Pregnancy Threatened Miscarriage ICD 10. SNMP Handbook: Abortion

A miscarriage is a true tragedy for women who dream of experiencing the joy of motherhood. Of course, the pathological process has its own etiology, but the result is the same - getting rid of the fetus from the body.

Most often, such a diagnosis occurs in the first trimester of pregnancy, and is reflected not so much in the physical health of the failed mother, but in her emotional background. In order to protect your own body from an extremely undesirable termination of pregnancy, it is necessary to understand in detail why there is a threat of miscarriage in the early stages, how to deal with this pathological condition.

According to statistics, in 20% of all clinical pictures in obstetrics there is a threat of abortion, that is, doctors do not exclude spontaneous miscarriage in the early stages. The phenomenon is really unpleasant, moreover, it makes the expectant mother pretty panic and nervous. And, nevertheless, most often the pathology occurs when a woman is unaware of her "interesting position", that is, for up to 12 obstetric weeks.

As you know, the process of bearing a fetus is complex and lengthy, it requires the participation of all internal organs and systems of the female body. With dysfunction of one of them, an unexpected termination of pregnancy is not excluded, that is, the inability of a woman to bear a fetus.

It is necessary to discuss in more detail the following pathogenic factors that lead to unexpected abortion at the beginning of the first trimester. This:

1. Hormonal imbalance in the female body. If testosterone predominates, and in a capacious concentration, then a miscarriage becomes a consequence of its increased activity. It is determined even during the planning period of the child, therefore it is desirable to restore the disturbed hormonal balance before conception.
2. Pathogenic infections. If an infection that is transmitted through sexual contact predominates in the body of sexual partners, then there is a high probability of infection of the fetus already in early pregnancy. As a result, the embryo dies at 5-7 obstetric weeks, therefore, when planning a pregnancy, the diagnosis of both partners is so important, and treatment as needed.
3. genetic factor. If the chromosomal sequence is disturbed in the body of the future baby, or the activity of the mutating gene increases, then the fetus is considered unviable, a miscarriage occurs.
4. . Quite often, signs of miscarriage in early pregnancy progress for this very reason. This is explained simply: if the mother has a positive Rh factor, and the father has a negative one, then the baby can adopt it from his father. It turns out that the positive antibodies of the mother enter into the so-called "conflict" with the negative antibodies of the conflict, as a result, a miscarriage may occur (usually in 80% of such clinical pictures).
5. Infectious diseases and acute inflammatory processes, accompanied by an increase, often cause miscarriage at the very beginning of pregnancy. The symptoms of the disease are the result of general intoxication of the body, therefore, a weakened resource is not able to hold the embryo, spontaneous miscarriage occurs.

However, these are far from all the factors that lead to premature termination of pregnancy. This outcome is often the result of the patient's wrong lifestyle, in particular:

• transferred abortions;
• unauthorized use of medicines;
• stress;
• chronic sleep deprivation;
• increased physical activity;
• malnutrition;
• bad ecology;

That is why every woman striving for motherhood should be vigilant about the period of family planning in order to avoid the activity of such pathogenic factors already in an “interesting position”.

If the doctor states the fact that there is a threat of termination of pregnancy, treatment should follow immediately, and it is highly likely that the woman will be sent to the hospital to maintain the pregnancy.

Important! Regardless of the reasons that caused the threat of termination of pregnancy, it is necessary to undergo a course of treatment and follow all the doctor's recommendations in the future.

Symptoms of pathology

Only a doctor can confirm or refute the threat of miscarriage by examining the patient. But a pregnant woman can guess about her abnormal condition even at home.

What could make her so upset?

• bloody discharge from the vagina of varying intensity, profusion;
• violation of the temperature regime, fever;
• drawing pains in the lower abdomen;
• confusion, fainting.

The symptoms of a threatened miscarriage are quite eloquent and cannot be ignored.

Symptoms eloquently indicate that a woman should pay attention to her health, go to the preservation in a timely manner and undergo a full course of treatment prescribed by qualified specialists strictly according to indications.

As a rule, such alarming signs appear unexpectedly, and the woman can no longer do anything to prevent this pathological phenomenon. But, if she is more attentive to her body, she will save the life of the baby in case of a miscarriage. For example, it is necessary to consult a doctor if there are pulling sensations in the lower abdomen, or brown discharge from the vagina of a thick consistency. A similar problem occurs with increased uterine tone.

As a rule, the decision begins with an unscheduled ultrasound, which allows you to characterize the pathology with the utmost accuracy and suggest the causes of its occurrence in the female body.

Delay in this matter can cost the child's life, and the health of the future mother will be aggravated. That is why, at the first signs of a threatened abortion, you should immediately contact a leading gynecologist, without waiting for a routine examination.

If the threat of a miscarriage nevertheless led to an unpleasant outcome, then the failed mother is obliged to receive all medical reports, certificates and other documents in which the diagnosis, causes and consequences are recorded. This is necessary in order to take into account all the negative aspects at the onset of the next pregnancy and take measures to prevent miscarriage.

Such records may contain some code or cipher. In this way, diagnoses are coded in accordance with ICD-10 - the International Classification of Diseases of the 10th revision. And a woman should know that the threat of miscarriage also has its own code according to ICD-10 and you should not be afraid of these numbers, you just need to check with the doctor what exactly they mean.

Diagnostics

Depending on the specific situation and the deviations in the state of health identified at the first stage of the survey, a wider range of studies may be prescribed.

If the menses come with a delay, are accompanied by acute pain and blood clots from the vagina, then most likely there was a spontaneous miscarriage. Doctors in such clinical pictures often say that the fetal egg simply did not take root (did not attach) in the female body.

If a blood clot is found, a woman should urgently contact her gynecologist and reliably find out if additional cleaning is required.

Important! Also, a control ultrasound of the pelvic organs will not be superfluous!

If a doctor diagnoses a miscarriage in the early stages, how does the pathological process occur in the female body? As a rule, a woman is unaware of her "interesting situation", waiting for the arrival of monthly menstruation. In some situations, she never finds out about the miscarriage, since moderate pain in the lower abdomen and heavy bleeding are symptoms of menstruation.

As a rule, the symptoms of a miscarriage in early pregnancy are not clear, and are very similar to the signs of PMS. However, every woman should monitor the volume of blood loss, in which case, immediately respond to heavy bleeding. Doctors in such situations resort to drug therapy, which provides a stable effect immediately after the start of the intake.

Before pregnancy

The risk of a threatened abortion can be reduced to a minimum even at the planning stage if you pass the necessary examinations:

• visit a gynecologist;
• take smears for flora and infections;
• sexually transmitted;
• do an ultrasound.

Laboratory studies will also be required:

• general analysis of blood and urine;
• blood chemistry;
• blood test for HIV;
• syphilis;
• hepatitis B and C;
• rubella;
• toxoplasmosis;
• cytomegalovirus.

If the doctor deems it necessary, the hormonal background, the blood coagulation system and immunity are also examined.

Important! If you have already encountered the problem of miscarriage and suffered a spontaneous miscarriage or a non-developing pregnancy, then in addition to the above examinations, genetic counseling is mandatory (it must be completed together with your spouse).

