Pathology of the first trimester of pregnancy, recurrent miscarriage

In all countries of the world, 10–30% of pregnancies are terminated in this way. A woman who has had two or more miscarriages in a row is diagnosed with “recurrent miscarriage,” and in 80% of cases it is associated with immunological disorders against the background of chronic endometritis, often asymptomatic.

According to the development of the pathological process, several stages of spontaneous abortion are distinguished: threatened abortion, incipient abortion, ongoing abortion, incomplete abortion, complete abortion, failed abortion.

Risk factors

The risk of spontaneous abortion increases significantly under the following conditions:

• delayed maternal sexual development (infantilism);
• previous induced abortions, especially during the first pregnancy;
• dysfunction of the endocrine glands: thyroid, adrenal glands, pituitary gland, ovaries;
• acute and chronic infectious diseases and intoxications;
• isthmic-cervical insufficiency;
• intrauterine adhesions (synechia);
• immunological incompatibility of the blood of mother and fetus according to the Rh factor;
• tumors of the genital organs, etc.

Physical factors - bruises, heavy lifting - are important only for predisposing reasons.

Terminology

Abortion is a fetus up to 20 (28) weeks of gestation, weighing less than 500 (1000) g, length less than 25 (35) cm, if it has been expulsed from the uterus.

Complete miscarriage - complete expulsion from the uterus of the product of fertilization before 20 (28) weeks of gestation.

Incomplete miscarriage - partial expulsion from the uterus of the fertilization product before 20 (28) weeks of gestation (the uterus is completely free of the fertilization product).

An inevitable miscarriage is a miscarriage in which there is no expulsion of the fertilization product, but there is profuse or prolonged vaginal bleeding, which is accompanied by effacement and dilatation of the cervix.

A threatened miscarriage is characterized by bloody discharge from the uterus, but the blood loss is less than with an inevitable abortion, the cervical canal is closed and expulsion of the fertilization product does not occur.

Incomplete miscarriage - death of an embryo or fetus before 20 (28) weeks of gestation with its complete retention in the uterus; miscarriage often occurs after 1-3 weeks or later.

An infected (septic) miscarriage is a miscarriage associated with a genital tract infection.

Symptoms of spontaneous abortion (miscarriage)

• Abortion is threatening. Pregnant women complain of mild pain in the lumbar region and lower abdomen. There is little or no discharge from the genital tract, the size of the uterus corresponds to the period of pregnancy, the external os is closed (in case of isthmic-cervical insufficiency, it is slightly open). With successful treatment, pregnancy subsequently develops normally.
• The abortion has begun. The pain intensifies, and scanty spotting bloody discharge from the vagina appears. The size of the uterus corresponds to the duration of pregnancy, the external os is closed or slightly open. Pregnancy can still be maintained, but the prognosis is worse.
• Abortion is in progress. The fertilized egg is expelled from the uterus through the cervical canal. Patients complain of bleeding (sometimes significant) and cramping pain in the lower abdomen. The size of the uterus corresponds to the gestational age or is less than usual. During vaginal examination, the cervix is ​​dilated or smoothed, spongy tissue (fertilized egg and blood clots) is palpated in its lumen. Continuing the pregnancy is impossible.
• The abortion is incomplete. Characterized by retention of parts of the fertilized egg in the uterine cavity, accompanied by bleeding, often significant. The discharge consists of parts of the fetus and eggs and blood clots. During vaginal examination: the cervical canal is slightly open, the size of the uterus is less than normal.
• The abortion is complete. Most often occurs in early pregnancy. The uterus is free from the remnants of the fertilized egg, contracts, the cervical canal closes, and bleeding stops.

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

• Inspection using mirrors: the source and volume of bleeding, the presence of products of conception in the cervical canal (if possible, remove and send for histological examination).
• Bimanual examination: consistency and length of the cervix, condition of the cervical canal and internal os of the cervix, size of the uterus (depending on the date of the last menstruation), condition and soreness of the appendages, vaginal vaults.
• Ultrasound scanning
• Most women with complications in early pregnancy require an ultrasound scan. A transvaginal scan (TVS) performed by an experienced technician is the gold standard. If TVS is not available, transabdominal scanning (TAS) can be used, but this method is not as accurate as TVS for diagnosing complications of early pregnancy.

