Abortion: how to make the right decision and other issues

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A miscarriage is always associated with serious consequences for a woman’s entire body and for her reproductive organs in particular; it also affects the family situation and disrupts a woman’s work schedule. An unfavorable pregnancy outcome requires great mental and physical costs on the part of parents. Therefore, turning to doctors to find out the causes of the problem is the very first and correct step on the path to having a child.

Any competent gynecologist will tell you that the problem of miscarriage can be solved. With proper preparation for pregnancy and its management, next time you will have a successful completion of pregnancy. Most girls after a miscarriage go to extremes: they try to get pregnant again as soon as possible. And if this succeeds, then the miscarriage very often recurs. But you need to give the body a rest for 2-3 months, then identify and eliminate the cause. And only then try.

Causes of miscarriage

Many are convinced that miscarriage occurs due to a fall, bruise or some other physical shock. Any woman who has had a miscarriage can remember that not long before she either fell or lifted something heavy. And I am sure that I lost my unborn child precisely because of this. However, those women whose pregnancy was normal also fall and lift heavy things. This is not why most sudden miscarriages occur. The reason is due to problems with pregnancy itself. About half of miscarriages occur due to abnormal genetic development of the fetus, which can be hereditary or accidental. Merciful nature, following in all respects the principles of natural selection, destroys an inferior and non-viable fetus. But there is no need to be afraid of this. The fact that one embryo has a defect does not mean that all the others will be the same.

In the other half of miscarriages, the woman's body is almost always to blame. They are caused by various known and unknown factors, such as: acute infectious diseases suffered in the first trimester of pregnancy, poor environment or difficult working conditions, excessive psychological or physical stress, abnormal development of the uterus, radiation, alcohol, smoking and certain types of drugs.

The causes of miscarriage in early and later stages may vary, although they may coincide. The most important thing is to find out and eliminate or compensate for your own cause of miscarriage. Having discovered the cause, the gynecologist will tell you how to avoid another loss.

Frozen pregnancy

Miscarriage statistics also include “frozen pregnancy.” Sometimes it happens that the embryo dies and is retained in the uterine cavity. Most often this fact is revealed by ultrasound. A dead fetus may begin to decompose, and this will thereby lead to poisoning of the mother’s body.

Doctors resort to surgical curettage, which is associated with the risk of inflammation and complications. With such a miscarriage, the next pregnancy is planned after the body has fully recovered - not earlier than a year. During this year, we will have to find out the cause of the frozen pregnancy and carry out treatment.

Miscarriage before 6 weeks

The main causes of miscarriage on this line are malformations of the embryo itself. Statistics say that 70-90% of embryos had chromosomal abnormalities: they are random and will not occur in other pregnancies. You may have been sick, taken medication, or been exposed to other harmful factors. Fate saved you from a child with developmental defects.

The human body is perfect and finds a way to correct the situation by miscarriage. Today is a tragedy for you. A real tragedy would be the preservation and birth of a sick, non-viable child. So don’t cry and understand: everything is for the best, tears won’t help your grief... And after three months, try again - it will almost certainly be successful.

It should also be noted that the fact of a miscarriage does not mean that you have lost something. So, at a period of 7-8 weeks, the absence of an embryo in the fertilized egg is detected - “anembryony”. It is believed that in 80-90% of cases, miscarriages are undiagnosed undeveloped pregnancies.

Why do women have abortions?

The content of the article

Every year, millions of couples experience unplanned pregnancies; every 4 out of 10 families decide to have an abortion. Medical abortions are also performed on patients when indicated for health or safety reasons. According to statistics, more than half of women have a history of at least one abortion by the age of 45.

Sometimes the solution is simple, sometimes it is difficult. But in any case, the decision to terminate a pregnancy is made by the woman herself. Surveys show that each patient has her own compelling reasons for an abortion:

• Fear of a negative reaction from children who already exist;
• Unpreparedness to be parents;
• This is not the right time in life to have a baby.
• The need to finish school, focus on work, or achieve other goals before having children.
• The partner does not want to be a father.
• Conception is the result of sexual violence.
• Pregnancy will affect your health.

Deciding to have an abortion does not mean you don't want or don't love children. In fact, 6 out of 10 people who terminate a pregnancy already have one. Many people just don’t want to have any more children in order to focus on raising the babies they’ve already born. Most women who have an induced abortion give birth later, when they feel they are in a better position to be a good mother.

Deciding if and when to have a child is a very personal one, and only you know what's best for you and your family.

Why can early miscarriage occur?

Here are the most common reasons, each of which significantly increases the risk of miscarriage:

• the presence of certain infectious diseases in the expectant mother, as well as STDs;
• intoxication of a woman’s body for various reasons, including due to her residence in an environmentally unfavorable region;
• all kinds of metabolic disorders in the body;
• hormonal imbalances, including those caused by disruption of the thyroid gland;
• various neoplasms in the uterus and other uterine, as well as cervical, pathologies;
• leading by the expectant mother a lifestyle that is far from healthy. May include drinking alcohol, smoking, taking psychotropic and narcotic drugs, as well as poor nutrition;
• obesity;
• disorders of the immune status;
• cardiac diseases;
• diabetes;
• the patient’s age being too early for pregnancy or, conversely, being too mature, greatly increases the risk of miscarriage;
• all kinds of pathologies of chromosomes and genes;
• prolonged exposure to stress or severe psycho-emotional trauma in a woman.

