Miscarriage

Miscarriage or spontaneous abortion is defined as loss of a pregnancy without outside intervention in the term between the beginning of pregnancy and 37 weeks gestation.
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Early spontaneous abortion: spontaneous abortion that occurs in the first 11 weeks of pregnancy + 6 days; - Late spontaneous abortion: from 12 to 21 weeks + 6 days; - Preterm delivery: from 22 to 36 weeks + 6 days (154 259 days).

-10 Classification.
Threatened

abortion 20.0. Spontaneous abortion 03: Incomplete abortion 03 03.4; Complete abortion 03.5 03.9. Habitual abortion 96. Preterm delivery 60.

Causes of miscarriage.
1. Uterus pathology: maldevelopment of Mullerian duct (ductal septum, arcuate or bicornous uterus), synechii, uterus hypoplasia, hysteromyoma, isthmic cervical insufficiency. 2. Chromosomal anomaly: structural abnormalities or quantitative aberrations of chromosomes.

3. Immunological abnormalities: cellular and humoral immunity dysfunctions, histocompatibility antigens, isoserological blood group and Rh-factor feto-maternal incompatibility. 4. Endocrinal pathology: ovarian hypofunction, lutein phase insufficiency, hyperandrogyny of suprarenal and ovarian genesis.
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5. Infection factor: acute and chronic infectious diseases of the mother, local genital lesions caused by bacterial flora, mycoplasma, chlamydia, toxoplasmosis, viruses. 6. Somatic diseases and intoxications. 7. Psychogenic factor.

Pathogeny
Cause
Increase in uterine contractive activity Separation of the fetus from the uterine walls Cervical dilatation Expulsion of fetus

 Spontaneous

abortion (miscarriage) expulsion of embryo/fetus in the term of gestation up to 22 weeks or up to 500 grams of weight regardless of presence or absence of vital signs.
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Miscarriage stages.

1. Threatened abortion. 2. Abortion in progress. 3. Incomplete abortion. 4. Complete abortion.

- Missed abortion (embryonic/fetal demise abortion). - Septic abortion

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Habitual

abortion (recurrent miscarriage) is normally diagnosed after two or more pregnancies end in miscarriages.

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Table 1. Signs of pregnancy in the first trimester

Case history data Delay of menstruation. Objective examination data Enlargement of uterus, change of its form and consistency. Nausea, vomiting, changed sense of smell and taste
Softening of cervix. Cyanosis of vaginal walls. Enlargement and engorgement of mammary glands.

Ultrasonograp hy (US) Embryonic/fetal visualization (according to gestation term).

Laboratory tests data Positive pregnancy test.

Increase of human chorionic gonadotropin (HCG) level in blood serum.

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Threatened abortion.
Patient complaints.

1. Abdominal cramps, after 16 weeks of gestation possible cramp-like pain. 2. Weak or moderate bloody discharge from genital tracts 3. Delay of menstruation.
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Examination.

Speculum examination. 1. External orifice of uterus is closed. 2. Weak or moderate bloody discharge.

Bimanual vaginal examination. 1.The uterus is irritable, the uterine tone is heightened. 2. The size of uterus corresponds to the term of gestation.
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US: general signs.

1. Cushion-like local myometrial thickening protruding into the uterine cavity. 2. Gestational sac contour deformation. 3. Visualization of placental or chorionic detachment areas.
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Table 2. Prognostic criteria for pregnancy progression.

Signs Case history

Favorable prognosis Pregnancy in progress

Unfavorable prognosis Spontaneous abortions in past history;Woman s age 34 years.

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Sonographic

Present heartbeat; absence of bradicardia; the size of the embryo corresponds to the size of the gestational sac; the sac is dynamically developing

Heartbeat absent; bradicardia; empty emty gestational sac; the size of the embryo does not correspond to the size of the sac; absence of fetal sac growth after 710 days; subchorionic hematoma.

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Biochemical

Normal level of biochemical markers.

Serum HCG level is below normal for the corresponding term of gestation; HCG level increase is below 66% within 48 hours (up to 8 weeks of gestation) or HCG level decreases; progesterone level is below normal rate for the term of gestation and decreases in dynamics.

