Clinical protocols. Miscarriage in early pregnancy: diagnosis and management tactics

In this section you will learn:

• How often does it occur?
• Causes of miscarriage
• Symptoms
• Stages
• Possible complications
• How to diagnose
• How to treat
• Recovery after treatment
• Prevention

An unexpected termination of pregnancy in the first trimester, accompanied by pain and bleeding, is called spontaneous abortion, or miscarriage. This dangerous condition not only stops the development of the embryo, but also threatens the life of the woman. The consequences of a miscarriage damage the reproductive organs and reduce the chances of becoming pregnant in the future.

How often does it occur?

Cases where a pregnancy ends in miscarriage in the first trimester are quite common and account for up to one quarter of the total pregnancy statistics. At the same time, some women find out about their pregnancy only after an involuntary interruption. There is a theory that 75% of all pregnancies end in miscarriage with the release of fetal tissue during the next menstruation, and the woman does not even know that the miscarriage has occurred.

The most critical period of gestation when miscarriages occur is 12–13 weeks. If you know you are pregnant, at this stage it is advisable to be especially responsible about your well-being and, if you have any doubts or suspicions, consult a doctor. Moreover, with each miscarriage, the chances of maintaining and safely giving birth to a healthy baby decrease; the consequences of sudden miscarriages are aggravated especially in women who were never able to safely give birth to at least one child. A thorough examination of the reproductive organs and treatment of pathological conditions will reduce the risk of unwanted termination of pregnancy in the future.

It is impossible to stop a process that has already begun; for this reason, you should take a responsible approach to planning and managing pregnancy. This will avoid factors predisposing to the removal of the fetus from the uterine cavity.

Causes of miscarriage

There can be many reasons for a miscarriage, and all of them need detailed investigation. Common causes of miscarriage include various anomalies and negative factors affecting pregnancy:

• Genetic mutations

They account for about half of the cases of spontaneous abortions. Inherited or acquired mutations lead to loss of fetal viability. Examples of such mutations: parental chromosomal, Turner syndrome, etc.

• Pathologies of the development of the uterus and ovaries

Benign and malignant tumors of the reproductive organs and the intrauterine septum often become an obstacle to the normal development of the embryo.

• Antiphospholipid syndrome

This disease of an immune nature provokes spontaneous abortion, usually in the second trimester of pregnancy.

• Endocrine diseases

If there is no medical supervision, with diseases such as diabetes or autoimmune thyroiditis, the risk of miscarriage increases.

• Hematological disorders

As a result of diseases such as dysfibrinogenemia, sickle cell anemia, etc., microthrombosis can form in the chorionic vessels, causing fetal death.

• Mother's illnesses

Homocystinuria, Marfan syndrome, pseudoxanthoma are diseases that can cause spontaneous abortion.

• External influences

Usually these are vapors from paints and varnishes, petroleum products and other chemicals in domestic and industrial conditions.

Most often, miscarriage occurs due to various reasons in combination, and is mainly of a genetic nature. In this case, the woman’s body becomes vulnerable to factors that begin the immediate process of expulsion of the fetus.

The following circumstances can provoke spontaneous abortion::

• sexually transmitted infections (the rarest cause);
• infections in the acute phase;
• chronic renal and cardiovascular diseases in the mother;
• stress loads;
• hard physical labor;
• mechanical factors: for example, isthmic-cervical insufficiency;
• bad habits: drinking alcohol and drugs, smoking, caffeine abuse.

All of the above factors can cause the death of the fetus and its subsequent removal from the uterine cavity or rejection of a viable embryo due to uterine contractions.

The cause of miscarriage after IVF is usually the miscarriage of pregnancy, when the body naturally removes a fetus from the uterus that cannot develop.

Another important factor influencing the likelihood of miscarriage is the woman's age . The higher it is, the higher the chances of sudden termination of pregnancy:

• 15% – risk for women under 35 years of age;
• from 20% to 35% – 35–40 years;
• 50% are women over 45 years old.

Continuing pregnancy does not always make sense. The following types of pregnancy inevitably end in miscarriage :

• Ectopic: in this case, implantation of the embryo does not occur inside the uterus, but in the fallopian tube, cervix or abdominal cavity - this not only causes cramping pain and bleeding, but can also provoke rupture of an organ not intended for bearing a pregnancy (for example, the fallopian tube) .
• Molar: if the egg has chromosomal abnormalities, it can be implanted into the endometrium, but due to the inability of the fetus to develop normally, the pregnancy ends in miscarriage.

Usually, when a molar or ectopic pregnancy is detected, its artificial termination is necessary.

