was made of randomized or quasi-randomized controlled trials comparing progestogen with placebo, no treatment, or any other treatment prescribed for the treatment of threatened miscarriage. Two studies (84 participants) were included in the meta-analysis. In one study, all participants met the inclusion criteria, while in the other, only the subgroup of participants who met the criteria was included in the analysis. There was no evidence that vaginal progesterone was more effective in reducing the risk of miscarriage than placebo (relative risk 0.47; 95% confidence interval (CI) 0.17 to 1.30). Scant data from two methodologically weak studies provided no evidence to support the routine use of progestogens for the treatment of threatened miscarriage. There is no information on the potential harm to mother or child, or both, when using progestogens. Further, large, randomized controlled trials of the effects of progestogens on the treatment of threatened miscarriage are needed that examine potential harms and benefits (9,10).

Progesterone is not given routinely for threatened miscarriage. Can be prescribed for threatened miscarriage due to progestogen deficiency corpus luteum. RecommendationsFDAcategoryD(Category D - there is evidence of the risk of adverse effects of drugs on the human fetus, obtained during research or practice. However, the potential benefit of using the drug in pregnant women may justify its use, despite the possible risk).

Natural micronized progesterone is not routinely prescribed for threatened miscarriage. It can be prescribed for threatened miscarriage due to progestogen insufficiency of the corpus luteum. RecommendationsFDAcategoryD. (There is evidence of the risk of adverse drug effects on the human fetus, obtained from research or practice. However, the potential benefit of using the drug in pregnant women may justify its use, despite the possible risk).

Dydrogesterone is not routinely prescribed for threatened miscarriage. It can be prescribed for threatened miscarriage due to progestogen insufficiency of the corpus luteum, the presence of chronic endometritis, the presence of retrochorial hematoma, the presence of antibodies to progesterone. Recommendation Category FDAnot determined.(In the absence of objective information confirming the safety of the use of drugs in pregnant and / or breastfeeding women, one should refrain from prescribing them to these categories of patients).

A review of randomized or quasi-randomized controlled trials in pregnant women with a history of at least one fetal loss, the presence of antiphospholipid (APL) antibodies, and who were receiving any therapy found that the only significant benefit of the observed therapy was that the combination of unfractionated heparin and aspirin reduced the rate of fetal loss by 54% (relative risk [RR] 0.46, 95% Confidence interval [CI]: 0.29 - 0.71) compared with aspirin alone. When studies of low molecular weight heparin (LMW) and unfractionated heparin were pooled together, there was a 35% reduction in miscarriage and preterm birth (RR 0.65, 95% CI: 0.49 - 0.86). Different dosages of heparin used in different studies included in the review did not affect outcomes. Therefore, the optimal dose of heparin (the one that brings the maximum benefit, causing the least harm) is not yet known. None of the other methods studied had any significant positive effect on pregnancy outcome compared with placebo, although a small positive effect of aspirin cannot be ruled out (11,12,13,14).

Other treatments- the use of urinals with a short cervix after the disappearance of the symptoms of a threatened miscarriage, but today there is no reliable data and its effectiveness.

Surgical intervention: in the presence of ICI, it is possible to suture the uterus, but today there is no reliable data and its effectiveness.

Preventive actions: prevention of preterm birth in risk groups:
Examination for APS in the presence of anamnestic and clinical criteria (see below) - lupus anticoagulant and the presence of antiphospholipid and anticardiolipid antibodies, APT, antithrombin 3, D-dimer, platelet aggregation.

Further management: dispensary observation, according to the protocol of conducting pregnant women.

Missed miscarriage

Non-drug treatment: No.

Medical treatment
Intravaginal misoprostol is effective method to terminate a missed pregnancy up to 24 weeks of gestation. Although the optimal dosage for the first trimester has not yet been clearly established, according to the Gilles study (15), intravaginal use at a dose of 800 mcg repeated after three days achieved an effect in 79% of women by the seventh day (or 87% by the 30th day) . In the second trimester (10–24 weeks), a lower dosage of 200 mcg intravaginally, repeated 12 hours later, is recommended (study by Jain (16)).

Other treatments- No

Surgical intervention: evacuation of the ovum up to 14-16 weeks, preferably manual vacuum aspiration (17,18,19).