Viable intrauterine pregnancy:

• The ovum is usually located, the embryo is visualized, and cardiac activity is clearly detected. The presence of cardiac activity is associated with the successful completion of a given pregnancy in 85-97%, depending on the gestational age. Subsequent medications and additional examinations may be required in the following situations: significant vaginal bleeding, subchorionic hematoma, as well as in patients with a history of miscarriages or after removal of intrauterine contraceptives.

Pregnancy of uncertain viability:

• Option 1 - the fertilized egg is usually located, the average internal diameter of the fertilized egg is 20 mm, the embryo is not visualized;
• Option 2 - the fertilized egg is located normally, the embryo is 7 mm, the fetal heartbeat is not visualized.

These patients should have a repeat scan after 7 days and evaluate over time whether the pregnancy is progressing (embryo growth, fetal cardiac activity).

Early pregnancy losses:

• Transvaginal ultrasound should be the standard examination of women in early pregnancy. Transabdominal ultrasound is performed if it is impossible to perform transvaginal ultrasound or to clarify the data obtained.

Signs of early pregnancy loss with retention of products of conception in the uterus:

• with a transvaginal examination, the average internal diameter of the gestational sac is > 20 mm, the embryo is not visualized, or with a transabdominal scan, the average internal diameter of the gestational sac is > 25 mm, the embryo is not visualized;
• embryo > 7 mm, no heartbeat on transvaginal scan, or embryo > 8 mm, no heartbeat visible on transabdominal ultrasound.

If the average internal diameter of the gestational sac is 25 mm and the embryo is not visualized, or if the embryo is 7 mm and there is no heartbeat, it is necessary to repeat the ultrasound no earlier than 7 days from the initial one and evaluate whether there is a change in the indicators.

NB! The variability of the results of measurements of the average internal diameter of the ovum and embryo by different specialists is 18%. In some cases, this can lead to a false-positive diagnosis of a non-developing pregnancy. In doubtful cases, when borderline values ​​of the average internal diameter of the ovum and the size of the embryo are obtained, it is necessary to re-scan after 7-10 days. The diagnosis of a non-developing pregnancy must be confirmed by two specialists in functional diagnostics, the data is stored on paper and, preferably, electronically.

Incomplete miscarriage:

• Ultrasound visualizes tissue with a diameter of 15 mm in the uterine cavity.

Complete miscarriage:

• Ultrasound shows endometrial thickness < 15 mm, and a fertilized sac or remaining products of conception have previously been detected.

Pregnancy of unknown location:

• There is no evidence of intrauterine or ectopic pregnancy or residual gestational sac in the presence of a positive pregnancy test or hCG level above 1000 IU/L.
• There may be three reasons why the location of pregnancy is not detected by ultrasound: very early intrauterine pregnancy, complete miscarriage, or early ectopic pregnancy. The diagnosis can be established during subsequent follow-up studies.
• It should be noted that at the first visit, even with transvaginal ultrasound using all research criteria, in 8-31% of cases it is impossible to establish an uterine or ectopic pregnancy.

Progesterone level

• Determination of serum progesterone may be a useful adjunct to ultrasound. Serum progesterone levels below 25 nmol/L are a predictor of pregnancy nonviability. A progesterone level above 25 nmol/L is likely to indicate a viable pregnancy, and a level above 60 nmol/L reliably indicates a normal pregnancy.
• During pregnancy of unspecified localization, it is recommended to study the hCG level over time, without determining progesterone in the blood serum.

Ultrasound with dynamic measurement of b-hCG levels

• Treatment tactics for women are determined individually depending on the clinical situation, patient preferences, ultrasound results and b-hCG studies.
• In 8-31% of women, at the first visit it is impossible to determine the localization of pregnancy: uterine or ectopic.
• If a complete miscarriage is diagnosed, all necessary tests should be applied to completely rule out an undiagnosed ectopic pregnancy.