The timing of a miscarriage may depend, among other things, on whether the patient has a genetic predisposition to miscarriage. Finally, often its specific cause remains unclear.

Are you ready to become a mother? When is the decision to have an abortion justified?

Family, relationships, school, work, life goals, health, safety and personal beliefs are the minimum considerations people weigh before having an abortion.

Questions to ask yourself before going to the clinic:

• Are you ready to become a mother?
• Will your health allow you to have children after an abortion?
• What will change for the family with the arrival of the baby?
• How will the birth of a baby affect your career goals, income and future plans?
• How will personal or religious beliefs regarding abortion subsequently affect the psyche?
• Do you want to have an abortion yourself or is someone influencing your decision?
• Can abortion change your life in ways you don't want?
• What support will you need if you decide to have an abortion or keep your baby?

Decisions about your pregnancy are deeply personal. You have the right to live the way you want. And if you understand that you will not be able to raise and support your child, and no one will support you in this, then the decision can be considered justified. If abortion is just a whim, then such an act can be called immoral.

The woman's age and the risk of miscarriage

A woman's ability to reproduce directly depends on age. This is due to the depletion of the ovarian reserve and the “aging” of the eggs.

The number of oocytes is determined during embryonic development. Female reproductive cells are stored in the ovaries and are not renewed. Like other cells of the body, they are exposed to unfavorable factors (environment, radiation, bad habits, etc.), which negatively affects the quality of the genetic material. Genome mutations reduce the chances of a successful pregnancy and pregnancy that occurs naturally or was initiated through ART.

Early miscarriages after IVF occur more often in patients over 40 years of age who use their own reproductive cells. When donor material is used, spontaneous abortions occur much less frequently, which indicates the influence of egg quality on the success of an IVF program.

Given the risk of mutations, preimplantation genetic testing (PGT) is recommended for certain couples. It is advisable to do the test in the following situations:

• the woman’s age is over 35 years;
• the age of the biological father exceeds 39 years;
• high risk of hereditary chromosomal abnormalities;
• unfavorable reproductive history (miscarriages, fetal death);
• unsuccessful attempts at fertilization.

Preimplantation testing involves the study of the genetic material of an embryo before transplantation into the uterine cavity. Excluding chromosomal abnormalities increases the chances of a successful pregnancy.

Who can I talk to about this topic?

Many people shift the responsibility for a difficult decision onto someone else's shoulders. You can’t do this, but you can simply consult with people who understand and support you. Of course, these should not be girlfriends and other strangers. The maximum people you can trust are parents, spouse and doctors.

A good gynecologist will definitely tell you about the consequences of an abortion, taking into account your state of health and the timing of your pregnancy. He will help you look at the situation impartially, because he sees the same patients every day. The doctor will provide real facts and will not judge.

When asking for advice, you should understand that no one should force you to make any decision about terminating or continuing your pregnancy.

DYNAMIC OBSERVATIONS CAN DETERMINE INCREASED VALUES THAT APPLY TO THE EMBRYO

.

Next, you need to conduct a check that concerns vital signs. During the normal course of pregnancy, in embryos whose CRT is more than 8 millimeters, a heartbeat can be observed during a transvaginal ultrasound. Heart rate depends on the week of pregnancy. The fetal heart rate should be smooth. As a rule, the lowest heart rate is 110 +15 beats per minute (6th month), and the highest is 172 +14 beats per minute (immediately in the prenatal period).

In addition to cardiac parameters, at the eighth week it is already possible to register the movements of the embryo. Otherwise (in the absence of cardiac and motor activity), we can talk about abnormal development of pregnancy.

It must be remembered that a thorough diagnosis at all stages of pregnancy will help to identify in time and, possibly, solve problems related to the development of the child and pregnancy in general.

When should you decide to have an abortion?

Abortion is a procedure performed to remove a fertilized egg from the uterine cavity. The operation is performed before 21 weeks of pregnancy and is considered safest if performed in the early stages (up to 12 weeks).

When choosing an abortion, you must understand that every day your baby is developing and growing. The longer the period, the sadder, more dangerous and unpleasant this procedure is. Therefore, if the decision is made before 6 weeks, you can have a medical abortion at the embryonic stage. At a longer term, a vacuum or surgical abortion is performed and the doctor has to remove the grown fetus, which is already developing organs.

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Abortion methods

Gynecology offers three methods of abortion: medication, vacuum and surgery. Each of them has its own limitations, pros and cons.

Medical abortion

. Method of terminating pregnancy without surgery. The essence of medical abortion is taking a drug that blocks the production of the hormone progesterone, which is vital for the fetus. The result is dilation of the cervix, release of the fertilized egg. Medication interruption is available for up to 6-7 weeks.

• Advantages of the medicinal method
  : minimum negative consequences, no psychological trauma remains. Medical abortion is highly safe due to the absence of surgical intervention
• Disadvantages of the drug method
  : availability only in early pregnancy, possibility of side effects (nausea, vomiting, headache, diarrhea). Uterine bleeding (menstruation) persists for a long time, requiring careful monitoring. Menstrual function is restored after 1-3 months
• Possible problems when visiting a bad gynecological clinic: when using low-quality drugs (expired, non-original, substitutes, etc.). which is often practiced in “cheap” gynecologies, the consequences are unpredictable - from allergic reactions to hormonal imbalance.

Vacuum abortion.