Preventive actions
Prevention of infection during the evacuation of the fetal egg - compliance with asepsis, the appointment of prophylactic antibiotic therapy.
Miscarriage prevention in groups of women with recurrent pregnancy loss or verified corpus luteum insufficiency, including induced pregnancies and pregnancies after IVF, is carried out by using:
- natural micronized progesterone (see FDA recommendations above) 200-400 mg intravaginally in the 1-2 trimesters of pregnancy to prevent recurrent and threatened miscarriage.
- krynon (progesterone) - FDA category D recommendations, for maintaining the luteal phase during the use of assisted reproductive technologies (ART) 1 applicator (90 mg of progesterone) intravaginally daily, starting from the day of embryo transfer, for 30 days from the moment of clinically confirmed pregnancy.
- dydrogesterone (see above FDA recommendations) 10 mg 2 times a day until 16-20 weeks of pregnancy with recurrent miscarriage.

Further management
- Appointment of microdoses of combined oral contraceptives from the first day of termination of pregnancy.
- Testing for STIs
- Medical genetic counseling is recommended for couples with recurrent NB.
- Treatment of chronic inflammation - chronic endometritis, chronic salpingitis, vaginitis, vaginosis, if any.
- Screening for APS if available diagnostic criteria (Sapporo, 1999) cadditions (MiyakisS. Etal., 2006): Anamnestic: cephalgia, ischemic heart disease, arterial and venous thrombosis, transient disorders cerebral circulation, fetal loss syndrome, preeclampsia, eclampsia.
Clinical:
1. Vascular thrombosis
2. Pathology of pregnancy: - one or more cases of intrauterine death of a morphologically normal fetus after 10 weeks of gestation, or - one or more cases of premature birth of a fetus of a morphologically normal fetus before 34 weeks of gestation due to severe preeclampsia and eclampsia or severe placental insufficiency, or - three and more consecutive cases of spontaneous abortions up to 10 non-gestations (exception - anatomical defects of the uterus, hormonal disorders, maternal or paternal chromosomal disorders).
- Persistent manifestations of the threat of spontaneous miscarriage against the background of ongoing therapy, the development of severe preeclampsia in the early stages of gestation.
- Determination of lupus anticoagulant and the presence of antiphospholipid and anticardiolipid antibodies, AchTV, antithrombin 3, D-dimer, platelet aggregation.

Habitual miscarriage:
a) genetic study (study of the karyotype of parents) in case of habitual miscarriage in the early stages;

B) if anatomical causes are suspected, the following are performed:
- Ultrasound in the 1st phase of the menstrual cycle can diagnose a submucosal uterus, intrauterine synechia, in the 2nd phase of the cycle - an intrauterine septum and a bicornuate uterus;
- MRI of the pelvis;
- hysterosalpingography in the first phase of the menstrual cycle reveals the presence of submucosal myomatous nodes, synechia, septum.

In the presence of anatomical causes, surgical removal is indicated. Surgical removal of the intrauterine septum, synechia, and submucosal fibroid nodes is accompanied by the elimination of miscarriage in 70-80% of cases (category C). The most effective surgical treatment with hysteroresectoscopy. Abdominal metroplasty is associated with a risk of postoperative infertility (category B) and does not improve the prognosis of subsequent pregnancies. After surgery to remove the intrauterine septum, synechia, depending on the severity of the pathology and the volume of surgical intervention, contraceptive estrogen-progestin preparations are prescribed; and continuation of hormone therapy for another 3 cycles; physiotherapy. At the onset of pregnancy, natural micronized progesterone 200-400 mg up to 20 weeks of pregnancy.

ICN - common cause termination of pregnancy in the second trimester of pregnancy. Painless shortening and subsequent opening of the cervix ending in miscarriage, which in the 2nd trimester leads to prolapse of the fetal bladder and / or rupture amniotic fluid, and in the 3rd trimester - to the birth of a premature baby. As a rule, it is impossible to estimate the likelihood of CCI before pregnancy.