During pregnancy

If symptoms of a threatened miscarriage occur during pregnancy, in addition to mandatory examinations for any pregnancy, a blood test for hormones, antibodies to phospholipids is prescribed - this analysis allows you to determine if there is a so-called antiphospholipid syndrome - a condition in which the mother's immune system rejects the fetus.

All pregnant women must undergo the so-called prenatal screening - a blood test that allows you to indirectly judge the presence of a genetic pathology in the fetus. If abnormalities in prenatal screening are detected, amnio- or cordocentesis may be recommended - studies in which the anterior abdominal wall, uterine wall are pierced and amniotic fluid (during amniocentesis) or umbilical cord blood (during cordocentesis) is taken.

Inspection of the cervix allows to exclude the formation of isthmic-cervical insufficiency. Ultrasound examination provides information about the presence of uterine tone, the condition of the cervix, possible detachment of the fetal egg or placenta, and also allows you to assess the condition of the fetus.

With the development of a threatened abortion, cardiotocography is widely used - a study that gives an idea of ​​uterine contractions and the condition of the fetus. Tokography is used to monitor the effectiveness of treatment.

Unfortunately, even with a thorough examination, it is not always possible to identify the cause of miscarriage, but it is necessary to try to do this, otherwise the situation may repeat itself.

Treatment

For treatment with the threat of miscarriage, antispasmodic drugs, as well as hormonal drugs, can be prescribed.

A pregnant woman should carefully listen to her inner feelings. Preservation of pregnancy in a hospital may be required when a pregnant woman shows some dangerous symptoms: a pulling pain in the lower abdomen, comparable to sensations with menstruation, aches in the lumbosacral region, strong uterine contractions, and sudden bleeding.

Such symptoms should immediately warn the woman that there is a threat of miscarriage (if the symptoms are strong, then it is possible that this misfortune has already happened). But in any case, the woman must be hospitalized under the supervision of doctors.

What to do with the threat of termination of pregnancy? Already a pulling feeling in the stomach should alert the expectant mother, become a reason for contacting a narrow-profile specialist.

With the threat of miscarriage, treatment is carried out in a specialized clinic. If necessary, a woman is placed on "preservation". In the hospital, the pregnant woman will be provided with the most sparing regimen (up to bed), drugs are prescribed that relieve the increased tone of the uterus, vitamins, etc. depending on the cause of the violation.

In some cases, for example, with cervical insufficiency, surgical intervention may be required (suturing the cervix, etc.).

Expectant mothers with habitual miscarriage are also hospitalized "for preservation" in the pregnancy pathology department of maternity hospitals or the miscarriage department of specialized women's centers.

Medical

The appointment of effective therapy will follow immediately. First of all, it is the peace of the future mother and an additional intake of sedatives, in particular, valerian or motherwort.

If, according to the results of the ultrasound, it becomes obvious that the uterus is in, the doctor individually prescribes suppositories with Papaverine or No-shpu, because it is these medications that will allow you to somewhat relax the smooth muscles and stop the rhythmic contractions of the uterus. Ginipral and magnesium preparations are used later, since their use in early pregnancy is undesirable.

Utrozhestan also demonstrates high efficiency in case of a threatened miscarriage, since its hormonal composition contains progesterone, which is vital for maintaining pregnancy. It is he who supports the vital activity of the fetus, eliminates uterine contractions, and prevents miscarriage at any time. You can take medication only on the recommendation of a doctor, otherwise, out of ignorance, you can only harm your unborn baby.

Also, intensive vitamin therapy will not be superfluous to increase the immunity of the mother and fetus in the womb, and special attention should be paid to multivitamin complexes such as Magne B6, Vitrum, Duovit, and others.

If there is an MBC code on the sick leave, which means a threat of termination of pregnancy (this may be 020.0 - a threatened abortion), the doctor only recommends lying down for preservation, and the final decision is for the expectant mother. Of course, the desire to go to the hospital is not always present, but sometimes there is simply no other way out to save the life of a child. So it’s not worth risking a child’s life, especially since this pathological condition can be easily eliminated with a competent medical approach and the vigilance of a pregnant woman.

Prevention

It is very important to consult a doctor or call an ambulance when the first unpleasant symptoms appear. A woman should completely exclude any physical activity.

Important! At the slightest threat of abortion, doctors advise bed rest.

After determining the causes of the threat of miscarriage in the early stages, the doctor prescribes a special treatment. Most often it consists in taking progesterone preparations. As a rule, the expectant mother is placed in a hospital under the supervision of doctors to carry out measures to preserve the pregnancy.

A woman may be prescribed additional examinations, in particular an intrauterine ultrasound examination. In some cases, to maintain pregnancy, it becomes necessary to carry out a surgical operation of suturing the cervix.

It is difficult to treat such a disease, and conservative methods are not always appropriate. That is why doctors strongly recommend taking care of all preventive measures.

For a successful conception you need:

• always stay in a good mood, do not get nervous over trifles;
• take vitamins in tablets, natural products;
• treat the main, if any;
• avoid increased physical exertion and emotional shocks;
• take care of the treatment and prevention of infections in the sexual partner.

If you correctly approach the planning of a long-awaited pregnancy, then the risk of miscarriage will be minimal. If it is present solely for health reasons, then it is advisable to lie down for preservation in the first trimester and remain under the supervision of doctors.

Prevention of miscarriages should begin at least a year before conception, when reasonable parents, like diligent hosts, prepare their bodies to receive a long-awaited guest.

Important! The health of the unborn child is closely related to the emotional and mental mood of a woman for a healthy pregnancy.

Emotionally, miscarriage prevention is also extremely important during pregnancy: joyful and confident expectation of a child, constant and quiet conversations with him, greeting every push, gentle stroking of the abdomen by mother and father and older children - all this is vital for the future baby.

Remember, according to the latest scientific research, the unborn child hears everything, feels everything, understands everything much earlier than previously thought.

Although there should not be a day without physical activity, the prevention of miscarriage requires reasonable limits. On the days corresponding to menstruation before the onset of pregnancy, no physical exercise should be carried out, except for training in deep breathing and alternating tension and relaxation during rest. For those women who have previously had a threatened miscarriage, this is a matter of paramount importance.

Do not get carried away with physical activity, it is better to do several exercises, but longer, slowly increasing the load. The best exercise is vigorous walks (without overwork) in the fresh air.

Prevention of miscarriage means the rejection of sudden movements at the very beginning of pregnancy, you can not:

• too sharply reach up with your hands;
• get up quickly from the bath;
• run too fast
• skate, ski, bike, horse (there is a danger of falling).

It is better not to go for a walk in slippery weather. Buy comfortable flat shoes that don't slip, leaving fashionable high heels until better times.

After a miscarriage

First of all, you must wait with the entry of sexual intercourse for at least 2 weeks (you should also not use tampons during this period). Some women only resume sexual activity after their first menstrual period after a miscarriage, which usually appears 4 to 6 weeks after the pregnancy loss.

Ovulation usually precedes menstruation, so there is a danger of a rapid subsequent pregnancy after a miscarriage. Experts recommend using contraceptive methods for at least three to four months after a miscarriage.