It is also called a mini-abortion. The essence of the procedure is the introduction of a special apparatus into the uterine cavity to suck out the fertilized egg. Vacuum interruption is available for up to 8 weeks.

• Advantages of vacuum termination
  : shorter recovery period, lower risk of complications than with surgical termination of pregnancy.
• Disadvantages of the vacuum method
  : availability only in the early stages of pregnancy, there is a possibility of complications. The safety of removing the fertilized egg in this way is quite high, but there are times when pregnancy persists after surgery (0.5-1% of cases). Since during a mini-abortion the fertilized egg is separated from the mucous membrane, bleeding (menstruation) will normally appear on the 4-5th day. This is due to hormonal changes.
• Possible problems if performed poorly
  : bleeding, inflammation, infertility.

Surgical
abortion .
The most dangerous and most popular method of abortion, which is offered by any gynecological
clinic
. Its essence is dilation of the cervix with special instruments and curettage. Surgical abortion is performed under ultrasound control and anesthesia. The method is available up to 12 weeks.

• Advantages of surgical termination
  : availability in later stages of pregnancy.
• Disadvantages of surgical termination
  : the method is traumatic, the highest risk of complications.
• What can you expect from a bad gynecologist
  : cervical rupture, bleeding, infection, infertility.

For control after curettage, a repeat ultrasound is performed. Modern methods of surgical abortion allow it to be performed on an outpatient basis.

Habitual miscarriage

Why some pregnancies end in miscarriages, and what can be done to reduce the risks of miscarriage during a second pregnancy, says Nana Kartlosovna Tetruashvili - Doctor of Medical Sciences, Professor, Head of the Second Obstetric Department of Pregnancy Pathology of the National Medical Research Center for Obstetrics, Gynecology and Perinatology. Academician V.I. Kulakova.

*The article is published in abbreviation. The full version of the article is in the journal “Obstetrics and Gynecology: News, Opinions, Education” No. 4 2017.

In Russia, miscarriage refers to its interruption from conception to 37 completed weeks (less than 259 days from the last menstruation). Since 2012 in Russia this time interval has been divided into the following periods:

• up to 12 weeks of pregnancy - early miscarriages;
• from 12 to 22 weeks - late miscarriages;
• from 22 to 27 weeks - very early premature birth;
• from 28 weeks – premature birth.

According to the classification adopted by the World Health Organization (WHO), there are:

• spontaneous miscarriages - loss of pregnancy before 22 weeks;
• premature birth - from 22 to 37 completed weeks of pregnancy with a fetal weight of more than 500 g.

According to the WHO definition, a recurrent miscarriage is considered to be the presence in a woman’s history of three or more spontaneous abortions in a row within 22 weeks . Doctors consider it advisable to examine and, if necessary, treat a married couple if a woman has had two or more consecutive pregnancy losses from the same partner.

Accidental and habitual miscarriage

All miscarriages are divided into two large types - sporadic (accidental) and habitual. In case of an accidental miscarriage, the woman’s reproductive function is not subsequently impaired; the effect of damaging factors is temporary. The cause of a spontaneous miscarriage can be, for example, an error in the process of gamete formation, which leads to the occurrence of abnormalities of the egg and (or) sperm and, as a consequence, to the formation of a genetically defective, non-viable embryo. In most cases, this phenomenon is episodic in nature and does not lead to repeated pregnancy losses.

However, in the group of women who lost their first pregnancy, there is a category of patients (1–5%) who subsequently experience repeated abortions. The risk of pregnancy loss after the first miscarriage is 13–17%. After two previous spontaneous interruptions, the risk increases to 36–38%. In general, habitual miscarriage accounts for 5 to 20% of the total miscarriage rate.

The influence of maternal age on the risk of early spontaneous miscarriages has been established. Thus, in the age group of 20–29 years, the risk of spontaneous miscarriage is 10%, while in 45 years and older it is 50%. It is likely that maternal age is a factor contributing to an increase in the frequency of chromosomal abnormalities in the fetus.

Causes of recurrent miscarriage

In the structure of the causes of habitual pregnancy losses, the following factors are distinguished:

1. genetic,
2. anatomical,
3. endocrine
4. immunological,
5. infectious.

If all of the above reasons are excluded, a recurrent miscarriage is classified as idiopathic. Some experts believe that 80% of idiopathic miscarriages are caused by unrecognized immune disorders.

There is no convincing evidence that endometriosis can cause recurrent miscarriage, nor that drug or surgical treatment of endometriosis reduces the incidence of recurrent miscarriage.

Critical periods in the first trimester of pregnancy are 6-8 weeks (death of the embryo) and 10-12 weeks (expulsion of the ovum).

Prevention

Women who have had at least two miscarriages or premature births are recommended to be examined before the next pregnancy to establish the causes, correct disorders and prevent subsequent complications. Prevention methods depend on the reasons underlying recurrent miscarriage (we will discuss them in more detail below). Timely determination of the cause of recurrent miscarriages and correct treatment tactics can prevent early fetal loss and maintain pregnancy.

A general measure of preconceptional preparation for patients with recurrent miscarriage can be considered taking folic acid 2–3 menstrual cycles before conception and in the first 12 weeks of pregnancy in a daily dose of 400–800 mcg. If a woman has a history of fetal neural tube defects during previous pregnancies, the dose should be increased to 4 mg/day. The optimal daily intake of folic acid should be considered 400–800 mcg. The protective effect of folic acid is most fully realized in combination with other vitamins involved in folate metabolism, in particular vitamins B6, B12, PP.