C) if infectious causes of habitual miscarriage are suspected (the most typical late miscarriages and premature birth) is carried out:
- Gram microscopy of smears from the vagina and cervical canal,
- bacteriological examination of the detachable cervical canal with a quantitative determination of the degree of colonization of pathogenic and opportunistic microflora and the content of lactobacilli,
- detection of gonorrheal, chlamydial, trichomonas infections, carriage of HSV and CMV using PCR;
- determination of IgGiIgM to HSV and CMV in the blood;
- biopsy of the endometrium on the 7th-8th day of the menstrual cycle with histological examination, PCR and bacteriological examination of the material from the uterine cavity is carried out to exclude the infectious cause of miscarriage.

D) In ​​case of hormonal insufficiency of the function of the corpus luteum, due to insufficiency of the corpus luteum in the program of pregravid preparation, the use of progesterone, natural micronized progesterone, dydrogesterone.

Treatment effectiveness indicators:
- The possibility of further prolongation of pregnancy in threatened miscarriage in women with recurrent miscarriage.
- The absence of early complications after the evacuation of the fetal egg in a failed abortion.

Hospitalization

Indications for hospitalization:
- emergency - threatening miscarriage with increased bleeding; failed abortion.

Information

Sources and literature

1. Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. Royal College of Obstetricians and Gynaecologists. The management of Early Pregnancy Loss. Green-top Guideline No. 25. London: RCOG 2006. 2. Nilsson IM, Astedt B, Hedner U, Berezin D. Intrauterine death and circulating anticoagulant (“antithromboplastin”). Acta Medicine Scandinavia 1975;197:153–159. 3. Lynch A, Marlar R, Murphy J, Davila G, Santos M, Rutledge J et al. Antiphospholipid antibodies in predicting adverse pregnancy outcome. A prospective study. Annals of Internal Medicine 1994;120:470–475. 4. Yasuda M, Takakuwa K, Tokunaga A, Tanaka K. Prospective studies of the association between anticardiolipin antibody and outcome of pregnancy. Obstetrics and Gynecology 1995;86:555–559. 5. Rand JH, Wu XX, Andree H, Lockwood C, Guller S, Scher J et al. Pregnancy loss in the antiphospholipid-antibody syndrome is a possible thrombogenic mechanism. New England Journal of Medicine 1977;337:154–160. 6.Yetman DL, Kutteh WH. Antiphospholipid antibody panels and recurrent pregnancy loss: prevalence of anticardiolipin antibodies compared with other antiphospholipid antibodies. Fertility and Sterility 1996;66:540–546. 7. Assistance in the complicated course of pregnancy, childbirth and the postpartum period, WHO Recommendations, 2003 8. Hassan S.S., Romero R., Vidydhari D. et al. Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, doubl-blind, placebo-controlled trial. Ultrasound Obstet Gynecol. 2011 Jul; 38 (1): 18-31 9. Wahabi HA, Abed Althagafi NF, Elawad M. Progestogen for treating threatened miscarriage. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD005943. DOI: 10.1002/14651858.CD005943.pub2 10. Wahabi H.A., Abed Althagafi N.F., Elawad M. et al. Progestogen for treating threatened miscarriage. Cochrane Database Syst. Rev. – 2011.-Vol.16, 3. – CD00594 11.Rand JH, Wu XX, Andree H, Lockwood C, Guller S, Scher J et al. Pregnancy loss in the antiphospholipid-antibody syndrome is a possible thrombogenic mechanism. New England Journal of Medicine 1977;337:154–160. 12.Yetman DL, Kutteh WH. Antiphospholipid antibody panels and recurrent pregnancy loss: prevalence of anticardiolipin antibodies compared with other antiphospholipid antibodies. Fertility and Sterility 1996;66:540–546. 13. Lynch A, Byers T, Emlen W, Rynes D, Shetterly SM, Hamman RF. Association of antibodies to beta2-glycoprotein 1 with pregnancy loss and pregnancy-induced hypertension: a prospective study in low-risk pregnancy. Obstetrics and Gynecology 1999;93:193–198. 14. Velayuthaprabhu S, Archunan G. Evaluation of anticardiolipin antibodies and antiphosphatidylserine antibodies in women with recurrent abortion. Indian Journal of Medical Sciences 2005;59:347–352. 15. Gilles JM, Creinin MD, Barnhart K, Westhoff C, Frederick MM, Zhang J. A randomized trial of saline solution-moistened misoprostol versus dry misoprostol for the first-trimester pregnancy failure. Am J Obstet Gynecol2004;190:389. 16 Jain JK, MichelDRl. A comparison of misoprostol with and without laminaria tents for induction of second-trimester abortion. Am J Obstet Gynecol1996;175:173. 17. Neilson JP, Hickey M, Vazquez J. Medical treatment for early fetal death (less than 24 weeks). The Cochrane Library Issue 3, 2006; Chichester, UK: John Wiley & Sons. 18.Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage: expectant; medical or surgical? Results of a randomized controlled trial (the MIST trial). BMJ 2006;332:1235-1238. 19. Neilson JP, Hickey M, Vazquez J. Medical treatment for early fetal death (less than 24 weeks). The Cochrane Library Issue 3, 2006; Chichester, UK: John Wiley & Sons.