It should be recognized that there are known risks associated with the rapid onset of the next pregnancy after a miscarriage. But waiting is preferable not for medical reasons, but for psychological reasons.

A woman after a pregnancy loss is worried about what will happen next. She feels fear and constantly asks herself if she can get pregnant again and have a baby. This is an abnormal mental condition that does not contribute to the orderly development of pregnancy.

Important! Miscarriages usually do not cause each other. The first miscarriage does not mean that the next pregnancy will be the same.

After three consecutive miscarriages, the chances of having a baby are 70%, four - 50%. If you lose your first pregnancy in the first three months, then the risk of losing another pregnancy is only slightly higher than the rest. Thus, while there is no guarantee that another pregnancy will proceed without any interference, a miscarriage does not cancel the chance for a happy motherhood.

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Threatened abortion (O20.0)

obstetrics and gynecology

general information

Short description

Approved by the Protocol of the meeting of the Expert Commission
on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 18 dated September 19, 2013

Spontaneous miscarriage- spontaneous abortion, which ends with the birth of an immature and non-viable fetus before the 22nd week of pregnancy, or the birth of a fetus weighing less than 500 grams (1)

habitual miscarriage- spontaneous termination of 3 or more pregnancies up to 22 weeks (WHO).
The risk of recurrent miscarriage is significantly higher in pregnant women with antiphospholipid antibodies or lupus anticoagulant (LA) (2, 3, 4, 5). Anticardiolipin (ALA) antibodies (the most commonly detected antiphospholipid antibodies) are present in less than 10% of normal pregnant women (2, 3, 6). Women with AL antibodies have a 3–9-fold increased risk of fetal loss compared with those who do not have these antibodies (2, 3, 6). Antiphospholipid antibodies contribute to arterial and venous thrombosis.

Missed miscarriage(non-developing pregnancy, missedabortion) - The term "early antenatal fetal death" refers to situations where the fetus has already died, but the uterus has not yet begun to expel it. Previously, many terms were used to describe this condition, including "empty gestational sac", "missed miscarriage" and "missed pregnancy". In practice, in such situations, the fetus is dead, but the cervical canal remains closed. Diagnosis is based on ultrasonography after clinical findings such as vaginal bloody discharge, no fetal heartbeat on electronic auscultation (from 12 weeks), no fetal movement (from 16 weeks), or if the uterus is much smaller than expected (2).

At any time, the reasons for termination of pregnancy can be:
- genetic;
- immunological (APS, HLA antigens, histocompatibility);
- infectious;
- anatomical (congenital anomalies, genital infantilism, intrauterine synechia, isthmic-cervical insufficiency);
- endocrine (deficiency of progesterone).

I. INTRODUCTION

Protocol name: Spontaneous miscarriage
Protocol code:

ICD-10 code(s):
O03 - Spontaneous miscarriage
020.0 - Threatened miscarriage
O02.1 - Miscarriage

Abbreviations used in the protocol:
Ultrasound - ultrasonography
WHO - World Health Organization
NB - non-developing pregnancy
APS - antiphospholipid syndrome
LA - lupus anticoagulant

Protocol development date: April 2013.

Protocol Users: obstetrician-gynecologists, general practitioners.

Classification

Clinical classification (WHO)

By gestational age:
- Early - spontaneous miscarriage before 12 weeks of pregnancy.
- Late - spontaneous miscarriage in terms of more than 12 weeks to 21 weeks of pregnancy.

According to clinical manifestations:
- threatening miscarriage;
- abortion in progress;
- incomplete miscarriage;
- complete miscarriage;
- missed miscarriage (non-developing pregnancy).

Abortion is in progress, incomplete and complete miscarriages are accompanied by bleeding (see protocol: "").

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of main diagnostic measures

Main:
1. The study of complaints, anamnesis (delayed menstruation for 1 month or more), special obstetric examination: external obstetric examination (height of the fundus of the uterus), examination of the cervix on the mirrors, vaginal examination.
2. Ultrasound examination is the main one in NB.
3. A short list of studies for hospitalization - not provided.

Diagnostic criteria

Complaints and anamnesis
Light spotting with a threatened miscarriage and in the presence of clinical manifestations of a missed miscarriage, sometimes accompanied by pain in the lower abdomen, with a delay in menstruation for 1 month or more, or with an established pregnancy. In the anamnesis there may be spontaneous miscarriages, infertility, menstrual dysfunction.

With a non-developing pregnancy, the subjective signs of pregnancy disappear, the mammary glands decrease in size and become soft. Menstruation does not return. In the expected period, no movement is noted. However, if fetal movements appear, they stop. Clinical signs of a non-developing pregnancy (pain, bloody discharge from the genital tract, lagging behind the size of the uterus from the expected gestational age) appear 2-6 weeks after the cessation of embryo development. The stages of NB interruption correspond to the stages of spontaneous abortion: threatened miscarriage, ongoing abortion, incomplete abortion.

A thorough study of the anamnesis is mandatory to determine the clinical criteria for the presence of APS in order to determine the scope of the examination and further management.

With a threatened miscarriage in women with recurrent miscarriage, if she was not examined before the onset of a real pregnancy; in women with a history of stillbirths, in women with a history of thromboembolic complications, it is necessary to conduct an examination during the current pregnancy in order to prevent spontaneous miscarriage and / or premature birth. In a miscarriage that has not occurred, a thorough history of APS is essential for further management after removal of the gestational sac.

Physical examination

BUTkusher examination
1. VSDM - corresponds to the gestational age with a threatened miscarriage, does not correspond with NB.
2. Examination of the cervix on the mirrors, vaginal examination:
- light bleeding;
- the cervix is ​​closed;
- the uterus corresponds to the expected gestational age with a threatened miscarriage and does not correspond with NB.

Laboratory research:
- determination of the concentration of hCG in the blood. The concentration of hCG corresponds to the gestational age with a threatened miscarriage, lower - with an undeveloped pregnancy;
- examination for suspected APS: lupus anticoagulant and the presence of antiphospholipid and anticardiolipid antibodies, AhTV, antithrombin 3, D-dimer, platelet aggregation;
- study of hemostasis parameters in case of miscarriage: blood clotting time, fibrinogen concentration, APT, INR, prothrombin time.

Instrumental Research

Ultrasound procedure:
- the presence of the fetus and its heartbeat, possibly the presence of a retroplacental hematoma;
- the absence of an embryo in the cavity of the fetal egg after 7 weeks of pregnancy or the absence of a heartbeat in a non-developing pregnancy.

Indications for expert advice:
- if APS is suspected, consultation with a therapist/hematologist with the results of a laboratory test;
- in case of a failed miscarriage with pronounced deviations of hemostasis - consultation of a hemostasiologist.