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IMPORTANT!!!
When

clinical signs of threatened abortion are present in the term of gestation less than 8 weeks and the prognosis for pregnancy progression is unfavorable it is not recommended to start a pregnancy maintenance therapy. - high rate of chromosomal anomalies in this term of gestation; - low efficiency of the therapy.
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Table 3. Therapy applied in threatened abortion cases.

Medical approach
Bed rest and total sex abstinence.

Efficiency
According to various research data
the efficiency is moderate.

Spasmolytics (papaverine hydrochloride, riabal, etc);

There is no evidence that this approach can be used efficiently and safely as means of miscarriage prevention.
Indications for progesterone use: 1 Two or more spontaneous abortions during the first trimester in the patients case history (recurrent miscarriage). 2 Lutein phase insufficiency confirmed before pregnancy. 3 Cured infertility. 4 Pregnancy as a result of implementation 21 of supporting reproductive

Hormonal therapy (progesterone or its synthetic analogs): - 1% progesterone solution, intramuscularly; utrogestan (vaginally or orally);

- dufaston (orally).

Table 4. Treatment efficiency monitoring.

Method
Dynamics monitoring of clinical symptoms change.
Estimation of the patients hormonal status using one or several methods stated below: - determination of serum HCG level in dynamics; - determination of serum progesterone level in dynamics; - hormonal colpocytology; - basal temperature measurement until 12 weeks of gestation.

Application mode
Twice daily. In the term of gestation before 8 weeks every 48 hours, after 8 weeks once weekly. Once weekly, until symptoms stop. Once weekly. During the course of treatment.

US

Is applied to confirm the progressing pregnancy.

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Abortion in progress. Examination for making the diagnosis. Speculum examination. 1. The cervix is shortened, the external orifice of the uterus is open. 2. Profuse bloody discharge. 3. Parts of gestational sac present in the cervical canal. 4. Amniotic fluid leakage (absent in the early terms of gestation).
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 Bimanual

examination to determine: - uterine tone; - size of uterus; - rate of cervical canal opening.

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US as needed for visualization of placental detachment (after 12 weeks gestation), gestational sac (before 12 weeks gestation).
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Abortion in progress management approach.

Term

of gestation less than 16 weeks. Emergency vacuum aspiration or curettage of uterine cavity walls is performed with adequate anesthesia. ! It is essential to conduct a pathohistological study of aborted tissues.

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 Term

of gestation more than 16 weeks. Vacuum aspiration or curettage of uterine cavity walls is performed after spontaneous expulsion of gestational sac. For prevention of endometritis antibiotic therapy is prescribed.
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 In

cases of bleeding after the expulsion of gestational sac or during the curettage, uterotonics are used to stimulate contractive function of the uterus: - oxytocin 10 units i.m. or i.v. by drop infusion for 500 ml 0,9% NaCl; - ergometrin 0,2 mg i.m. or i.v.; - misoprostol 800 mg per rectum.

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Medical method of uterine contents evacuation.

This

non-surgical abortion method may be used when the patient refuses from surgical hemostasis and general anesthesia.

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Necessary conditions for performing medical hemostasis.

1. Provided incomplete abortion in the first trimester of gestation has been confirmed. 2. No absolute indications for surgical evacuation have been established. 3. The patient has agreed to be hospitalized in a medical establishment with emergency healthcare facilities available 24 hours a day.
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Contraindications.
Absolute: - adrenal insufficiency; - long-term glucocorticoid therapy; - anticoagulation therapy or hemoglobinopathies; - anemia (Hb 100 g/l); - mitral stenosis; - glaucoma; - intake of nonsteroidal anti-inflammatory agents within previous 48 hours.

Relative: - hypertension; - severe bronchial asthma.

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Cases when surgical evacuation is required:

-

beginning of profuse bleeding; - presence of infection symptoms; - if evacuation of uterine contents does not start within 8 hours after mesoprostol was administered; - if US examination reveals remaining fetal membranes in the uterine cavity after 7 10 days.
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Complete abortion management approach.

It

is not required to perform instrumental revision of the uterus provided the patient has no complaints, there is no bleeding, and the US examination does not show tissues in the uterine cavity. Control US examination is done after 1 week.