1. Genetic causes of recurrent miscarriage

Genetic factors in the structure of the causes of recurrent miscarriage account for 3-6%.

Diagnostics

Anamnesis

• Hereditary diseases in family members.
• The presence of congenital anomalies in the family.
• Birth of children with mental retardation.
• The presence of infertility and (or) miscarriage of unknown origin in a married couple and relatives.
• Presence of unclear cases of perinatal death.

Special research methods

• Study of the karyotype of the parents (especially indicated for married couples at the birth of a child with developmental defects in the presence of a history of miscarriage, as well as in cases of recurrent miscarriage in the early stages).
• Cytogenetic analysis of abortion (in cases of stillbirth or neonatal death).

Indications for consultation with other specialists

If changes in the karyotype are detected in parents, a consultation with a geneticist is necessary to assess the degree of risk of having a child with pathology or, if necessary, to decide on egg or sperm donation.

Further management

If at least one of the spouses has a pathological karyotype, due to the high risk of developmental disorders in the fetus, it is recommended to carry out prenatal diagnosis during pregnancy - chorionic villus biopsy or amniocentesis.

2. Anatomical causes of recurrent miscarriage

The anatomical causes of recurrent miscarriage include the following:

• congenital anomalies of the uterus:

- complete doubling of the uterus;

- two-horned, saddle-shaped, one-horned uterus;

- partial or complete intrauterine septum;

• acquired anatomical defects;
• intrauterine synechiae (Asherman's syndrome);
• submucous uterine fibroids;
• isthmic-cervical insufficiency.

The frequency of anatomical abnormalities in patients with recurrent miscarriage ranges from 10–16%.

Diagnostics

Anamnesis

With anatomical pathology of the uterus, late terminations of pregnancy and premature birth are more often observed, however, with implantation on the intrauterine septum or near the myomatous node, early terminations of pregnancy are also possible.

For isthmic-cervical insufficiency, spontaneous abortion in the second trimester or early premature birth, which occurs relatively quickly and with little pain, is more often noted.

To diagnose uterine malformations, information about the pathology of the urinary tract (often accompanying congenital anomalies of the uterus) and the peculiarities of the formation of menstrual function (for example, indications of a hematometer with a functioning rudimentary uterine horn) can help.

Special research methods

Hysteroscopy has become widespread in recent years and has become the gold standard for diagnosing intrauterine pathology. With hysteroscopy, you can examine the uterine cavity, determine the nature of the intrauterine pathology and, if you have the necessary equipment (resectoscope), perform low-traumatic surgical treatment - removal of synechiae, submucosal fibroid node, endometrial polyp.

Ultrasound examination (ultrasound) is performed in the first phase of the menstrual cycle for the presumptive diagnosis of submucous uterine fibroids, intrauterine synechiae, endometrial pathology, and in the second phase of the cycle - to identify the intrauterine septum, synechiae and bicornuate uterus.

To make a diagnosis, hysterosalpingography is performed, which allows one to study the shape of the uterine cavity, identify the presence of submucous nodes of fibroids, synechiae, septum, and also determine the patency of the fallopian tubes. It is carried out in the first phase of the menstrual cycle after the cessation of bleeding (7–9 days of the cycle).

Before performing hysterosalpingography, it is necessary to exclude inflammatory diseases of the pelvic organs or treat them.

In some difficult cases, magnetic resonance imaging (MRI) of the pelvic organs is used to verify the diagnosis. An MRI is important in the presence of a rudimentary uterine horn to decide whether it is advisable to remove it.

Termination of pregnancy due to anatomical abnormalities of the uterus may be associated with unsuccessful implantation of the fertilized egg (on the intrauterine septum, near the submucous node of fibroids), insufficient vascularization and reception of the endometrium, close spatial relationships in the uterine cavity (for example, with deformation of the cavity by a fibroid node), often accompanied by isthmic -cervical insufficiency and hormonal disorders.

Treatment

Surgery

In the presence of an intrauterine septum, submucous nodes of fibroids and synechiae, surgical treatment by hysteroresectoscopy is most effective. The frequency of subsequent miscarriages in this group of women after treatment is 10% (before surgery 90%).

Surgical removal of the intrauterine septum, synechiae, and submucous nodes of fibroids leads to the elimination of miscarriage in 70–80% of cases. However, it is ineffective in women with uterine malformations who have a history of normal births followed by repeated miscarriages. Probably, in such cases, the anatomical factor is not decisive, and it is necessary to look for other causes of miscarriage.

Drug treatment

Evidence of the effectiveness of introducing a spiral, high doses of estrogen drugs, a Foley catheter into the uterine cavity after operations to remove synechiae, and the intrauterine septum has not been obtained.

It is recommended to plan pregnancy no earlier than 3 months after the operation. To improve endometrial growth, cyclic hormonal therapy is carried out over 3 menstrual cycles.

Isthmic-cervical insufficiency

The anatomical causes of recurrent miscarriage also include isthmic-cervical insufficiency, which is recognized as the most common factor in late miscarriages and early premature births.

The incidence of isthmic-cervical insufficiency in patients with recurrent miscarriage is 13–20%.