Differential Diagnosis

Disease	Complaints	Inspection of the cervix in the mirrors, bimanual examination	Chorionic gonadotropin	Ultrasound procedure
threatened miscarriage	delayed menstruation, pulling pains in the lower abdomen, bloody discharge from the genital tract	Bloody discharge, cervix is ​​closed, uterus is gestational age	Corresponds to the gestational age or slightly less	A fetal egg is determined in the uterine cavity, there may be areas of detachment with the formation of hematomas
Missed miscarriage	delayed menstruation, pulling pains in the lower abdomen, bloody discharge from the genital tract when interrupting a failed miscarriage	The cervix is ​​closed, the uterus is at or less than the expected gestational age, sometimes scanty spotting	lowered	In the uterus, the fetal egg is less than 3 weeks or more from the expected gestational age
Ectopic pregnancy	Delayed menstruation, abdominal pain, fainting, easy bleeding,	Scanty bloody discharge from the cervical canal, closed cervix, uterus slightly larger than normal, uterus softer than normal, painful adnexal mass, painful cervical movement	Less than the norm adopted for this period of pregnancy, but may be within the normal range.	In the uterine cavity, a fetal egg is not determined, in the area of ​​\u200b\u200bthe appendages, education is determined. It is possible to visualize the embryo and its heartbeat outside the uterine cavity. May show free fluid in the abdomen
Menstrual irregularity	Delayed menstruation, spotting. As a rule, not the first episode of such violations	The cervix is ​​closed, the uterus is of normal size	Test negative	In the uterine cavity, the fetal egg is not determined

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment Goals: prolongation of pregnancy in threatening pregnancy and removal of the fetal egg in case of a failed abortion.

Treatment tactics

threatened miscarriage

Non-drug treatment (7):
- Medical treatment is usually not necessary.
- Advise the woman to refrain from strenuous activity and sexual intercourse, but bed rest is not necessary.
- If the bleeding has stopped, continue observation in the w / c. If bleeding recurs, reassess the woman's condition.
- If bleeding continues, evaluate fetal viability (pregnancy test/ultrasound) or possibility of ectopic pregnancy (ultrasound). Continued bleeding, especially if the uterus is larger than expected, may indicate twins or a mole.
- If ICI is suspected, determination of the length of the cervix by ultrasound with a vaginal probe at 18-24 weeks of gestation (A.8).

Medical treatment
A review was made of randomized or quasi-randomized controlled trials comparing progestogen with placebo, no treatment, or any other treatment prescribed for the treatment of threatened miscarriage. Two studies (84 participants) were included in the meta-analysis. In one study, all participants met the inclusion criteria, while in the other, only the subgroup of participants who met the criteria was included in the analysis. There was no evidence that vaginal progesterone was more effective in reducing the risk of miscarriage than placebo (relative risk 0.47; 95% confidence interval (CI) 0.17 to 1.30). Scant data from two methodologically weak studies provided no evidence to support the routine use of progestogens for the treatment of threatened miscarriage. There is no information on the potential harm to mother or child, or both, when using progestogens. Further, large, randomized controlled trials of the effects of progestogens on the treatment of threatened miscarriage are needed that examine potential harms and benefits (9,10).

Progesterone is not given routinely for threatened miscarriage. It can be prescribed for threatened miscarriage due to progestogen insufficiency of the corpus luteum. RecommendationsFDAcategoryD(Category D - there is evidence of the risk of adverse effects of drugs on the human fetus, obtained during research or practice. However, the potential benefit of using the drug in pregnant women may justify its use, despite the possible risk).

Natural micronized progesterone is not routinely prescribed for threatened miscarriage. It can be prescribed for threatened miscarriage due to progestogen insufficiency of the corpus luteum. RecommendationsFDAcategoryD. (There is evidence of the risk of adverse drug effects on the human fetus, obtained from research or practice. However, the potential benefit of using the drug in pregnant women may justify its use, despite the possible risk).

Dydrogesterone is not routinely prescribed for threatened miscarriage. It can be prescribed for threatened miscarriage due to progestogen insufficiency of the corpus luteum, the presence of chronic endometritis, the presence of retrochorial hematoma, the presence of antibodies to progesterone. Recommendation Category FDAnot determined.(In the absence of objective information confirming the safety of the use of drugs in pregnant and / or breastfeeding women, one should refrain from prescribing them to these categories of patients).

A review of randomized or quasi-randomized controlled trials in pregnant women with a history of at least one fetal loss, the presence of antiphospholipid (APL) antibodies, and who were receiving any therapy found that the only significant benefit of the observed therapy was that the combination of unfractionated heparin and aspirin reduced the rate of fetal loss by 54% (relative risk [RR] 0.46, 95% Confidence interval [CI]: 0.29 - 0.71) compared with aspirin alone. When studies of low molecular weight heparin (LMW) and unfractionated heparin were pooled together, there was a 35% reduction in miscarriage and preterm birth (RR 0.65, 95% CI: 0.49 - 0.86). Different dosages of heparin used in different studies included in the review did not affect outcomes. Therefore, the optimal dose of heparin (the one that brings the maximum benefit, causing the least harm) is not yet known. None of the other methods studied had any significant positive effect on pregnancy outcome compared with placebo, although a small positive effect of aspirin cannot be ruled out (11,12,13,14).

Other treatments- the use of urinals with a short cervix after the disappearance of the symptoms of a threatened miscarriage, but today there is no reliable data and its effectiveness.

Surgical intervention: in the presence of ICI, it is possible to suture the uterus, but today there is no reliable data and its effectiveness.

Preventive actions: prevention of preterm birth in risk groups:
Examination for APS in the presence of anamnestic and clinical criteria (see below) - lupus anticoagulant and the presence of antiphospholipid and anticardiolipid antibodies, APT, antithrombin 3, D-dimer, platelet aggregation.

Further management: dispensary observation, according to the protocol of conducting pregnant women.

Missed miscarriage

Non-drug treatment: No.

Medical treatment
Intravaginal misoprostol is an effective method for terminating miscarriages up to 24 weeks' gestation. Although the optimal dosage for the first trimester has not yet been clearly established, according to the Gilles study (15), intravaginal use at a dose of 800 mcg repeated after three days achieved an effect in 79% of women by the seventh day (or 87% by the 30th day) . In the second trimester (10–24 weeks), a lower dosage of 200 mcg intravaginally, repeated 12 hours later, is recommended (study by Jain (16)).

Other treatments- No

Surgical intervention: evacuation of the ovum up to 14-16 weeks, preferably manual vacuum aspiration (17,18,19).

Preventive actions
Prevention of infection during the evacuation of the fetal egg - compliance with asepsis, the appointment of prophylactic antibiotic therapy.
Miscarriage prevention in groups of women with recurrent pregnancy loss or verified corpus luteum insufficiency, including induced pregnancies and pregnancies after IVF, is carried out by using:
- natural micronized progesterone (see FDA recommendations above) 200-400 mg intravaginally in the 1st-2nd trimesters of pregnancy to prevent recurrent and threatened miscarriage.
- krynon (progesterone) - FDA category D recommendations, for maintaining the luteal phase during the use of assisted reproductive technologies (ART) 1 applicator (90 mg of progesterone) intravaginally daily, starting from the day of embryo transfer, for 30 days from the moment of clinically confirmed pregnancy.
- dydrogesterone (see above FDA recommendations) 10 mg 2 times a day until 16-20 weeks of pregnancy with recurrent miscarriage.