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Cervical incompetence (CI).

unrelated to uterine contractive activity spontaneous effacement and dilatation of the cervix which causes miscarriage (more frequently in the second trimester). Cervical incompetence is normally managed by cervical cerclage, which is placing a preventive or therapeutic suture on the cervix.
CI
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Preconditions for placing a suture:

-

the fetus is alive, no malformations have been detected; - gestational sac is intact; - there are no signs of chorionamnionitis; - no uterine contractions or bleeding are observed; - first or second degree of vaginal cleanness.
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Reproductive system rehabilitation after a spontaneous abortion.

1. Prevention of infectious-inflammatory diseases, sanitization of chronic inflammation areas, normalization of vaginal biocenosis, diagnostics and treatment of TORCH-infections. 2. Psychological rehabilitation after the miscarriage. 3. Non-specific pre-gravid preparation: - anti-stress therapy; - nutrition normalization; - 3 months before conception: folic acid 400mcg daily; - establishing a healthy work-leisure balance; - giving-up unhealthy habits. 4. Genetic consultation.
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Labour diagnostics and confirmation.

The onset of cramp-like pains in the lower abdominal regions; appearance of mucinousbloody or watery discharge from genital tract. Every 10 minutes contractions 15-20 seconds long are registered. The form and location of the cervix changes the cervix is shortened and smoothed. Cervical dilatation. Gradual descent of the presenting part of the fetus into pelvis minor.
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Tocolytic therapy.

Tocolytic therapy is administered before 34 weeks gestation, in cases when the cervix is less that 3cm dilated; there is no amnionitis, preeclampsia or bleeding; and the fetus condition is satisfactory. Tocolytic therapy is prescribed during the period of 48 hours, necessary for performing antenatal preventive procedures against respiratory distress syndrome (RDS) with glucocorticoids. Nifedipin 10 mg sublingually. Beta-mimetics (ginepral, ritodrin). 2 hours after the start of the tocolytic therapy the diagnosis of premature labour is confirmed. If the premature labour progresses the tocolytic therapy is cancelled.
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Fetal RDS prevention procedures are performed from 24th to 34th week of gestation: i.m. dexametasone 6 mg every 12 hours, 24 mg for the course of treatment.

When

signs of infection are present, intranatal antibacterial therapy is prescribed.

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Peculiarities of the first labor stage management.

Fetal condition evaluation: - auscultation of the fetus (every 30 minutes during the latent phase, every 15 minutes during the active phase); - cardiotocography.

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In order to achieve reliable auscultation results the following methods are used: - the patient is placed in lateroposition; - the auscultation is started after the end of the most intensive contraction phase; - the auscultation is performed during at least 60 seconds.
If the gestational sac is ruptured the surgeon should be alerted to the color and amount of amniotic fluid.
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Evaluation of maternal condition:

-

body temperature measurement every 4 hours; - pulse rate measurement every 2 hours; - arterial pressure measurement every 2 hours; - urinary output measurement every 4 hours.

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Labour progressing evaluation:

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frequency and duration of contractions; - cervical opening rate; - fetal head descent level.

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Assistance during labor.

1. Individual psychological support from the patients husband, relatives, medical staff. 2. Keeping the patient clean. 3. Ensuring that the patients mobility. 4. Assisting the patient with food and drink intake. 5. Labor pain relief at the patients request (narcotic analgetics are not used).
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Care and assistance during the second labor stage.

Auscultation of the fetus is performed every 5 minutes. Arterial pressure and pulse of the patient are measured every 15 minutes. Obstetric care methods are chosen in accordance with the phase requirements of the second labor stage. The patient is either in upright or supine position for labor management. Episioperineotomy and pudendal anesthesia are not performed.
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Active management of the third labor stage.

Introduction of uterotonics. Expulsion of placenta by controlled umbilical cord traction. Uterine cavity massage via abdominal wall after placenta expulsion every 15 minutes during 2 hours. Parturient canal examination after the labor is performed when bleeding is present, after operative delivery or home delivery. Cold compress on the lower abdomen in the early postpartum period is not applied.
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