Risk factors

• History of cervical trauma (post-traumatic isthmic-cervical insufficiency):
• damage to the cervix during childbirth (lacerations not repaired surgically; surgical delivery through the natural birth canal - obstetric forceps, delivery of a large fetus, a fetus in the breech presentation, fetal-destroying operations, etc.);
• invasive methods of treating cervical pathology (conization, amputation of the cervix);
• induced abortions, late pregnancy terminations.
• Congenital anomalies of the uterus.
• Functional disorders - connective tissue dysplasia, increased levels of relaxin in the blood serum (noted in multiple pregnancies, ovulation induction by gonadotropins).
• Increased load on the cervix during pregnancy - multiple births, polyhydramnios, large fetus.
• Anamnestic indications of low-painful rapid termination of pregnancy in the second trimester or early premature birth.

Outside of pregnancy, methods for assessing the condition of the cervix, as a rule, do not provide complete information about the likelihood of developing isthmic-cervical insufficiency during pregnancy. Such an assessment is possible only in case of post-traumatic isthmic-cervical insufficiency, accompanied by gross violations of the anatomical structure of the cervix.

Preparing for pregnancy in patients with recurrent miscarriage and isthmic-cervical insufficiency should begin with the treatment of chronic endometritis and normalization of the vaginal microflora.

Due to the fact that the obturator function of the cervix is ​​impaired, the uterine cavity becomes infected with opportunistic flora and (or) other microorganisms. An individual selection of antibacterial drugs is carried out, followed by an assessment of the effectiveness of treatment based on the results of bacteriological examination, PCR, and microscopy of vaginal discharge.

In high-risk patients (suffering from recurrent miscarriage in the second trimester), monitoring of the condition of the cervix is ​​necessary from the 12th week of pregnancy if post-traumatic isthmic-cervical insufficiency is suspected, from the 16th week - if functional isthmic-cervical insufficiency is suspected from at least 2 -weekly intervals, if necessary - weekly. Monitoring includes speculum examination of the cervix and transvaginal cervicometry (ultrasound assessment of the length of the cervix and the condition of the internal os).

Clinical manifestations of isthmic-cervical insufficiency:

• feeling of pressure, fullness, stabbing pain in the vagina;
• discomfort in the lower abdomen and lower back;
• mucous discharge from the vagina, may be streaked with blood;
• scanty bleeding from the vagina.

It must be remembered that isthmic-cervical insufficiency can be asymptomatic.

Diagnostics

Ultrasound with a transvaginal probe, including stress tests (pressure test on the fundus of the uterus, cough test, position test when the patient stands up).

Measuring the length of the cervix using ultrasound data allows us to identify a group at increased risk of developing preterm birth.

At a period of 24–28 weeks, the average length of the cervix is ​​45–35 mm, at a period of 32 weeks or more – 35–30 mm. Shortening of the cervix to 25 mm or less at 20–30 weeks is a risk factor for preterm birth.

Treatment

Suturing the cervix in women with isthmic-cervical insufficiency reduces the incidence of preterm birth until the 33rd week of pregnancy. At the same time, such patients require tocolytic drugs, hospitalization, and antibacterial therapy, unlike patients who were prescribed only bed rest.

For surgical correction of isthmic-cervical insufficiency, the following conditions are necessary:

• a living fetus without developmental defects;
• gestational age no more than 25 weeks;
• whole amniotic sac;
• normal uterine tone;
• no signs of chorioamnionitis;
• absence of vulvovaginitis;
• absence of bloody discharge from the genital tract.

Sutures from the cervix are removed at 37 weeks of pregnancy or at any time during leakage or rupture of amniotic fluid, bleeding from the uterine cavity, cutting of sutures (formation of a fistula), and the beginning of regular labor.

Also in recent years, convincing evidence has been obtained of the effectiveness of vaginal progesterone at a dose of 200 mg for the prevention of preterm birth in a high-risk group (women with asymptomatic shortening of the cervix less than 25 mm, as well as a history of preterm birth). Vaginal administration of micronized progesterone in these cases can reduce the risk of premature birth by 42%.

3. Endocrine causes of recurrent miscarriage

According to various authors, endocrine causes of miscarriage range from 8 to 20%. The most significant of them are luteal phase deficiency, hypersecretion of luteinizing hormone, thyroid dysfunction, and diabetes mellitus.

Severe thyroid disease or diabetes can lead to repeated miscarriages. However, with compensated diabetes mellitus, the risk of recurrent miscarriages does not differ from that in the general population.

Diagnostics

History data that you need to pay attention to:

• later menarche;
• irregular menstrual cycle (oligomenorrhea,
• amenorrhea);
• sudden increase in body weight;
• weight loss;
• infertility;
• habitual early miscarriages.

The examination allows us to identify body features, height, body weight, the presence of hirsutism, the severity of secondary sexual characteristics, and the presence of stretch marks; When examining the mammary glands, galactorrhea may be detected.

Special research methods

Hormonal research:

• in the 1st phase of the menstrual cycle (7–8th day), the content of follicle-stimulating hormone, luteinizing hormone, prolactin, thyroid-stimulating hormone, testosterone is determined,

17-hydroxyprogesterone, dehydroepiandrosterone sulfate;

• in the 2nd phase of the menstrual cycle (21–22 days), progesterone levels are determined (normative levels of progesterone are very variable, the method cannot be used without taking into account other factors).

Ultrasound:

• in the 1st phase of the menstrual cycle (7–8th day) – diagnosis of endometrial pathology, polycystic ovaries;
• in the 2nd phase of the menstrual cycle (20–21 days) - measurement of endometrial thickness (normally 10-11 mm, correlates with progesterone content).