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of protocol developers with qualification data:
Doshchanova A.M. - Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics and Gynecology for subordination and internship of JSC "MUA".
Patsaev T.A. - Doctor of Medical Sciences, Head of the Operational Unit of the Republican State Enterprise on the REM " Science Center obstetrics, gynecology and perinatology" of the Ministry of Health of the Republic of Kazakhstan.

Reviewers:
Mireeva A.E. - doctor of the highest category, doctor of medical sciences, professor of the department of obstetrics and gynecology on internship at KazNMU named after. S.D. Asfendiyarova

Indication of no conflict of interest: missing.

Indication of the conditions for revising the protocol: The protocol is reviewed at least once every 5 years, or upon receipt of new data related to the application of this protocol.

Attached files

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Topic number 5: Diagnosis of miscarriage and overmaturity

Pregnancy

Lecture plan

1. Relevance of the problem of miscarriage

2.Basic concepts: miscarriage, prematurity, habitual miscarriage. Classification.

3. Etiology, pathogenesis of miscarriage. Risk Factors for Miscarriage

4.Clinic, diagnosis of spontaneous miscarriage.

5. Differential diagnosis of spontaneous miscarriage.

6.Clinic, diagnosis of preterm birth. Complications from the mother and fetus.

7. The urgency of the problem of overwearing. The concept of post-term and prolonged pregnancy. Risk factors for overexposure.

8. Diagnosis, complications from the side of the mother and fetus in case of overdose.

MISSION OF PREGNANCY

Definition of the concept, classification and frequency of miscarriage.

Miscarriage called its interruption from the moment of conception to 37 weeks of pregnancy.

Habitual miscarriage (miscarriage) It is generally accepted that women have a history of two or more spontaneous abortions in a row up to 22 weeks.

The frequency of spontaneous termination of pregnancy in Russia remains quite high and ranges from 15 to 23% of all registered pregnancies, while recurrent miscarriage accounts for up to 50% of miscarriages. (See Appendix 2)

Depending on the gestational age in which the termination of pregnancy occurs, spontaneous miscarriages and premature births are distinguished.

Spontaneous miscarriage (abortion)- this is a spontaneous termination of pregnancy before the fetus reaches a viable gestational age (body weight of 500 g or more).

Miscarriage (prematurity) according to WHO definition, the birth of a child is called from 22 to 37 weeks of pregnancy, starting from the 1st day of the last normal menstruation with a regular menstrual cycle, while the body weight of the fetus is 500-2500g. In our country, births that occur between the 28th and 37th weeks of pregnancy are considered premature. Spontaneous termination of pregnancy in terms of 22 to 37 weeks is allocated to a separate category, not related to premature birth, and the death of a child is taken into account only if he lived for at least 7 days outside the womb.

The frequency of preterm births in the world in last years is 5-10% and, despite the emergence of new technologies, does not decrease, and in developed countries it increases, primarily as a result of the use of new reproductive technologies.

Premature babies account for 60-70% of cases of early neonatal mortality, 50% of neurological diseases, and severe chronic lung diseases.

Stillbirths in preterm births are 8-13 times more frequent than in urgent ones.

Classification of spontaneous miscarriages (abortions) and premature births.

ICD - 10

O03 - spontaneous abortion

O20.0 - threatened abortion

N96 Habitual miscarriage

O60 - preterm birth

1.The gestational age at which the abortion occurs:

Early spontaneous miscarriages (up to 12 weeks) up to 14 weeks (Russia)

Late spontaneous miscarriages (from 12 to 22 weeks)

Premature birth (from 22 to 37 weeks)

2.Clinical forms (stages) of spontaneous miscarriages:

Threatening miscarriage (abortion);

Initiated abortion

· Abortion in progress;

Incomplete abortion;

complete abortion;

Infected abortion;

Non-developing (frozen) pregnancy.