Uterine pregnancy

For a potentially viable intrauterine pregnancy up to 6-7 weeks of gestation, the following rules apply:

• The average doubling time for b-hCG is 1.4-2.1 days.
• In 85% of patients, every 48 hours the level of b-hCG increases by 66% or more, in 15% - by 53-66% (more than 48 hours the slowest increase in b-hCG level was recorded by 53%).
• Intrauterine pregnancy is usually visualized by ultrasound when the gestational sac is greater than or equal to 3mm. This corresponds to the b-hCG value: - 1500-2000 IU/l with a transvaginal scan (sometimes with a b-hCG value of 1000 IU/l), or approximately 6500 IU/l with a transabdominal scan, which should only be used if it is impossible to perform a transvaginal scan.

There is no proven range of values ​​for multiple pregnancies.

Lead tactics

The management of women with miscarriages in early pregnancy depends on the presence/absence of symptoms and which clinical group the patient belongs to.

Waiting tactics

• If moderate pain and/or scanty bleeding occurs, or there is questionable ultrasound data about the viability of pregnancy, many patients express a desire to take a “wait and see” approach in the hope that the pregnancy will end successfully, or a miscarriage will occur without the need for subsequent medical intervention.
• Expectant management for threatened and incipient miscarriages is possible in the first trimester of pregnancy, when there is no clinically significant (moderate, heavy) uterine bleeding, signs of infection, excessive pain, or hemodynamic disturbances.
• Non-developing pregnancy - in case of questionable ultrasound data and suspicion of a non-developing pregnancy, dynamic ultrasound and monitoring of the patient’s condition are indicated.
• In the event of bleeding from the genital tract, observation in these cases should be carried out in a gynecological hospital. It is necessary to inform the patient about the high frequency of chromosomal pathology of the fetus in sporadic early miscarriages, explain the validity of expectant management and the inappropriateness of excessive drug therapy in case of questionable ultrasound data.

Drug therapy

• Drug therapy aimed at prolonging pregnancy.
• If a miscarriage begins (cramping pain, bleeding with stable hemodynamics and no signs of infection), when ultrasound reveals a viable fertilized egg in the uterine cavity, symptomatic therapy is indicated to relieve pain and stop bleeding.
• An incipient miscarriage is an indication for hospitalization in the gynecological department.

Effectively

• To relieve severe pain (O02.1 Failed miscarriage; O02.8 Other specified abnormal products of conception; O02.9 Abnormal product of conception, unspecified), it is permissible to use drotaverine hydrochloride in a dose of 40-80 mg (2-4 ml) intravenously or intramuscularly.
• For severe bleeding from the genital tract, tranexamic acid is used for hemostatic purposes in a daily dose of 750-1500 mg. In case of heavy bleeding, intravenous drip administration of tranexamic acid 500-1000 mg per day for 3 days is possible; for moderate bleeding, the drug is used orally at a dose of 250-500 mg 3 times a day for 5-7 days.

Effectively

The use of gestagens for recurrent miscarriage: the incidence of miscarriage is reduced compared with placebo or no treatment, without increasing the incidence of postpartum hemorrhage or pregnancy-induced maternal hypertension.

Schemes for prescribing gestagens.

Dydrogesterone (duphaston)

• Threatened miscarriage - 40 mg once, then 10 mg every 8 hours until symptoms disappear.
• Habitual miscarriage - 10 mg 2 times a day until the 20th week of pregnancy, followed by a gradual decrease.

Micronized progesterone (utrogestan)

• Habitual and threatening miscarriage - intravaginally, 100-200 mg 2 times a day until the 12th week of gestation.

NB! The simultaneous administration of 2 drugs that have a unidirectional pharmacological effect is unacceptable (in this case, combining different gestagens).

Unreasonable prescription of drug therapy; simultaneous prescription of drugs that are synonymous, analogues or antagonists in terms of pharmacological action, etc., associated with a risk to the patient’s health and/or leading to an increase in the cost of treatment.

It is unacceptable to exceed the dosage of drugs established in the instructions for the drug:

• Excessive doses of the drug block receptors, i.e. Exceeding doses of gestagens disrupts the sensitivity of progesterone receptors and, instead of maintaining pregnancy, can provoke a miscarriage.