Symptoms

A miscarriage begins in the presence of all the typical symptoms of pregnancy - nausea, vomiting, distortion of olfactory and taste perception. Because of this, a woman may not notice the threat to her pregnancy until the symptoms manifest themselves openly:

• Cramping pain in the abdomen

Painful sensations are characteristic of menstruation, but during a miscarriage the pain takes on a different character. This is a more intense, ongoing, aching pain, which is often accompanied by the same sensations in the lower back.

• Bleeding from the vagina

Accompany a quarter of all miscarriages. This symptom is not as serious as it might seem at first glance: slight spotting is only a sign of a threatened miscarriage, when the pregnancy can still be maintained. Intense bleeding is a characteristic sign of a more serious stage of miscarriage.

Each woman experiences a miscarriage differently: general health can be satisfactory or difficult. This condition is characterized by pale skin and tachycardia. Significant blood loss is accompanied by loss of strength, dizziness, hypotomy, and fainting. Once a miscarriage begins, it is impossible to stop it, and you should consult a doctor at the first suspicion of a threat to pregnancy.

Stages

Depending on the course, the process of spontaneous abortion may have the following stages:

• Beginning of abortion

A miscarriage begins with partial detachment of the fetus and its membranes from the wall of the uterus, the process is accompanied by bleeding and spasmodic pain in the abdomen due to contractions of the uterus.

• Abortion in progress

The embryo, having finally separated from the endometrium of the uterus, moves towards the cervical canal - is located near it or in its lumen. The cervix is ​​dilated by one finger. All this is accompanied by severe bleeding and pain in the abdominal area.

• Incomplete abortion

This is the stage in which the embryo has already been expelled from the uterus, but there is an embryonic membrane inside it. Because of this, the pharynx is slightly open, while the cervical tissues acquire their former elasticity. The pain goes away, the bleeding subsides. This is the most common outcome of miscarriage.

• Complete abortion

This happens quite rarely: a complete abortion means that all parts of the embryo came out of the uterus unhindered. Bleeding, pain, and contractions of the uterus have stopped, and the organ is regaining its shape.

Fragments of the fruit look like a dense clot of tissue. They are similar in appearance to menstrual flow with part of the endometrium, which is often accompanied by pain. If a miscarriage occurs, it is better to save fetal fragments for laboratory testing.

Complications

A miscarriage usually does not go away without a trace and has complications that affect not only the ability to bear a child, but also the woman’s health. The consequences of a miscarriage can be:

• Posthemorrhagic anemia

Its symptoms are weakness, dizziness, pale skin. Occurs due to significant blood loss during chorion detachment and expulsion of the fetus from the uterus.

• Endometritis

Appears due to the contact of infectious agents on the endometrium, manifests itself with an increase in temperature, vaginal discharge, pain and a decrease in general well-being.

• Placental polyp

Appears as a result of improper processing after spontaneous abortion, if a fragment of the embryo or its membrane remains inside the uterus. It makes itself felt with abdominal pain.

Diagnostics

At the first sign of a possible miscarriage, a woman should immediately go to the gynecologist. After a medical examination, you will need to do the following tests:

• Analyzes

An approaching and ongoing miscarriage is characterized by changes in the composition of the blood: a decrease in hemoglobin, hematocrit and an increase in the level of leukocytes. The hCG level remains the same, but will change after the miscarriage is completed.

• Transvaginal ultrasound

Allows you to see the location of the chorion and the fetus, its viability (by the presence of a heartbeat), see chorion detachment and blood discharge on the uterine wall.

In case of recurrent miscarriages, their cause should be determined, for which the following types of studies are indicated:

• Laboratory tests of anticardiolipin antibodies, lupus anticoagulant and beta-2-glycoprotein antibodies with determination of antiphospholipid syndrome.
• Diagnosis of parental chromosomes, aborted material and family genetic abnormalities.
• Examinations for antiphospholipid defects in the structure of the uterus: hysteroscopy, hysterosalpingography, sonohysterography. They allow you to identify the uterine septum and other defects that prevent normal pregnancy.

Antiphospholipid syndrome is a serious problem for pregnancy. To confirm it, the presence of one clinical and one laboratory criterion is necessary:

• Clinical criteria include diagnosed vascular thrombosis, three or more unfounded miscarriages one after another, unexplained fetal death at 10 weeks, at least one premature birth before 34 weeks with eclampsia or placental insufficiency.
• Laboratory criteria are the presence of anticardiolipin antibodies at a level above average for more than two weeks, long-term phospholipid-dependent coagulation in screening tests, normalization of blood coagulation when reacting with phospholipids.

When conducting laboratory tests for antiphospholipid syndrome, it is important to exclude other causes of bleeding disorders so that the diagnosis is reliable.