The “gold standard” for diagnosing luteal phase deficiency is a histological examination of material obtained from endometrial biopsy in the 2nd phase of the cycle during 2 menstrual cycles. An endometrial biopsy to verify luteal phase deficiency is performed 2 days before the expected menstruation (on the 26th day of a 28-day cycle). This method is used in cases where the diagnosis is unclear. To study changes in the endometrium during the so-called “implantation window” period, a biopsy is performed on the 6th day after ovulation.

When luteal phase deficiency is combined with hyperprolactinemia, an MRI of the brain is performed. An alternative method is radiography of the skull (area of ​​the sella turcica).

Polycystic ovary syndrome

If you have polycystic ovary syndrome, the risk of spontaneous abortion is 40%.

To make a diagnosis of polycystic ovary syndrome, the so-called Rotterdam diagnostic criteria adopted in 2003 are used:

• anovulation or oligoovulation;
• clinical and (or) laboratory signs of hyperandrogenism (hirsutism, acne, virilization, increased serum androgen levels);
• polycystic ovaries according to ultrasound (>11 follicles with a diameter of 2 to 9 mm in each ovary).

Only 2 of the 3 criteria listed above are necessary to make a diagnosis.

Laboratory tests needed to make a diagnosis of polycystic ovary syndrome include hormonal testing, glucose tolerance testing, and fasting glucose levels.

Treatment of patients with polycystic ovary syndrome includes non-drug treatment - weight loss (diet therapy, physical activity), as well as drug treatment as preparation for pregnancy.

Pubertal and postpubertal adrenogenital syndrome

Adrenogenital syndrome is a hereditary disease associated with a violation of the synthesis of hormones of the adrenal cortex due to damage to the genes responsible for the synthesis of a number of enzyme systems. The disease has an autosomal recessive type of inheritance with the transmission of mutant genes from both parents, who are healthy carriers.

In 90% of cases, adrenogenital syndrome is caused by mutations in the CYP21B gene, leading to impaired synthesis of 21-hydroxylase.

Diagnostics

Hormonal study: high levels of 17-hydroxyprogesterone, dehydroepiandrosterone sulfate.

1. Immunological causes of recurrent miscarriage

About 80% of all previously unexplained cases of repeated pregnancy losses (after excluding genetic, anatomical, hormonal causes) are associated with immune disorders.

There are autoimmune and alloimmune disorders that lead to recurrent miscarriage. In autoimmune disorders, the target of the immune system is the mother's own tissues, i.e. the immune response is directed against its own antigens. In this situation, the fetus suffers secondarily as a result of damage to maternal tissue.

In alloimmune disorders, the woman's immune response is directed against embryonic/fetal antigens received from the father and therefore potentially foreign to the mother's body.

Autoimmune disorders that are most common in patients with recurrent miscarriage include the presence of antiphospholipid, antithyroid, and antinuclear autoantibodies in the serum. It has been established that 31% of women with recurrent miscarriage outside pregnancy have autoantibodies to thyroglobulin and thyroid peroxidase.

Antiphospholipid syndrome

It is now generally accepted that an autoimmune condition such as antiphospholipid syndrome leads to the death of the embryo/fetus.

Among patients with recurrent miscarriage, antiphospholipid syndrome is 27–42%, according to other researchers – 30–35%, and without treatment, embryo/fetal death is observed in 85–90% of women who have autoantibodies to phospholipids.

The importance of therapy for antiphospholipid syndrome lies in the fact that thrombosis becomes the main complication of the disease. The risk of thrombotic complications increases during pregnancy and the postpartum period, as there is a physiological increase in the coagulation potential of the blood.

Clinical criteria for antiphospholipid syndrome:

• vascular thrombosis: one or more clinical episodes of venous, arterial thrombosis or thrombosis of small vessels of any location, confirmed by Doppler measurements or histological examination, and during histological examination, thrombosis should not be accompanied by signs of inflammation of the vascular wall (vasculitis);
• pathology of pregnancy:
• at least one unexplained antenatal death of a morphologically normal fetus (confirmed by ultrasound or pathological examination) at more than 10 weeks of gestation;
• at least one premature birth with a morphologically normal fetus before 34 weeks of pregnancy due to severe preeclampsia or severe placental insufficiency;
• at least three unexplained spontaneous miscarriages before the 10th week of pregnancy after excluding anatomical abnormalities, hormonal disorders in the mother, or chromosomal pathology
• parents.

Laboratory criteria for antiphospholipid syndrome:

• detection in the blood of anticardiolipin immunoglobulins of class G (IgG) and (or) immunoglobulins of class M (IgM) in medium or high titer (increase at least twofold) with an interval of 12 weeks using a standardized enzyme-linked immunosorbent assay method to measure 2-glycoprotein-dependent antibodies to cardiolipin;
• determination of lupus anticoagulant in plasma (increase at least twofold) with an interval of at least 12 weeks using methods according to the recommendations of the International Society of Thrombosis and Hemostasis, including the following steps:
• establishing the fact of prolongation of the phospholipid-dependent phase of blood coagulation based on the results of screening tests, such as activated partial thromboplastin time (APTT), kaolin time, Russell test with dilution, prothrombin time with dilution;
• inability to correct for prolonged screening test times by mixing with normal platelet-free plasma;
• shortening the time of screening tests or its normalization after adding excess phospholipids to the test plasma and excluding other coagulopathies, for example the presence of a factor VIII inhibitor or heparin;
• determination of autoantibodies to β2-glycoprotein twice with an interval of 12 weeks.

