Early miscarriage is a spontaneous termination of pregnancy for up to 12 obstetric weeks, often in the absence of cardiac activity in the fetus or an empty embryo sac. Usually, an early miscarriage is accompanied by pain in the lower abdomen or lower back of various kinds, bloody discharge from the vagina with a possible admixture of purulent masses or amniotic waters. Diagnosis includes confirmation of pregnancy, physical examination of the patient, examination of the birth canal and transvaginal ultrasound scan. Treatment depends on its form and may consist in drug prolongation, termination of pregnancy or vacuum aspiration.
Early miscarriage is a pathological condition in obstetrics and gynecology, which is characterized by spontaneous abortion for up to 12 weeks. According to official statistics, about 15-20% of all confirmed pregnancies end in spontaneous termination. Early miscarriage is the most common complication in obstetrics, it accounts for about 80% of all spontaneous abortions and in 70% of cases occurs before the clinical manifestation of pregnancy. About a third of all cases of early miscarriages occur at up to 8 obstetric weeks due to the absence of an embryo. This condition is most common among mothers over the age of 40. This is due to the high frequency of chromosomal abnormalities, which are the cause of more than 50% of all cases of early miscarriages.
More than half of cases of early miscarriages are caused by fetal chromosomal mutations, in particular, autosomal trisomies, X–chromosome monosomies and polyploidies. A smaller part of cases are provoked by factors that have a teratogenic effect on the fetus and create an unfavorable environment for its development. This includes the mother’s use of alcohol, cigarettes, large amounts of caffeine (over 4 cups per day) or narcotic substances, infectious diseases (syphilis, chlamydia, toxoplasmosis), taking certain medications (NSAIDs, retinoids, antimycotics, antidepressants), occupational hazards (ionizing radiation, toxins, etc.).
Also, the cause of early miscarriage may be the mature age of the mother (after 40 years, the risk of spontaneous abortion is more than 40%) abnormalities in the development of the genitals, severe obesity, direct abdominal trauma, chronic diseases (antiphospholipid syndrome, polycystic ovaries, thyroid diseases, etc.).
Signs of early miscarriage
There are several clinical variants of early miscarriage: threatening, incipient, septic and incomplete miscarriages, miscarriage in progress. Threatening miscarriage is manifested by pain in the suprapubic and lumbar regions of a pulling nature, scanty bloody discharge from the vagina. At the same time, hypertonus of the uterus is observed, its dimensions correspond to the term of pregnancy, and the internal pharynx is closed. An early miscarriage that has begun has the same symptoms, but they are more pronounced, and the cervical canal goes into a slightly open state. Miscarriage in the course is characterized by recurrent pains in the lower abdomen of a cramping nature, more pronounced bloody discharge, less often – with an admixture of amniotic fluid. During the examination, the uterus has dimensions smaller than those prescribed for this period of pregnancy, the external and internal pharynx are open. In the lumen of the vagina or cervix, the elements of the fetal egg can be determined.
Incomplete early miscarriage (incomplete abortion) is a condition of a woman in which, after termination of pregnancy, elements of the fetal egg remain in the uterus. It is accompanied by moderate pain in the lower back and lower abdomen, massive bleeding, which can lead to hemorrhagic shock. Septic or infected early miscarriage is an abortion characterized by signs of infection of the genitals: a sharp increase in body temperature, general weakness, pelvic pain, purulent discharge from the vagina, increased heart rate and BH, muscular defiance of the anterior abdominal wall.
Diagnosis of early miscarriages is based on the collection of anamnestic data and complaints of the patient, objective examination, data from laboratory and instrumental research methods. When interviewing a woman, an obstetrician-gynecologist pays attention to the date of the last menstruation, bad habits, occupational hazards, chronic diseases present, recent infections, medication intake and the results of past pregnancies. Collecting complaints, the specialist clarifies the amount of bleeding from the vagina, the presence of pus or amniotic fluid, the nature and localization of the pain syndrome. During the basic examination of a woman with a suspected early miscarriage, the general condition, body temperature, heart rate, BH and blood pressure are assessed. Next, an examination of the abdomen is performed, followed by a vaginal examination with mirrors and a bimanual examination to assess the size and consistency of the uterus. Among laboratory tests, in addition to basic analyses, the level of progesterone and human beta-chorionic gonadotropin (β-hCG) is measured to determine a possible ectopic pregnancy.
Ultrasound examination (ultrasound) occupies a leading place in the diagnosis of early miscarriage. At the moment, transvaginal ultrasound (FA) is the “gold standard” in the diagnosis of pregnancies in the early stages. Only if it is impossible to perform it, transabdominal scanning (TAS) is used. Signs of early miscarriage include the average internal diameter of the fetal egg over 20 mm on the FA and 25 mm on the TAC, respectively, the absence of cardiac activity or the complete absence of its visualization. Differential diagnosis of early miscarriage is carried out with benign and malignant neoplasms of the cervix and vagina, chorionepithelioma and ectopic pregnancy.
The treatment regimen for early miscarriage directly depends on the clinical form of the pathology and the mother’s decision. With a threatening or incipient miscarriage, prolongation of pregnancy is possible, with intrauterine fetal death, a medical abortion is indicated. In order to preserve pregnancy and prevent early miscarriage, gestagens are used. Tranexamic acid is also used for hemostatic purposes, and drotaverine is used to relieve pain. If it is impossible to prolong pregnancy, drug curettage is indicated. There are various options for its implementation, in which prostaglandin analogues can be combined with antiprogestin.
Surgical treatment is indicated in cases of infected and incomplete early miscarriage, as well as massive bleeding caused by the latter. The essence of surgery is to remove the remaining chorionic or placental tissues and complete hemostasis. As a rule, such interventions are performed using a vacuum aspirator or other vacuum sources, less often resort to instrumental scraping. According to modern research, prior to surgery for early miscarriage, the preliminary (1-1.5 hours) use of NSAIDs and drugs from the benzodiazepine group is effective.
Prognosis and prevention
The prognosis for early miscarriage is favorable in most cases. The risk of repeated spontaneous termination of pregnancy increases slightly and amounts to 19-20% compared to the average of 15%. Among married couples who failed to identify the cause of early miscarriage, in more than 65% of cases, repeated pregnancy goes well.
There is no specific prevention of early miscarriage. Non-specific preventive measures imply the exclusion of etiological factors through full-fledged antenatal fetal protection and rational pregnancy planning. If a couple wants to have a child, it is recommended to visit specialized centers and consult a geneticist. After confirming the fact of pregnancy, in order to prevent early miscarriage, a woman should exclude all teratogenic factors, completely abandon bad habits and undergo all control examinations according to the recommendations of an obstetrician-gynecologist.