3.Clinical forms of preterm birth (PR):

· Threatening PR

· Beginning PR

Started PR

Etiology and pathogenesis of miscarriage

The etiology of miscarriage is extremely diverse and depends on many factors.

1.Chromosomal abnormalities(usually miscarriage occurs before 8 weeks).

2.Endocrine Causes(thyroid disease, hyperandrogenism of various origins, ovarian hypofunction) - antiphospholipid syndrome.

3.Anatomical causes(malformations of the uterus, uterine fibroids, ICI - isthmic-cervical insufficiency, etc.).

4.Immunological causes(eg, autoimmune process with the formation of autoantibodies to hCG, antiphospholipid syndrome).

5.Infectious diseases of the mother:

acute infectious diseases during pregnancy ( respiratory infections, infections of the urinary system, etc.).

chronic extragenital diseases (chronic tonsilitis, chronic pyelonephritis, etc.).

urogenital infections and inflammatory diseases of the pelvic organs (PID) (colpitis in pregnant women is diagnosed in 55-65% of cases).

6.Unexplained reasons.

Risk factors for miscarriage

1. Socio-demographic factors (mother's age, insufficient/malnutrition, occupational hazards, low social status, environmental factors, heavy smoking, drug use).

2. Extragenital diseases of the mother (EGD) (arterial hypertension, bronchial asthma, heart disease, hyperthyroidism, diabetes mellitus, anemia with a hemoglobin level of less than 90 g/l).

3. Complications of pregnancy (preeclampsia, polyhydramnios, multiple pregnancy, placenta previa).

Clinic and diagnosis of early and late spontaneous miscarriage (abortion)

For clinical picture Spontaneous abortion is characterized by the following symptoms:

- Pain in the lower abdomen of varying degrees of intensity;

- bloody discharge from the genital tract.

Depending on the severity of these symptoms, the following stages of spontaneous miscarriage are distinguished:

· threatened miscarriage: drawing pains in the lower abdomen and in the lumbar region, bloody discharge, as a rule, is absent. The tone of the uterus is increased. The uterus is enlarged according to the delay in menstruation, there are no changes in the cervix. Vaginal examination showed no pathological changes.

· Started spontaneous miscarriage: pain intensifies, slight (moderate) bloody discharge from the genital tract appears. On vaginal examination, the size of the uterus corresponds to the gestational age. The cervix is ​​preserved, the cervical canal is closed or ajar.

· Abortion in progress: regular cramping pains in the lower abdomen, spotting is often abundant. The size of the uterus is less than the estimated gestational age, the internal and external uterine os are open (the elements of the fetal egg may be in the cervical canal or in the vagina). In more late dates pregnancy, amniotic fluid leakage is possible. Pregnancy can no longer be saved.

· incomplete abortion: bleeding continues (may lead to significant blood loss and hemorrhagic shock). On bimanual examination, the uterus is less than the estimated gestational age.

· Complete abortion: bleeding stops, the cervical canal closes, the uterus contracts. Diagnosis is retrospective and based on history. (this happens if the pregnancy is interrupted in the early stages).

· infected abortion: characterized by fever, chills, pain in the lower abdomen, bloody discharge from the genital tract, sometimes purulent. On examination: tachycardia, tachypnea, tension in the muscles of the anterior abdominal wall (because infection has begun). On bimanual examination, the uterus has a soft consistency, painful on palpation, the cervical canal is dilated. In an uncomplicated abortion, the infection is limited to the uterine cavity. Complicated infected abortion - the infection went higher.

· Non-developing pregnancy(antenatal fetal death): there is no uterine contractility. The dead fetal egg is not expelled from the uterus, but undergoes autolysis (mummification of the embryo).

To clarify the diagnosis, the vagina and cervix are examined on mirrors, a bimanual examination.

Additional research methods:

Determination of hCG to confirm pregnancy and diagnose its condition.

· Ultrasound OMT-during uterine pregnancy, there are signs of impaired development of the fetal egg (absence of the heartbeat of the embryo, absence of the embryo, etc.).

The main complication of spontaneous miscarriage- uterine bleeding.