The diagnosis of antiphospholipid syndrome is reliable if at least one clinical and one laboratory criterion is present.

Therapy is selected individually depending on the activity of the autoimmune process; it includes antiplatelet agents, anticoagulants, and, if necessary, therapeutic plasmapheresis outside pregnancy.

In case of thrombosis during pregnancy and in the postpartum period, together with vascular surgeons, they decide on the need for surgical treatment, including the installation of a vena cava filter to prevent pulmonary embolism.

Patient education

If the patient is diagnosed with antiphospholipid syndrome, she must be informed about the need for treatment during pregnancy and monitoring of the condition of the fetus. If signs of venous thrombosis of the vessels of the legs appear - redness, swelling, pain along the veins - you should urgently consult a doctor.

Patients with antiphospholipid syndrome with vascular thrombosis require hemostasis control and observation by a vascular surgeon, rheumatologist, and after pregnancy.

Alloimmune disorders and genetically determined thrombophilias can also lead to pregnancy losses.

1. Infectious causes of recurrent miscarriage

The role of an infectious factor as a cause of recurrent miscarriage is currently widely debated. It is known that with primary infection in the early stages of pregnancy, damage to the embryo incompatible with life is possible, which leads to sporadic spontaneous miscarriage.

However, the likelihood of reactivation of the infection at the same time, resulting in repeated pregnancy losses, is negligible.

Bacterial-viral colonization of the endometrium, as a rule, is a consequence of the inability of the immune system and nonspecific defenses of the body to completely eliminate the infectious agent and limit its spread. In this regard, before pregnancy in women with recurrent miscarriage, it is necessary to exclude the diagnosis of chronic endometritis.

Treatment of threatened miscarriage in patients with recurrent miscarriage

In the early stages of pregnancy, if nagging, aching pain in the lower abdomen and lower back, sanguineous or bloody discharge from the genital tract occurs in women with recurrent miscarriage, along with pathogenetic therapy, it is necessary to carry out treatment aimed at normalizing the tone of the uterus. Until the 12th week of pregnancy, treatment includes the following:

• semi-bed rest;
• physical and sexual rest;
• antispasmodics intramuscularly or rectally;
• magnesium citrate preparation.

The duration of treatment is determined individually depending on the symptoms of threatened miscarriage.

In the presence of partial detachment of the chorion or placenta (before the 20th week of pregnancy), hemostatic therapy is carried out along with antispasmodic therapy.

Forecast

According to the 2nd obstetric department of pregnancy pathology (miscarriage) of the Federal State Budgetary Institution National Medical Research Center for Obstetrics, Gynecology and Perinatology named after. acad. IN AND. Kulakov" of the Ministry of Health of Russia, when identifying the cause, correcting disorders outside of pregnancy, and monitoring during pregnancy, the birth of viable children in couples with recurrent miscarriage reaches 95–97%. According to world literature, positive results are about 70%.

*article was prepared with the support of the Presidential Grants Foundation

31.01.2020

Preparing for an abortion

Before termination of pregnancy, a gynecological examination is performed. Pre-manipulation diagnostics includes:

• consultation and examination by a gynecologist with a smear;
• general blood test according to indications;
• coagulogram according to indications;
• fluorography according to indications;
• ECG according to indications;
• blood tests for HIV and syphilis.

If there are no contraindications for abortion, then the woman is offered a suitable method of terminating the pregnancy. The gynecologist explains in detail all the nuances of the intervention and, if necessary, prescribes additional consultations with doctors and tests.

Planning a new pregnancy

The next stage of treatment is planned together with a fertility specialist. It is important to determine the cause of the miscarriage. For this purpose, complex diagnostics is used with the following measures:

• study of a woman’s hormonal status;
• immunological testing;
• cytogenetic analysis of abortion;
• analysis for antiphospholipid syndrome.

Both spouses are recommended to consult a therapist, geneticist, endocrinologist, hematologist, and reproductive specialist. A man may need the help of an andrologist. Also, future parents should use the services of a psychologist.

The specifics of repeat IVF depend on the examination results. At the stage of preparation for fertilization, the following activities can be carried out:

• treatment of each spouse for identified diseases;
• hormone therapy;
• immunotherapy;
• physiotherapy;
• treatment of infectious diseases;
• vitamin therapy;
• specific prevention of infections;
• lifestyle correction;
• eliminating bad habits;
• normalization of work and rest regimes (up to changes in professional activities).

The timing of a new IVF is determined individually. The period of rehabilitation after a miscarriage and preparation for a new pregnancy can last more than 3 months, but usually does not exceed six months.

Recovery period

After any type of abortion, the woman is under the supervision of a gynecologist to avoid complications. If necessary, the doctor prescribes drug therapy, laser, etc., and the woman goes home. A follow-up appointment with a gynecologist should occur a week after the procedure.

After a vacuum abortion, a long rehabilitation period will be required. The doctor prescribes antibacterial and, if necessary, antispasmodic agents. Physical activity, visiting saunas and swimming pools, and taking a bath are not recommended. You should not resume sexual intercourse for 3 weeks, and then you need to protect yourself with a condom for a month. After 2-3 weeks, you should definitely go to the treating gynecologist for a post-vacuum examination, undergo the necessary tests and ultrasound.

