Miscarriage is the spontaneous termination of pregnancy up to 28 weeks of gestation, which does not allow the fetus to reach a mature viable state. Miscarriage is manifested by aching or cramping abdominal pain, bloody discharge, expulsion of the fetal egg from the uterus. Diagnosis is based on the data of gynecological examination and ultrasound. The outcome of pregnancy depends on the stage of spontaneous termination: with a threatening abortion, pregnancy can usually be saved, with a start, it is extremely rare.
Miscarriage (spontaneous termination of pregnancy, spontaneous abortion) is an obstetric pathology in which fetal gestation suddenly stops at a stage when the fetus is still undeveloped and unviable. Depending on the term of miscarriage, early (up to 12 weeks of gestation) and late (from 12 to 28 weeks of gestation) miscarriages are distinguished. Most spontaneous abortions occur in the first trimester of pregnancy before the completion of the main stages of embryogenesis and the formation of the placenta. Miscarriage after 28 weeks of gestation is considered premature birth.
Miscarriage includes non-developing pregnancy: anembryonia (empty fetal egg) and frozen pregnancy (death of the embryo or fetus without its expulsion). Miscarriage, occurring more than 2 times in a row, is called a habitual abortion.
What causes miscarriage
Early spontaneous termination of pregnancy is most often associated with chromosomal pathology, less often with a violation of implantation of a fertilized egg into the uterine mucosa. The causes of spontaneous termination of pregnancy may be endocrine disorders (progesterone deficiency, hypothyroidism); autoimmune diseases of the mother (antiphospholipid syndrome); deformities of the uterine cavity (bicornuate uterus, septate uterus, synechiae, adhesions, fibroids, polyps).
Previous abortions accompanied by the development of cervical insufficiency (CI), genital inflammation (endometritis, endocervicitis, adnexitis), infections (influenza, toxoplasmosis, chlamydia, rubella, mycoplasmosis) suffered during pregnancy have a negative impact on the outcome of pregnancy.
The risk of miscarriage increases with a habitual miscarriage, multiple pregnancies, Rh incompatibility, the presence of diabetes mellitus, hypertension, kidney failure, folic acid deficiency, active physical exertion, injuries, smoking, etc. Pregnancy as a result of IVF, the presence of an IUD at the time of conception, invasive prenatal diagnostic procedures (amniocentesis, chorion biopsy, cordocentesis) can also increase the risks of miscarriage.
Signs of miscarriage
According to the clinical symptoms of miscarriage, there is a threatening abortion, an abortion that has begun and an abortion in progress. With the threat of spontaneous termination of pregnancy, aching pains and heaviness appear in the lower abdomen and in the sacrum; in later periods, the pains are cramping. There may be mucosal or bloody discharge from the vagina. The tone of the uterus is increased, its size corresponds to the gestation period; the cervix is closed, of normal length; fetal growth and development are most often not disturbed.
The abortion that has begun is characterized by more pronounced paroxysmal pains and bloody discharge from the genital tract, a slightly open cervix, but not yet rejected fetus. During abortion, there are regular cramping pains in the lower abdomen, often – abundant bloody discharge. The internal and external pharynx of the cervix are open, the fetal egg may be in the cervical canal or in the vagina, the size of the uterus is estimated to be less than the gestation period, amniotic fluid leakage is possible.
With a complete spontaneous termination of pregnancy, the fetal egg is expelled from the uterus completely, the uterus contracts and the bleeding stops. With incomplete abortion, some elements of the fetal egg are delayed in the uterine cavity, the uterus does not contract completely, large blood loss and the development of hypovolemic shock are possible.
Uncomplicated infected abortion is characterized by an inflammatory process in the endometrium (endometritis) and fetal membranes (chorionitis, amnionitis), fever, tachycardia, uterine soreness, bloody, sometimes purulent discharge from the genital tract. With a complicated infected abortion, the condition of the pregnant woman worsens, fever, chills, pain, dyspeptic and dysuric phenomena, purulent processes in the pelvis (salpingitis, parametritis, pelvioperitonitis) occur. The septic form of spontaneous termination of pregnancy is accompanied by symptoms of generalized septic infection and the development of infectious and toxic shock.
The obstetrician-gynecologist makes the diagnosis of spontaneous termination of pregnancy on the basis of clinical symptoms, the results of vaginal, bimanual examination, ultrasound examination. A thorough gynecological examination allows you to assess the condition of the cervix, detect discharge or bleeding from the cervical canal, expulsion of the fetal egg and its remains. Bimanual examination helps to determine the size of the uterus, its consistency and tone.
Ultrasound helps to establish the signs of spontaneous termination of pregnancy: the absence of an embryo in the fetal egg, detachment of the fetal egg (placenta), discrepancy in the size of the embryo (fetus) to the gestation period, the absence of a fetal heartbeat.
Spontaneous termination of pregnancy should be differentiated from anovulatory uterine bleeding, neoplasms of the uterus and vagina, cystic drift and ectopic pregnancy. If necessary, colposcopy, biopsy, culdocentesis and diagnostic laparoscopy are performed.
During the diagnosis, a general blood test is performed, the level of hCG and progesterone in the blood, Rh factor, platelet count, and fibrinogen levels are determined. If an infected abortion is suspected, blood, urine and material obtained after curettage are examined. With the usual spontaneous termination of pregnancy, a cytogenetic study of the remains of the fetal egg is carried out.
If there is a threat of miscarriage in the first trimester, bed rest, sexual rest, diet, sedatives and antispasmodics, vitamin E, hormonal drugs (usually gestagens) are prescribed. The threat of spontaneous termination of pregnancy in the second and third trimesters requires inpatient treatment and constant monitoring of the condition of the cervix and fetus. Antispasmodic, tocolytic agents are used, with CI – at 14-16 weeks of gestation, a circular suture is applied to the cervix.
When an abortion has begun, urgent hospitalization, hemostatic agents are indicated, in the first trimester of pregnancy – estrogen-containing drugs, progesterone. During abortion, surgical removal of the remains of the fetal egg is performed by vacuum aspiration or curettage of the uterine cavity. In the case of a failed abortion in the first trimester of pregnancy, the deceased fetal egg is removed instrumentally or medicinally; in late gestation, labor is performed. After curettage of the uterus, antibacterial therapy and oxytocic drugs are prescribed. Patients with Rh (-) blood are injected with antiresus immunoglobulin.
The general principles of treatment of the septic form of spontaneous termination of pregnancy, which are used by clinical gynecology, are: infusion and transfusion therapy, oxygen inhalation, antibacterial therapy, instrumental removal of the remains of the fetal egg and necrotic tissues. If antimicrobial therapy is ineffective, hysterectomy with adnexectomy is possible – removal of the uterus with appendages. In case of spontaneous termination of pregnancy at the term of 22-28 weeks, measures are taken to care for a deeply premature baby.
Spouses need to undergo a full examination to identify the causes of spontaneous termination of pregnancy, lead a healthy lifestyle and plan the next pregnancy no earlier than 3 months after the miscarriage. Treatment of pregnant women with a history of habitual abortion should be started before the clinical manifestations of spontaneous termination of pregnancy. After a single spontaneous abortion, the chances of carrying a future pregnancy remain high.