Further management
- Appointment of microdoses of combined oral contraceptives from the first day of termination of pregnancy.
- Testing for STIs
- Medical genetic counseling is recommended for couples with recurrent NB.
- Treatment of chronic inflammation - chronic endometritis, chronic salpingitis, vaginitis, vaginosis, if any.
- Screening for APS if available diagnostic criteria (Sapporo, 1999) cadditions (MiyakisS. Etal., 2006): Anamnestic: cephalgia, ischemic heart disease, arterial and venous thrombosis, transient cerebrovascular accident, fetal loss syndrome, preeclampsia, eclampsia.
Clinical:
1. Vascular thrombosis
2. Pathology of pregnancy: - one or more cases of intrauterine death of a morphologically normal fetus after 10 weeks of gestation, or - one or more cases of premature birth of a fetus of a morphologically normal fetus before 34 weeks of gestation due to severe preeclampsia and eclampsia or severe placental insufficiency, or - three and more consecutive cases of spontaneous abortions up to 10 non-gestations (exception - anatomical defects of the uterus, hormonal disorders, maternal or paternal chromosomal disorders).
- Persistent manifestations of the threat of spontaneous miscarriage against the background of ongoing therapy, the development of severe preeclampsia in the early stages of gestation.
- Determination of lupus anticoagulant and the presence of antiphospholipid and anticardiolipid antibodies, AchTV, antithrombin 3, D-dimer, platelet aggregation.

Habitual miscarriage:
a) genetic study (study of the karyotype of parents) in case of habitual miscarriage in the early stages;

B) if anatomical causes are suspected, the following are performed:
- Ultrasound in the 1st phase of the menstrual cycle can diagnose a submucosal uterus, intrauterine synechia, in the 2nd phase of the cycle - an intrauterine septum and a bicornuate uterus;
- MRI of the pelvis;
- hysterosalpingography in the first phase of the menstrual cycle reveals the presence of submucosal myomatous nodes, synechia, septum.

In the presence of anatomical causes, surgical removal is indicated. Surgical removal of the intrauterine septum, synechia, and submucosal fibroid nodes is accompanied by the elimination of miscarriage in 70-80% of cases (category C). The most effective surgical treatment with hysteroresectoscopy. Abdominal metroplasty is associated with a risk of postoperative infertility (category B) and does not improve the prognosis of subsequent pregnancies. After surgery to remove the intrauterine septum, synechia, depending on the severity of the pathology and the volume of surgical intervention, contraceptive estrogen-progestin preparations are prescribed; and continuation of hormone therapy for another 3 cycles; physiotherapy. At the onset of pregnancy, natural micronized progesterone 200-400 mg up to 20 weeks of pregnancy.

CI is a common cause of abortion in the second trimester of pregnancy. Painless shortening and subsequent opening of the cervix, which ends in a miscarriage and the subsequent opening of the cervix, which in the 2nd trimester leads to prolapse of the fetal bladder and / or outflow of amniotic fluid, and in the 3rd trimester to the birth of a premature baby, are pathognomonic signs of CI. As a rule, it is impossible to estimate the likelihood of CCI before pregnancy.

C) if infectious causes of habitual miscarriage are suspected (late miscarriages and premature births are the most common), the following is performed:
- Gram microscopy of smears from the vagina and cervical canal,
- bacteriological examination of the detachable cervical canal with a quantitative determination of the degree of colonization by pathogenic and opportunistic microflora and the content of lactobacilli,
- detection of gonorrheal, chlamydial, trichomonas infections, carriage of HSV and CMV using PCR;
- determination of IgGiIgM to HSV and CMV in the blood;
- biopsy of the endometrium on the 7th-8th day of the menstrual cycle with histological examination, PCR and bacteriological examination of the material from the uterine cavity is carried out to exclude the infectious cause of miscarriage.

D) In ​​case of hormonal insufficiency of the function of the corpus luteum, due to insufficiency of the corpus luteum in the program of pregravid preparation, the use of progesterone, natural micronized progesterone, dydrogesterone.

Treatment effectiveness indicators:
- The possibility of further prolongation of pregnancy in threatened miscarriage in women with recurrent miscarriage.
- The absence of early complications after the evacuation of the fetal egg in a failed abortion.

Hospitalization

Indications for hospitalization:
- emergency - threatening miscarriage with increased bleeding; failed abortion.

Information

Sources and literature

1. Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. 1. Royal College of Obstetricians and Gynaecologists. The management of Early Pregnancy Loss. Green-top Guideline No. 25. London: RCOG 2006. 2. Nilsson IM, Astedt B, Hedner U, Berezin D. Intrauterine death and circulating anticoagulant (“antithromboplastin”). Acta Medicine Scandinavia 1975;197:153–159. 3. Lynch A, Marlar R, Murphy J, Davila G, Santos M, Rutledge J et al. Antiphospholipid antibodies in predicting adverse pregnancy outcome. A prospective study. Annals of Internal Medicine 1994;120:470–475. 4. Yasuda M, Takakuwa K, Tokunaga A, Tanaka K. Prospective studies of the association between anticardiolipin antibody and outcome of pregnancy. Obstetrics and Gynecology 1995;86:555–559. 5. Rand JH, Wu XX, Andree H, Lockwood C, Guller S, Scher J et al. Pregnancy loss in the antiphospholipid-antibody syndrome is a possible thrombogenic mechanism. New England Journal of Medicine 1977;337:154–160. 6.Yetman DL, Kutteh WH. Antiphospholipid antibody panels and recurrent pregnancy loss: prevalence of anticardiolipin antibodies compared with other antiphospholipid antibodies. Fertility and Sterility 1996;66:540–546. 7. Assistance in the complicated course of pregnancy, childbirth and the postpartum period, WHO Recommendations, 2003 8. Hassan S.S., Romero R., Vidydhari D. et al. Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, doubl-blind, placebo-controlled trial. Ultrasound Obstet Gynecol. 2011 Jul; 38 (1): 18-31 9. Wahabi HA, Abed Althagafi NF, Elawad M. Progestogen for treating threatened miscarriage. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD005943. DOI: 10.1002/14651858.CD005943.pub2 10. Wahabi H.A., Abed Althagafi N.F., Elawad M. et al. Progestogen for treating threatened miscarriage. Cochrane Database Syst. Rev. – 2011.-Vol.16, 3. – CD00594 11.Rand JH, Wu XX, Andree H, Lockwood C, Guller S, Scher J et al. Pregnancy loss in the antiphospholipid-antibody syndrome is a possible thrombogenic mechanism. New England Journal of Medicine 1977;337:154–160. 12.Yetman DL, Kutteh WH. Antiphospholipid antibody panels and recurrent pregnancy loss: prevalence of anticardiolipin antibodies compared with other antiphospholipid antibodies. Fertility and Sterility 1996;66:540–546. 13. Lynch A, Byers T, Emlen W, Rynes D, Shetterly SM, Hamman RF. Association of antibodies to beta2-glycoprotein 1 with pregnancy loss and pregnancy-induced hypertension: a prospective study in low-risk pregnancy. Obstetrics and Gynecology 1999;93:193–198. 14. Velayuthaprabhu S, Archunan G. Evaluation of anticardiolipin antibodies and antiphosphatidylserine antibodies in women with recurrent abortion. Indian Journal of Medical Sciences 2005;59:347–352. 15. Gilles JM, Creinin MD, Barnhart K, Westhoff C, Frederick MM, Zhang J. A randomized trial of saline solution-moistened misoprostol versus dry misoprostol for the first-trimester pregnancy failure. Am J Obstet Gynecol2004;190:389. 16 Jain JK, MichelDRl. A comparison of misoprostol with and without laminaria tents for induction of second-trimester abortion. Am J Obstet Gynecol1996;175:173. 17. Neilson JP, Hickey M, Vazquez J. Medical treatment for early fetal death (less than 24 weeks). The Cochrane Library Issue 3, 2006; Chichester, UK: John Wiley & Sons. 18.Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage: expectant; medical or surgical? Results of a randomized controlled trial (the MIST trial). BMJ 2006;332:1235-1238. 19. Neilson JP, Hickey M, Vazquez J. Medical treatment for early fetal death (less than 24 weeks). The Cochrane Library Issue 3, 2006; Chichester, UK: John Wiley & Sons.