After a surgical abortion, you will also need to follow all of the above measures. After the operation, the woman is prescribed medications to help avoid infection and normalize menstrual function.

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.

Abortion: how and where to have the operation without complications in St. Petersburg

Unfortunately, many women consider this procedure to be almost ordinary and make the decision to have an abortion without thinking about the possible consequences. But this is an operation that is unsafe for health. The decision to have an abortion must be made by the woman consciously, since there is no absolutely safe method. The price of artificial termination of pregnancy, if performed poorly, will be infertility.

If abortion is the only possible solution, the choice of a gynecologist is very important. Terminating a pregnancy in a gynecological private clinic will reduce the risk significantly. It is better to pay the cost of services from a reliable medical center with a good gynecology department than to face the impossibility of conceiving in the future.

INFECTIOUS DISEASES OF THE MOTHER

Each of us has encountered some kind of infectious disease, and, as usual, we are all accustomed to taking it for granted. But in the case of pregnancy, this matter must be approached completely differently, because spontaneous termination of pregnancy can occur not only from infection, but also from its complications.

Acute viral diseases such as herpes, rubella, inflammation of the parotid gland, chicken pox, cytomegalovirus and others can lead to miscarriage, the birth of a stillborn or defective (in the physiological sense, with defects) child. The virus penetrates the fetus through the placenta, causing damage to it. In addition to this specific route of transmission of infection, there is a possibility of infection of the child even during conception through sperm. In this case, spontaneous termination of pregnancy occurs in the initial stages of gestation. It is equally important to pay attention to infectious diseases on a chronic basis - we are talking about problems with the kidneys (chronic pyelonephritis), tonsillitis, etc., as well as infectious diseases that can pass in a latent state, for example, toxoplasmosis.

Quite often you can encounter colpitis (up to 65%) in women of reproductive age, as a result of which the vaginal mucosa becomes inflamed. The cause of colpitis can be urogenital diseases - chlamydia (15-20%), candidiasis (especially often manifested after taking antibiotics, about 15%), mycoplasmosis (25%), cytomegaly. All of the above infections can lead to pregnancy.

Inflammation of the inner mucous membrane of the uterus, in which light discharge occurs, is called chronic endometritis, which also has an extremely negative effect on pregnancy.

Abortion: how to choose a clinic?

Signs of taking patients seriously:

• Before the abortion, the doctor will suggest you undergo an ultrasound examination. The choice of method is based on diagnostic results showing the gestational age and location of the embryo.
• The gynecologist explains the essence of the procedure, talks about the drugs and possible consequences.
• The cost of an abortion should not be too high or too low.

Price _

unprofessional termination of pregnancy - complications dangerous to health!

Doctors at the Diana Medical Center in St. Petersburg will provide qualified medical care and support at any time, no matter what decision you make. If you care about your health and want to quickly and efficiently terminate your pregnancy, then our specialists will help you. You can make an appointment by phone or on our website.

ANATOMICAL FACTORS OF MISTARRIAGE

The most common cause of spontaneous abortion in the second trimester is isthmic-cervical insufficiency (ICI). This disease is characterized by a pathological condition of the cervix and isthmic part of the uterus, in which their muscles are no longer able to hold the fetus in the correct position. The incidence of miscarriages with ICI is about 40%.

The cervix consists of smooth muscle (about 15%) and connective tissue (the main part). As you approach the superior os, the connective tissue is replaced more by muscles that function similarly to the principle of the sphincter. Disruption in the development of the uterus is a very serious problem, especially if we are talking about pregnancy, because 15% of cases with this diagnosis end in miscarriage. Inadequate functioning of the ovaries, anatomical pathologies of the uterus, isthmic-cervical insufficiency - all this leads to a violation of the ability to reproduce. Depending on the duration of pregnancy, it is possible to determine the criterion that turned out to be destructive for the process of embryogenesis.

If we talk about the anatomical features of the female genital organs, which lead to spontaneous abortion, then one of these reasons may be a uterus with different degrees of bicornuity - saddle-shaped, complete or incomplete intrauterine septum, as well as an intrauterine septum.

Uterine defects can be associated with a decrease in ovarian functionality, resulting in disruption of the process of attachment (implantation) of a fertilized egg to the wall of the uterus, as a result of which decidualization itself is disrupted.

Recently, cases of benign tumors of the uterus in adult women, which are called uterine fibroids, have become more frequent. The percentage of cases of spontaneous interruption of variability with this diagnosis is approximately six. This indicator varies depending on the location and size of the tumor. Indeed, the risk of miscarriage seriously increases if in the lower half of the uterus the placenta is adjacent to fibroid nodes.

When will IVF help?

Unlike the first, repeated IVF is often more effective, since the individual mechanism of pregnancy disorders is clarified and appropriate adjustments are made. Advance preparation and careful monitoring of embryo development make it possible to prevent or promptly stop factors unfavorable for a new pregnancy. To increase your chances of success, you should:

• trust the doctor and follow his instructions exactly;
• take care of a favorable psycho-emotional background;
• Seek help at the first warning sign.

The effectiveness of IVF to a certain extent depends on the specialists who run the program. The support of experienced doctors will help on the path to happy parenting. An important factor is technological equipment and the possibility of using advanced reproductive technologies. Reproductive employs highly qualified specialists. The clinic has modern equipment that allows it to conduct tests aimed at diagnosing rare disorders.