According to the instructions, the indications for prescribing gestagenic drugs in the first trimester of pregnancy are: prevention of habitual and threatened abortion due to progesterone deficiency.

The effectiveness of prescribing gestagens for therapeutic purposes in cases of threatening and incipient sporadic spontaneous miscarriage has not been convincingly proven at present.

However, a 2012 systematic review found that dydrogesterone reduced the risk of spontaneous abortion by 47%.

Ineffective.

Prescribing bed rest for early miscarriage does not increase the rate of favorable pregnancy outcomes (level of evidence B).

Currently, there is no convincing evidence of the effectiveness and validity of the use of magnesium preparations for miscarriage in early pregnancy.

If drug therapy is ineffective and/or negative dynamics according to ultrasound data, management tactics should be reconsidered by discussing it with the patient.

NB! Ultrasound signs indicating an unfavorable outcome of intrauterine pregnancy:

• absence of heartbeat of an embryo with a coccygeal-parietal size of more than 7 mm;
• absence of an embryo when the size of the ovum (measured in three orthogonal planes) is more than 25 mm during transvaginal scanning.

Additional signs

• an abnormal yolk sac, which may be older than gestational age, irregular in shape, peripherally displaced, or calcified;
• embryonic heart rate is less than 100 per minute at a gestational age of 5-7 weeks of pregnancy;
• large retrochorial hematoma - more than 25% of the surface of the fetal egg.

Prevention of spontaneous miscarriage

There are no specific methods for preventing sporadic miscarriage. Patients should be informed about the need to promptly consult a doctor during pregnancy if they experience pain in the lower abdomen and bleeding from the genital tract.

It is ineffective to prescribe:

• bed rest
• sexual rest
• hCG
• uterine relaxants
• estrogens
• progesterone (orally, intravaginally, intramuscularly) - with the exception of patients with recurrent miscarriage
• mono- and multivitamins

Effective:

• prophylactic administration of progesterone preparations (orally, intramuscularly, vaginally) to women with recurrent miscarriage in the first trimester.

To prevent neural tube defects and other developmental defects, which partially lead to early spontaneous miscarriages, it is recommended to take folic acid two to three menstrual cycles before conception and in the first 12 weeks of pregnancy in a daily dose of 400 mcg (0.4 mg).

If a woman has a history of fetal neural tube defects during previous pregnancies, the prophylactic dose of folic acid should be increased to a therapeutic dose of 3-5 mg/day.

Prevention of implantation losses after ART.

Effective: the use of progesterone to support the luteal phase after ART, as it can increase the rate of pregnancy progression and live births. The method of administration of progesterone does not matter. When prescribing progestin support after ART, you should follow the instructions for the medications and follow the general principles of prescribing medications.

Ineffective: The use of estrogens and hCG to support the luteal phase after ART does not improve outcomes, and the use of hCG is associated with an increased incidence of ovarian hyperstimulation syndrome.

Forecast

The prognosis is usually favorable. After one spontaneous miscarriage, the risk of losing a subsequent pregnancy increases slightly and reaches 18-20% compared to 15% in the absence of a history of miscarriages.

If there are two consecutive spontaneous abortions, examination is recommended before the desired pregnancy occurs to identify the causes of miscarriage in this married couple.

Psychological aspects of early pregnancy loss.

Clinicians of all specialties should be aware of the psychological consequences associated with miscarriage and should provide psychological support and follow-up care, as well as access to professional psychological counseling (Evidence Level of Recommendation B).

Early miscarriage negatively affects the mental well-being of a proportion of women, their spouses and other family members (evidence level III). For some women, the psychological trauma is quite serious and long-lasting, even if the miscarriage occurs very early in pregnancy. And this fact cannot be ignored by specialists providing medical care to such patients.

Women who have had a miscarriage should be given the opportunity to receive further help. Not only doctors who cared for the patient during the miscarriage stage, but also primary care workers (general practitioners, nurses, midwives, patronage staff), psychological support and counseling services can be involved in the provision of assistance.

Long-term management plans should be clearly communicated to the patient in the discharge instructions.

