Threatened abortion is the risk of miscarriage no later than 22 weeks of gestation. The condition is accompanied by aching or pulling pain in the lower abdomen, the release of a small amount of blood, but the cervix retains its structure. Diagnosis is based on complaints of the pregnant woman, clinical symptoms, examination, ultrasound data. The purpose of treatment is to preserve the fetus and maximize the prolongation of the child’s gestation. Hormonal drugs, antispasmodics are used to relieve the tone of the myometrium, symptomatic treatment aimed at stopping bleeding.
O20.0 Threatened abortion
Clinical protocols recommend not to use the term “threatened abortion” in order to reduce the psychological burden on a woman at risk of losing a desired pregnancy. Instead, it is proposed to call this condition a threatening miscarriage. The definition includes cases when there is a detachment of the fetal egg at an early stage – up to 12 weeks. A late threat of abortion is the appearance of uterine tone and bleeding from 12 to 22 weeks. Later than this period, similar symptoms are called the threat of premature birth. It is mistakenly believed that miscarriage is provoked by sexual activity, blunt abdominal injuries, physical exertion. The main causes are chromosomal abnormalities, infections, endocrine disorders.
Spontaneous threat of termination of short-term pregnancy in 50% of patients is associated with chromosomal abnormalities of the embryo. After week 16, a threatening miscarriage is the result of genetic defects in 10% of cases. The shorter the gestation period, the higher the probability that the threatened abortion will turn into a spontaneous miscarriage. The infection can cause a violation of the development of the fetal egg and a threatened abortion with chronic endometritis, viral infection during pregnancy. The danger is higher at an early stage, until the placenta is formed, which acts as a protective filter.
There are factors that significantly increase the risk of threatened abortion. They are associated with endogenous conditions, features of the lifestyle of the expectant mother. Acute and chronic diseases, as well as the effects of external stimuli and pathogens, are of great importance. These factors are taken into account when registering a woman with an obstetrician-gynecologist and managing pregnancy:
- Mother’s age. In women 20-30 years of age, threatened abortion occurs in 9-15%, after 30 years this figure increases to 20%, and in 45-year-olds – up to 80%. Young girls under the age of 18 are also often faced with the development of the threat of termination of gestation due to an immature hypothalamic-pituitary system, physiological dysfunction of the ovaries.
- Endocrine diseases of the mother. Thyroid pathology, uncompensated diabetes mellitus, polycystic ovary syndrome cause endocrine changes that worsen the condition of the endometrium, the production of hormones of the ovarian corpus luteum. Obesity leads to a change in the synthesis of steroid hormones, which leads to their imbalance.
- Pregnancy loss in the anamnesis. In women with habitual miscarriage, the risk is 30%. If there was a history of normal childbirth and there are no spontaneous miscarriages, then the risk of termination of gestation in a pregnant woman is only 5%.
- Taking medications. The use of drugs with teratogenic effects (retinoids, anticoagulants), large doses of nonsteroidal anti-inflammatory drugs inhibit prostaglandin synthesis and worsen embryo implantation, which can later cause the threat of miscarriage.
- The effect of toxic substances. The threat of termination of gestation may occur in women working in harmful conditions, in hazardous production. Alcohol with systematic use, smoking 10 cigarettes a day, and cocaine use have a toxic effect on the endometrium and fetus. Coffee, soft drinks with caffeine have a dose-dependent effect. The danger is the use of 4-5 cups of strong drink or 100 mg of caffeine per day.
- Autoimmune diseases. Antiphospholipid syndrome, systemic lupus erythematosus are associated with the formation of antibodies to phospholipids and other cell structures. A woman has an increased tendency to microthrombosis. Blood clots form in the vessels of the endometrium, which disrupts the nutrition of the embryo, leads to a threatened abortion or death of the fetal egg.
The mechanism of development of threatening miscarriage is associated with increased contractility of the uterus. In case of infection, the blood flow in the vessels feeding the embryo is disrupted, their spasm occurs. The embryo does not receive the right amount of nutrients and oxygen. At this stage, his death may occur. A spasm of microvessels leads to their rupture, there is a slight bleeding into the uterine wall, a retrochorial hematoma is formed. She peels the fetal egg from the endometrium. If the bleeding is not stopped in time, the threatened abortion turns into a miscarriage in progress. Pregnancy loss in the 1st and early 2nd trimester occurs without rupture of the fetal membranes.
Symptoms of threatened abortion
Unpleasant symptoms appear against the background of complete well-being. The pregnant woman begins to feel a feeling of discomfort in the lower abdomen, which gradually turns into a pulling, aching pain. The pain is localized indistinctly above the pubis, can give to the sacrum, lower back, perineum. With a threatened abortion, the sensations do not turn into contractions, otherwise it indicates the progression of pathology and a developing miscarriage.