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of protocol developers with qualification data:
Doshchanova A.M. - Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics and Gynecology for subordination and internship of JSC "MUA".
Patsaev T.A. - Doctor of Medical Sciences, head of the operating unit of the Republican State Enterprise on the REM "Scientific Center for Obstetrics, Gynecology and Perinatology" of the Ministry of Health of the Republic of Kazakhstan.

Reviewers:
Mireeva A.E. - doctor of the highest category, doctor of medical sciences, professor of the department of obstetrics and gynecology on internship at KazNMU named after. S.D. Asfendiyarova

Indication of no conflict of interest: missing.

Indication of the conditions for revising the protocol: The protocol is reviewed at least once every 5 years, or upon receipt of new data related to the application of this protocol.

Attached files

Attention!

• By self-medicating, you can cause irreparable harm to your health.
• The information posted on the MedElement website and in the mobile applications "MedElement (MedElement)", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Handbook" cannot and should not replace an in-person consultation with a doctor. Be sure to contact medical facilities if you have any diseases or symptoms that bother you.
• The choice of drugs and their dosage should be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and the condition of the patient's body.
• The MedElement website and mobile applications "MedElement (MedElement)", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Handbook" are exclusively information and reference resources. The information posted on this site should not be used to arbitrarily change the doctor's prescriptions.
• The editors of MedElement are not responsible for any damage to health or material damage resulting from the use of this site.

Spontaneous abortion (miscarriage) - spontaneous termination of pregnancy before the fetus reaches a viable gestational age.

According to the WHO definition, abortion is the spontaneous expulsion or extraction of an embryo or fetus weighing up to 500 g, which corresponds to a gestational age of less than 22 weeks.

ICD-10 CODE

O03 Spontaneous abortion.
O02.1 Missed miscarriage.
O20.0 Threatened abortion.

EPIDEMIOLOGY

Spontaneous abortion is the most common complication of pregnancy. Its frequency is from 10 to 20% of all clinically diagnosed pregnancies. About 80% of these losses occur before 12 weeks of gestation. When accounting for pregnancies by determining the level of hCG, the loss rate increases to 31%, with 70% of these abortions occurring before the moment when pregnancy can be recognized clinically. In the structure of sporadic early miscarriages, 1/3 of pregnancies are interrupted in a period of up to 8 weeks according to the type of anembryony.

CLASSIFICATION

According to clinical manifestations, there are:

threatening abortion;
initiation of an abortion
abortion in progress (complete and incomplete);
non-developing pregnancy.

The classification of spontaneous abortions adopted by WHO differs slightly from that used in the Russian Federation, combining a miscarriage that has begun and an abortion in progress into one group - an inevitable abortion (i.e., continuation of the pregnancy is impossible).

ETIOLOGY (CAUSES) OF MISSION

The leading factor in the etiology of spontaneous abortion is chromosomal pathology, the frequency of which reaches 82-88%.

The most common variants of chromosomal pathology in early spontaneous miscarriages are autosomal trisomy (52%), monosomy X (19%), polyploidy (22%). Other forms are noted in 7% of cases. In 80% of cases, death occurs first, and then expulsion of the fetal egg.

The second most important among the etiological factors is metroendometritis of various etiologies, which causes inflammatory changes in the uterine mucosa and prevents normal implantation and development of the fetal egg. Chronic productive endometritis, more often of autoimmune origin, was noted in 25% of so-called reproductively healthy women who terminated a pregnancy by induced abortion, in 63.3% of women with recurrent miscarriage and in 100% of women with NB.

Among other causes of sporadic early miscarriages, anatomical, endocrine, infectious, immunological factors are distinguished, which to a greater extent serve as the causes of habitual miscarriages.

RISK FACTORS

Age is one of the main risk factors in healthy women. According to data obtained from the analysis of the outcomes of 1 million pregnancies, in the age group of women from 20 to 30 years, the risk of spontaneous abortion is 9–17%, at 35 years old - 20%, at 40 years old - 40%, at 45 years old - 80%.

Parity. Women with two or more pregnancies have a higher risk of miscarriage than nulliparous women, and this risk does not depend on age.

History of spontaneous abortions. The risk of miscarriage increases with the number of miscarriages. In women with one miscarriage in history, the risk is 18-20%, after two miscarriages it reaches 30%, after three miscarriages - 43%. For comparison: the risk of miscarriage in a woman whose previous pregnancy ended successfully is 5%.

Smoking. Consumption of more than 10 cigarettes per day increases the risk of spontaneous abortion in the first trimester of pregnancy. These data are most revealing in the analysis of spontaneous abortion in women with a normal chromosome set.

The use of non-steroidal anti-inflammatory drugs in the period preceding conception. Data have been obtained indicating a negative effect of the inhibition of PG synthesis on the success of implantation. When using non-steroidal anti-inflammatory drugs in the period before conception and in the early stages of pregnancy, the frequency of miscarriages was 25% compared with 15% in women who did not receive drugs in this group.

Fever (hyperthermia). An increase in body temperature above 37.7 ° C leads to an increase in the frequency of early spontaneous abortions.

Trauma, including invasive methods of prenatal diagnosis (choriocentesis, amniocentesis, cordocentesis), the risk is 3–5%.

The use of caffeine. With a daily intake of more than 100 mg of caffeine (4-5 cups of coffee), the risk of early miscarriage is significantly increased, and this trend is valid for a fetus with a normal karyotype.

Exposure to teratogens (infectious agents, toxic substances, teratogenic drugs) is also a risk factor for spontaneous abortion.

Folic acid deficiency. When the concentration of folic acid in the blood serum is less than 2.19 ng / ml (4.9 nmol / l), the risk of spontaneous abortion significantly increases from 6 to 12 weeks of pregnancy, which is associated with a higher frequency of abnormal fetal karyotype formation.

Hormonal disorders, thrombophilic conditions are to a greater extent the causes of not sporadic, but habitual miscarriages, the main cause of which is an inferior luteal phase.

According to numerous publications, from 12 to 25% of pregnancies after IVF end in spontaneous abortion.

CLINICAL PICTURE (SYMPTOMS) OF SPONTANEOUS ABORTION AND DIAGNOSIS

Basically, patients complain of bloody discharge from the genital tract, pain in the lower abdomen and in the lower back with a delay in menstruation.