Diagnosis of spontaneous abortion (miscarriage)

Diagnosis is based on an assessment of medical history, complaints and clinical manifestations. An ultrasound examination is the most informative, allowing you to assess the tone of the uterus, the shape of its cavity, the condition of the cervix, fertilized egg, embryo/fetus. Threatened and ongoing abortion should be differentiated from dysfunctional uterine bleeding, cervical diseases, ectopic pregnancy and hydatidiform mole.

During an abortion, the fertilized egg is completely peeled off from the wall of the uterus. It descends into the cervical canal, its lower part may even protrude beyond the external os of the cervix. This condition can result in complete or incomplete abortion.

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.

Treatment of spontaneous abortion (miscarriage)

Treatment is carried out depending on the stage.

• In case of threatened and incipient abortion, bed rest in a gynecological hospital, antispasmodic and sedatives are prescribed. If the level of male sex hormones of adrenal origin is elevated, as confirmed by laboratory data, glucocorticoids are prescribed. In case of hypofunction of the corpus luteum, progesterone-based drugs are used. Electroanalgesia and acupuncture may be used.
• For infantilism and ovarian hypofunction, hormonal therapy is used: estrogens and progesterone. For hyperandrogenism - prednisolone.
• In case of threatened or incipient abortion caused by isthmic-cervical insufficiency, surgical treatment is necessary.
• In case of an ongoing abortion or an incomplete abortion, instrumental removal of the fetal egg or its parts is indicated.
• With a late abortion, without significant bleeding, they wait for the spontaneous birth of the fertilized egg. In case of retention of parts of the placenta in the uterus, curettage (scraping) is indicated.

Signs of an incipient miscarriage

In the initial stage of spontaneous abortion, aching, sometimes cramping pain in the lower abdomen or lumbar region is observed. When the placenta separates from the wall of the uterus, bloody discharge appears from the genital tract. As the detachment process progresses, the bleeding intensifies. Often, heavy bleeding may occur, leading to severe anemia. Together with the blood, the fertilized egg comes out of the uterus. After this, the uterus begins to contract and the bleeding stops. If parts of the membranes and placenta remain in the uterus, it will not contract and bleeding will continue. Heavy uterine discharge can become life-threatening. The cervix remains slightly open, which favors the development of inflammatory diseases due to the entry of pathogenic microorganisms there.

Sometimes the elements of the fertilized egg retained in the uterus are very small, and bleeding may stop, but subsequently polyps are formed from these elements, preventing the healing of the surface of the uterus. They can lead to prolonged bleeding from the genital tract.

Determining whether the fetus is developing in the womb or not can be determined by determining the level of human chorionic gonadotropin (hCG) over time. An increase in the amount of this hormone in two days indicates a normal pregnancy. If the level of human chorionic gonadotropin remains the same or decreases, it means that the development of the fetus has stopped.

Prevention of spontaneous abortion (miscarriage)

• Prevention of induced abortions.
• Use of contraceptive methods.
• Preparing for pregnancy: diagnosis and treatment of genital tract infections in a married couple before pregnancy.

Prepared based on materials:

1. Kazan-2011. II All-Russian scientific and practical seminar “Reproductive potential of Russia: Kazan readings. Women’s health is the nation’s health.” Post-release and materials of the scientific program. – M.: Publishing house of the magazine StatusPraesens, 2012. – P. 28.
2. Miscarriage: hoping to win the battle. Symposium “Pathogenetic aspects of miscarriage and their correction.” – M.: Publishing house of the magazine StatusPraesens, 2011. – P. 40–42.
3. Radzinsky V. E. Obstetric aggression. – M.: Publishing house of the magazine StatusPraesens, 2011. – P. 688.

What can an abortion be like?

The content of the article

Doctors distinguish several methods of artificial abortion:

• medicinal;
• vacuum aspiration;
• saline abortion;
• surgical intervention: curettage, minor caesarean section, etc.

The choice of method depends on a number of factors, including the length of pregnancy (up to 5-7 weeks, up to 12 weeks, later), age and health of the woman. It is important here to contact a gynecologist as early as possible and discuss the current situation with him.

So what are the features of various abortion methods, what determines their choice, what advantages they may have and, most importantly, consequences?