Symptoms of threatened miscarriage

1. Bleeding. Sometimes it is strong, sometimes it is expressed by periodic bleeding;
2. Various intensity of pain in the lower abdomen, which can be girdling, frequent or transient; pain may also appear in the sacral area;
3. Feeling of uterine tension (changes in tone). There is discomfort, and later cramping or pulling pain may begin;
4. Temperature increase. This symptom often indicates the presence of an infection in the body and can cause a miscarriage. A temperature within 37.3 is a hyperthermic effect of progesterone and is considered normal and a temporary phenomenon (appears mainly in the early stages).

Any of these symptoms are a threat to pregnancy and require immediate medical consultation, examination and special measures to prevent miscarriage. There are cases when, in the absence of the listed symptoms, an examination by a gynecologist reveals an increased tone of the uterus, disturbances in the fetal heart rhythm during an ultrasound examination, or a dangerous infection is detected in the blood that was not there before conception. There are a lot of threats to miscarriage, but if a woman is under the constant supervision of a specialist and follows all the recommendations, then the danger is reduced to zero.

Treatment

Treatment of miscarriage comes down mainly to cleansing the endometrium of the uterus from fetal fragments, restoring the tissue and shape of the organ. When making a diagnosis, in order to prevent complications, the doctor prescribes the following treatment:

• Scraping

This is a surgical operation. The walls of the uterus are mechanically cleared of embryonic tissue, and only with a complete abortion this procedure is not necessary. The operation usually requires general anesthesia and is carried out in three stages:

• probing of the uterine cavity: necessary in order to find out the location of the fetus and not damage the walls of the organ;
• peeling off the fetus and its fragments using surgical instruments;
• removal of the detached fetus through the cervical canal.

During the surgical extraction of the fetus, severe bleeding is observed due to tissue damage, which ends after curettage of the uterine walls. If bleeding continues and there are no contractions of the uterus under medication, it may require complete removal.

• Drug therapy

Combined with surgery and prescribed after it. First of all, these are drugs that contract the uterus to remove fetal remains from it, and also stop bleeding. To prevent infections, your doctor will prescribe antibiotics (amoxicillin or another antibacterial drug) and antifungal drugs (for example, fluconazole).

Recovery

Typically, the recovery period after a miscarriage is ten days. Rehabilitation is individual for each woman. Typically, recovery requires attention to the following points:

• Symptom control

A common consequence of a miscarriage can be pain in the lower abdomen, bleeding, and discomfort in the mammary glands. To control symptoms, you should consult your doctor.

• Menstrual cycle

Menstruation usually returns 3 to 6 weeks after a miscarriage. After the cycle is restored, pregnancy can occur again. However, it is better to postpone this moment until the health that has been shaken after the miscarriage is fully restored.

• Physical activity

You should pay close attention to your well-being and rid yourself of overwhelming tasks. It is better to postpone housework or professional duties that require physical effort until you have fully recovered. It is recommended to resume sexual intercourse no earlier than two weeks after a miscarriage, otherwise an infection may enter the uterus.

• Psychological condition

After a miscarriage, many women experience great emotional distress, which can cause loss of appetite, sleep disturbances, loss of energy and, as a result, depression. If after a miscarriage a woman cannot recover for a long time, it is very important to get professional help from a psychotherapist in a timely manner.

There is always a chance

Most women whose first pregnancy ended in miscarriage, when examined before pregnancy and the causes are eliminated, have a high chance of a successful next pregnancy (about 85 percent).
“A woman who has lost a child needs the support of her family and friends. Sometimes words are unnecessary, just be there. The standard phrases from the series “You will definitely give birth”, “It was just an embryo” hurt very much. The best consolation is to advise you to see a doctor,” says Natalya Kalinina. Published on the portal wday.ru

Cleaning

A fully emerged embryo looks like a gray bubble of a regular round shape. If during examination there are no signs of the presence of fragments of the fetal membrane or the fetus in the uterus, then further therapy is not necessary. Normally, the uterus clears in a couple of weeks, and a woman may notice spotting with white spots on her underwear.

If the fetus is only partially delivered or there is a frozen pregnancy, then the woman undergoes an emergency gynecological cleansing, during which the remaining particles are removed by scraping the endometrium with a special spoon-like instrument - a curette.

A woman can be completely sure that the fetus has definitely left the body entirely, but even a small amount of remaining tissue can become a source of inflammation, since the process of necrosis occurs there and pathogenic organisms multiply. Therefore, if a miscarriage occurs outside of a hospital setting, you need to see a gynecologist just in case.

Methodology

Curettage is done in a gynecological chair under general anesthesia. The cervix is ​​dilated and the doctor uses a curette to scrape off the inner layer of the uterus. The operation takes 30-40 minutes. Then the resulting material is sent for histology for additional research.

In some cases, hysteroscopy is performed - an examination of the uterus using an innovative portable camera. Cleaning with hysteroscopy will be as safe as possible, since the risk of tissue damage is minimal.