Depending on the clinical symptoms, there are threatening spontaneous abortion that has begun, an abortion in progress (incomplete or complete) and a miscarriage.

Threatening abortion is manifested by pulling pains in the lower abdomen and lower back, there may be scanty bloody discharge from the genital tract. The tone of the uterus is increased, the cervix is ​​not shortened, the internal os is closed, the body of the uterus corresponds to the gestational age. The ultrasound records the fetal heartbeat.

With the onset of abortion, pain and bloody discharge from the vagina are more pronounced, the cervical canal is ajar.

During abortion, regular cramping contractions of the myometrium are determined in the course. The size of the uterus is less than the estimated gestational age; in the later stages of pregnancy, leakage of the OM is possible. The internal and external pharynx are open, the elements of the fetal egg are in the cervical canal or in the vagina. Bleeding may be of varying intensity, often abundant.

Incomplete abortion is a condition associated with a delay in the uterine cavity of the elements of the fetal egg.

The absence of full uterine contraction and closure of its cavity leads to continued bleeding, which in some cases causes large blood loss and hypovolemic shock.

More often, incomplete abortion is observed after 12 weeks of pregnancy in the case when the miscarriage begins with the outflow of OB. With a bimanual examination, the uterus is less than the expected gestational age, bloody discharge from the cervical canal is abundant, using ultrasound in the uterine cavity, the remains of the fetal egg are determined, in the II trimester - the remains of placental tissue.

Complete abortion is more common in late pregnancy. The fertilized egg comes out completely from the uterine cavity.

The uterus contracts and the bleeding stops. On bimanual examination, the uterus is well contoured, smaller than the gestational age, the cervical canal can be closed. With a complete miscarriage, ultrasound determines the closed uterine cavity. There may be small bleeding.

Infected abortion is a condition accompanied by fever, chills, malaise, pain in the lower abdomen, bloody, sometimes purulent discharge from the genital tract. During a physical examination, tachycardia, tachypnea, defence of the muscles of the anterior abdominal wall are determined, with a bimanual examination - a painful, soft uterus; the cervical canal is dilated.

In case of an infected abortion (with mixed bacterial and viral infections and autoimmune disorders in women with habitual miscarriage, obstetric anamnesis aggravated by antenatal fetal death, recurrent genital infections), immunoglobulins are prescribed intravenously (50-100 ml of 10% Gamimun © solution, 50-100 ml of 5% solution octagama©, etc.). They also carry out extracorporeal therapy (plasmapheresis, cascade plasma filtration), which consists in physicochemical blood purification (removal of pathogenic autoantibodies and circulating immune complexes). The use of cascade plasma filtration implies detoxification without plasma removal. In the absence of treatment, generalization of infection in the form of salpingitis, local or diffuse peritonitis, septicemia is possible.

Non-developing pregnancy (antenatal fetal death) - the death of an embryo or fetus during a pregnancy of less than 22 weeks in the absence of expulsion of the elements of the fetal egg from the uterine cavity and often without signs of a threat of interruption. To make a diagnosis, an ultrasound is performed. The tactic of abortion is chosen depending on the gestational age. It should be noted that antenatal fetal death is often accompanied by disorders of the hemostasis system and infectious complications (see the chapter "Non-developing pregnancy").

In the diagnosis of bleeding and the development of management tactics in the first trimester of pregnancy, the assessment of the rate and volume of blood loss plays a decisive role.

With ultrasound, the following are considered unfavorable signs in terms of the development of the fetal egg during uterine pregnancy:

Absence of embryonic heartbeat with CTE more than 5 mm;

Absence of an embryo with the size of the fetal egg measured in three orthogonal planes, more than 25 mm with transabdominal scanning and more than 18 mm with transvaginal scanning.

Additional ultrasound signs that indicate an unfavorable outcome of pregnancy include:

An abnormal yolk sac that does not correspond to the gestational age (more), irregularly shaped, displaced to the periphery or calcified;

HR of the embryo is less than 100 per minute in the period of 5-7 weeks;

large retrochorial hematoma (more than 25% of the surface of the fetal egg).

DIFFERENTIAL DIAGNOSIS

Spontaneous abortion should be differentiated from benign and malignant diseases of the cervix or vagina. During pregnancy, bleeding from the ectropion is possible. To exclude diseases of the cervix, a careful examination in the mirrors is carried out, if necessary, colposcopy and / or biopsy.

Bloody discharge during a miscarriage is differentiated from those during an anovulatory cycle, which is often observed with a delay in menstruation. There are no symptoms of pregnancy, the test for hCG b subunit is negative. On bimanual examination, the uterus is of normal size, not softened, the cervix is ​​firm, not cyanotic. There may be similar menstrual irregularities in history.

Differential diagnosis is also carried out with hydatidiform mole and ectopic pregnancy.

With a hydatidiform mole, 50% of women may have a characteristic discharge in the form of vesicles; the uterus may be longer than the expected pregnancy. Typical picture on ultrasound.

With an ectopic pregnancy, women may complain of spotting, bilateral or generalized pain; often fainting (hypovolemia), a feeling of pressure on the rectum or bladder, a test for bhCG is positive. On bimanual examination, there is pain when moving the cervix. The uterus is smaller than it should be at the time of the expected pregnancy.

You can palpate a thickened fallopian tube, often bulging of the vaults. With ultrasound in the fallopian tube, you can determine the fetal egg, if it breaks, you can detect the accumulation of blood in the abdominal cavity. To clarify the diagnosis, a puncture of the abdominal cavity through the posterior fornix of the vagina or diagnostic laparoscopy is indicated.

Diagnosis example

Pregnancy 6 weeks. Started miscarriage.

TREATMENT

GOALS OF TREATMENT

The goal of treating a threatened abortion is to relax the uterus, stop bleeding and prolong pregnancy if there is a viable embryo or fetus in the uterus.

In the USA, Western European countries, a threatened miscarriage up to 12 weeks is not treated, considering that 80% of such miscarriages are “natural selection” (genetic defects, chromosomal aberrations).

In the Russian Federation, a different tactic for managing pregnant women with a threat of miscarriage is generally accepted. With this pathology, bed rest (physical and sexual rest), a complete diet, gestagens, vitamin E, methylxanthines are prescribed, and as a symptomatic treatment, antispasmodic drugs (drotaverine, suppositories with papaverine), herbal sedative drugs (decoction of motherwort, valerian).

NON-DRUG TREATMENT

Oligopeptides, polyunsaturated fatty acids must be included in the pregnant diet.

MEDICAL TREATMENT

Hormone therapy includes natural micronized progesterone 200-300 mg/day (preferred) or dydrogesterone 10 mg twice daily, vitamin E 400 IU/day.

Drotaverine is prescribed for severe pain intramuscularly at 40 mg (2 ml) 2-3 times a day, followed by the transition to oral administration from 3 to 6 tablets per day (40 mg in 1 tablet).

Methylxanthines - pentoxifylline (7 mg / kg of body weight per day). Candles with papaverine 20–40 mg twice a day are used rectally.