There may be no discharge from the genital tract at the initial stage. This is characteristic of the formation of a small hematoma behind the fetal egg, which does not empty into the uterine cavity. If its detachment occurs along the edge, then the pregnant woman notices spotty spotting or sucrovichno-bloody discharge on the underwear, which look like streaks of dark blood with an admixture of mucus. With the threat of miscarriage, they do not transform into massive bleeding with scarlet or dark blood. Secretions appear several times a day, gradually their number decreases under the influence of therapy. If this does not happen, the progression of pathology is assumed.
Violation of general well-being is not typical. Pain in the lower abdomen does not reduce the performance of a pregnant woman, but there is a desire to lie down, rest. This often helps to reduce the intensity of unpleasant sensations. Increased pain is provoked by nervous experiences, physical exertion or lack of proper rest. Sexual relations can also become a factor in the progression of threatened abortion.
If you do not consult a gynecologist in time, a threatening miscarriage can develop into an abortion in progress, which cannot be stopped. At the same time, severe cramping pains appear, which can lead to the opening of the cervix. At 22 weeks, the fetus is not viable, so birth leads to its death. Termination of pregnancy is accompanied by bleeding. A woman needs medical care to reduce the risk of massive blood loss, the addition of infectious complications. The temperature or signs of intoxication indicate a septic abortion.
Incomplete miscarriage is an incomplete process in which the fetus is separated, but the fetal membranes remain in the uterus. This disrupts uterine contractions, the vessels of the uterus gape, so there is a high probability of bleeding. Complications of this condition can be hemorrhagic shock, DIC syndrome, endometritis. Inflammation of the mucous membrane in the future becomes the cause of infertility resistant to treatment.
If characteristic complaints appear, it is necessary to contact an obstetrician-gynecologist for examination and diagnosis. After confirmation of the diagnosis, hospitalization may be required for treatment and dynamic observation. Examination of a pregnant woman includes:
- Examination on the chair. Physical examination shows that the cervix is tightly closed, but there may be a small amount of brown discharge in the vagina. Bimanual examination does not cause pain, the vaginal arches are free. On palpation, the uterus remains undisturbed, soft, but there is a slight soreness. The ovaries are not palpated.
- Laboratory diagnostics. It is necessary to assess the function of the ovaries and monitor pregnancy. Blood is taken for hCG, to confirm a progressive pregnancy, the analysis is carried out in dynamics with an interval of several days. Determine the level of progesterone. According to the indications, an analysis for estrogens can be prescribed.
- Ultrasound of the pelvis. The “gold standard” for the diagnosis of threatened miscarriage is ultrasound with a transvaginal sensor, the accuracy of the technique is higher than when examining transabdominal. According to ultrasound data, signs of fetal viability are determined. The fetal egg is visualized in the uterine cavity, the heartbeat is determined in the embryo or fetus. If the results are questionable, the study is repeated twice by different specialists with an interval of 7-10 days.
Treatment of threatened miscarriage
A pregnant woman with bleeding and the threat of miscarriage in a short period of time should be urgently hospitalized in the department of gynecology. She is assigned a therapeutic and protective regime, it is not recommended to get out of bed. In some institutions, lifting the foot end of the bed by 5 cm is practiced as an additional method of therapy. Medication preserving therapy is prescribed:
- Progesterone preparations. Didrogesterone or micronized progesterone is used. They are prescribed to maintain the function of the placenta according to an individual scheme. Women who have had interruptions in the past for a short period of time, drugs are prescribed preemptively until signs of a threat appear.
- Estrogens. They are included in the treatment regimen from the 6th week of gestation, if their deficiency is revealed according to the results of tests. They are necessary to improve the action of progesterone. The dosage is selected individually.
- Removal of uterine tone. Drotaverine and papaverine are allowed to be used to relieve pain and muscle spasm in pregnant women. They are prescribed intramuscularly, later they switch to tablet forms. A solution of magnesium sulfate has a pronounced tocolytic effect. It is used to reduce uterine tone, lower blood pressure and improve fetal nutrition.
- Hemostatic therapy. To stop bleeding, sodium ethamzylate is used in the form of a solution intramuscularly or intravenously. Aminocaproic and tranexamic acid are allowed for use.
Prognosis and prevention
With timely access to an obstetrician-gynecologist and proper treatment, the prognosis is favorable. The fetus can be preserved if the area of the detachment of the fetal egg is small, the bleeding has stopped, and the hematoma gradually resolves. For the remaining gestation period, the woman is under the careful supervision of a doctor in order to notice the deterioration in time and take measures to prevent complications. Prevention of threatening spontaneous abortion consists in pre-gravidar preparation, rehabilitation of foci of infection in the body. Women need to start taking folic acid and vitamin E 2 months before conception.