Approaches to the treatment of threatened abortion are fundamentally different in the Russian Federation and abroad. Most foreign authors insist on the inexpediency of maintaining a pregnancy for less than 12 weeks.

It should be noted that the effect of the use of any therapy - drug (antispasmodics, progesterone, magnesium preparations, etc.) and non-drug (protective regimen) - has not been proven in randomized multicenter studies.

The appointment of drugs that affect hemostasis (etamsylate, vikasol ©, tranexamic acid, aminocaproic acid and other drugs) in case of bloody discharge to pregnant women has no basis and proven clinical effects due to the fact that bleeding during miscarriages is due to detachment of the chorion (early placenta) rather than coagulation disorders. On the contrary, the doctor's task is to prevent blood loss, leading to violations of hemostasis.

Upon admission to the hospital, a blood test should be performed, the blood group and Rh status should be determined.

With an incomplete abortion, profuse bleeding is often observed, in which emergency care is necessary - immediate instrumental removal of the remnants of the fetal egg and curettage of the walls of the uterine cavity. More gentle is the emptying of the uterus (preferably vacuum aspiration).

Due to the fact that oxytocin may have an antidiuretic effect, after emptying the uterus and stopping bleeding, the administration of large doses of oxytocin should be discontinued.

During the operation and after it, it is advisable to administer an intravenous isotonic sodium chloride solution with oxytocin (30 IU per 1000 ml of solution) at a rate of 200 ml/h (in the early stages of pregnancy, the uterus is less sensitive to oxytocin). Antibacterial therapy is also carried out, if necessary, treatment of posthemorrhagic anemia. Women with Rh-negative blood are injected with immunoglobulin anti-Rhesus.

It is advisable to control the condition of the uterus by ultrasound.

With a complete abortion during pregnancy less than 14-16 weeks, it is advisable to conduct an ultrasound scan and, if necessary, curettage of the walls of the uterus, since there is a high probability of finding parts of the fetal egg and decidual tissue in the uterine cavity. At a later date, with a well-contracted uterus, curettage is not performed.

It is advisable to prescribe antibiotic therapy, treat anemia according to indications and administer anti-Rhesus immunoglobulin to women with Rh-negative blood.

SURGERY

Surgical treatment of missed pregnancy is presented in the chapter "Non-developing pregnancy".

Management of the postoperative period

In women with a history of PID (endometritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvioperitonitis), antibiotic therapy should be continued for 5-7 days.

In Rh-negative women (during pregnancy from an Rh-positive partner) in the first 72 hours after vacuum aspiration or curettage during pregnancy for more than 7 weeks and in the absence of Rh AT, Rh immunization is prevented by administering anti-Rhesus immunoglobulin at a dose of 300 mcg (intramuscularly).

PREVENTION

Methods of specific prevention of sporadic miscarriage are absent. To prevent neural tube defects, which partially lead to early spontaneous abortions, it is recommended to prescribe folic acid 2–3 menstrual cycles before conception and in the first 12 weeks of pregnancy at a daily dose of 0.4 mg. If a woman has a history of neural tube defects during previous pregnancies, the prophylactic dose should be increased to 4 mg/day.

INFORMATION FOR THE PATIENT

Women should be informed about the need to consult a doctor during pregnancy in case of pain in the lower abdomen, in the lower back, in the event of bleeding from the genital tract.

FURTHER MANAGEMENT

After curettage of the uterine cavity or vacuum aspiration, it is recommended to exclude the use of tampons and refrain from sexual intercourse for 2 weeks.

FORECAST

As a rule, the prognosis is favorable. After one spontaneous miscarriage, the risk of losing the next pregnancy increases slightly and reaches 18-20% compared to 15% in the absence of a history of miscarriage. In the presence of two consecutive spontaneous abortions, it is recommended to conduct an examination before the desired pregnancy occurs to identify the causes of miscarriage in this married couple.

1. Protocols for the diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 764 of December 28, 2007)
   1. 1. Miscarriage and prematurity / / Manual for doctors and interns / Okhapkin M.B., Khitrov M.V., Ilyashenko I.N.-Yaroslavl 2002, p34 2. Obstetric bleeding / Guidelines.- Bishkek, 2000, C .13 3. Assistance in complicated pregnancy and childbirth. / A guide for midwives and doctors. Reproductive Health and Research, WHO, Geneva, 2002 4.Daylene L. Ripley MD. Atony, Invertion, and Rupture. Emergent Care Uterine Emergencies. Obstetrics and Gynecology Clinics, V.26, No. 3, Sept. 1999 5. Allan B MacLean, James Neilson. Maternal Morbility and Mortality. Report Of WHO, 2000 6. University of Iowa Family Practice Handbook, Fourth Edition, 2002 7. McDonald S, Prendiville WJ, Elbourne D Prophylactic syntometrine vs oxytocin in the third stage of labor (Cochrane Review) The Cochrane Library, 1998, 2, Update Software Oxford, Prendiville 1996 8. Prendiville WJ, The prevention of post partum haemorrhage: optimizing routine management of the third stage of labor Eur J Obstet Gynecol Reprod Biol, 1996, 69, 19-24 9. Khan GQ, John IS, Chan T, Wani S, Hughes AO, Stirrat GM Abu Dhabi third stage trial: oxytocin versus Syntometrine in the active management of the third stage of labor Eur J Obstet Gynaecol and Reprod Biol, 1995, 58, 147-51 A. Evans. Obstetrics/ Handbook of the University of California, 1999 11.Managing Complications in Pregnancy and Childbirth: a Guide for midwives and doctors. Department of Reproductive Health and Research Family and Community Health. World Health Organization, Geneva, 2003 12. Postpartum Haemorrage Module: Education Material for teachers of Midwifery. Maternal Health and Safe Motherhood Program. Family and Reproductive Health. World Health Organization, Geneva, 1996 13.Haemorrage: Intervention Group 6. Mother-Baby Package Spreadsheet. Family and Reproductive Health. World Health Organization, Geneva, 1999 14. Prendeville WD, Elbourne D, McDonald C. Active management of the third stage of labor versus expectant management (Cochrane Library Abstract, Issue 1, 2003). 15. Caroli G., Bergel E. Injections into the umbilical vein to eliminate the defect of the afterbirth / placental remnants (Cochrane Library Abstract, Issue 1, 2003). 16.15. Vorobyov A. Hematology in the struggle for human life 2005.-No. pp.2-5. 16. Eliasova L.G. Indicators of maternal mortality as criteria for the quality and level of organization of the work of obstetric institutions ..// St. Petersburg State Pediatric Medical Academy 10. 02.06.-p.1-3. 17. Barbara Shane. Outlok: special issue on maternal and neonatal health. //Issue 19, Number 3 18.Sara Mackenzie MD Obstetrics: late prenatal bleeding. //Management of Yowa University of Family Medicine. Ed. 4, chapter 14.

Information

Bazylbekova Z.O. MD Head of the Department of Pregnant Women with Obstetric Pathology and Extragenital Diseases of the Republican Research Center for Maternal and Child Health (RNITsOMiR).

Nauryzbayeva B.U. MD Department of Physiology and Pathology of Childbirth of the Republican Scientific Research Center for Maternal and Child Health (RNITsOMIR).