ICD spontaneous miscarriage. Threat of early pregnancy loss

1. Protocols for 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 preterm pregnancy//Manual for doctors and interns/Okhapkin M.B., Khitrov M.V., Ilyashenko I.N.-Yaroslavl 2002, p.34 2.Obstetric hemorrhage/Methodological recommendations.- Bishkek, 2000, p. .13 3. Providing assistance during complicated pregnancy and childbirth./ Guide for midwives and doctors. Reproductive health and research, WHO, Geneva, 2002 4. Daylene L. Ripley MD. Atony, Inversion, 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 hemorrhage: 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 10. K. Niswander, A.Evans. Obstetrics / University of California Handbook, 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, Elburn D, McDonald S. Active versus expectant management of the third stage of labor (Cochrane Library Abstract, issue 1, 2003). 15. Karoli G., Bergel E. Injections into the umbilical cord vein to eliminate a defect in the placenta/remnants of the placenta (Cochrane Library Abstract, issue 1, 2003). 16.15. Vorobiev A. Hematology in the fight for human life 2005.-No. 9. p.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. //Volume 19, Number 3 18.Sara Mackenzie MD Obstetrics: Late Antepartum Hemorrhage. //Manual of the University of Family Medicine of Yova. Ed. 4, chapter 14.

Information

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

Nauryzbaeva B.U. Doctor of Medical Sciences Department of Physiology and Pathology of Childbirth of the Republican Research Center for Maternal and Child Health (RNICMHMR).

The threat of miscarriage is a condition in which the uterus begins to contract vigorously, getting rid of the fetus located in its cavity. The occurrence of this pathology is possible at any stage of pregnancy and is a common problem in obstetrics and gynecology.

The likelihood of spontaneous abortion from the moment of conception until the 22nd week of pregnancy is considered to be a threat of early miscarriage, which is not uncommon. A threatened late-term abortion is considered to be a pathology that occurs from 22 to 28 weeks of pregnancy. From 28 to 37 weeks, the appearance of uterine hypertonicity can lead to premature birth, which can have negative consequences for the health and development of the baby.

The appearance of a threatening state of pregnancy is dangerous for the health of a woman and the life of her unborn child - untimely detection of the symptoms of this disease and delay in receiving medical care lead to a fatal outcome of pregnancy.

There are several types of pathology:

• anembryony - absence of an embryo in the fertilized egg;
• Chorioadenoma - pathological placental formation from the father's chromosomes;
• threatened miscarriage - the likelihood of detachment of the fertilized egg from the uterine wall;
• beginning miscarriage - partial rejection of the embryo;
• complete miscarriage - the fertilized egg exfoliates completely and leaves the uterine cavity;
• incomplete miscarriage - when the embryo is rejected, fetal particles remain in the uterus;
• failed miscarriage - the fertilized egg does not detach, but dissolves.

According to the list of the International Classification of Diseases (ICD-10), this diagnosis is presented as “Threatened abortion” and has code O20.

If there is a threat of miscarriage in the early stages, pregnancy cannot always be maintained

Causes of threatened abortion in the early stages

There are several reasons that create the risk of miscarriage:

1. Hormonal imbalances. With the onset of pregnancy, changes in hormone levels occur in a woman's blood. If the norms necessary for the successful gestation of the fetus are violated, there is a threat of miscarriage. In many cases, this occurs due to progesterone deficiency, which can occur due to an excess of prolactin in the pregnant body. A threatened abortion is also possible when the level of male hormones increases - this condition is called hyperandrogenism.
2. Genetic failures. There are situations when, in the initial stages of pregnancy, chromosomal or gene mutations occur, the consequences of which are abnormal malformations of the fetus. In case of genetic failures incompatible with life, spontaneous abortion occurs in the first two months of pregnancy (up to the eighth week). If the pathology is not fatal (for example, with Down syndrome), then the pregnancy can be saved, but the risks of miscarriage will be high throughout its entire duration. Genetic failures can be caused by heredity or adverse effects of external factors, such as poor ecology, chemicals in food, radiation, etc.
3. The presence of infectious or inflammatory processes in the pelvic organs. With the onset of pregnancy, the body's immunity decreases - at this time, the expectant mother is more exposed to the emergence of new and exacerbation of chronic diseases. When infections and inflammation occur, the reproductive system of a pregnant woman weakens and ceases to function fully, which can contribute to miscarriage.
4. The occurrence of Rh conflict (immunological cause). A woman’s body that has a negative Rh factor in the blood while carrying a child with a positive Rh factor may perceive the fetus as a foreign formation in the body and will spontaneously try to get rid of it.
5. Presence of gynecological pathologies. Abnormal structure of the uterus (bicornuate or with a septum), endometriosis, fibroids - lead to dysfunction of the reproductive organ, which is the cause of miscarriage.
6. Isthmic-cervical insufficiency. With this pathology, the cervix is ​​weakened and is not able to support the fetus, which is constantly increasing in size. Miscarriage for this reason in most cases occurs at the beginning of the second trimester.
7. Exposure to stress and emotional turmoil. Regular exposure to stressful or conflict situations and nervous tension can negatively affect the development of pregnancy, and in some cases cause its termination.
8. Getting injured. Injury to the abdominal area can lead to partial or complete placental abruption, which will lead to fetal death and miscarriage.

The threat of spontaneous abortion can occur for any of the above reasons or a combination of several.

Symptoms of threatened abortion

Symptoms that occur when there is a threat of miscarriage can be both obvious and mild:

• pulling or cramping pain in the lower abdomen and lower back;
• bloody discharge from the genital tract (even in small quantities);
• copious clear or cloudy discharge - may be amniotic fluid (leakage is possible from the beginning of the second trimester);
• hypertonicity of the uterus - strong tension in the muscles of the reproductive organ, leading to a “fossilization” of the abdomen.

If even one symptom appears, a pregnant woman requires immediate medical attention.

The appearance of nagging pain in the lower abdomen may indicate the onset of spontaneous abortion

Diagnostics

If there is a suspicion of a threat of spontaneous abortion, the woman is first sent for a gynecological examination to determine the condition of the cervix, as well as to exclude anomalies in the structure of this organ (if the pregnant woman has not yet registered). During the examination, the doctor must take a smear to check for sexually transmitted diseases or endocrine disorders.

The most effective way to diagnose pregnancy problems is an ultrasound examination, based on the results of which the doctor can determine the degree of risk of miscarriage or its type and subsequently prescribe the necessary treatment.

To identify hormonal disorders, as well as infectious or inflammatory diseases, a pregnant woman is given directions for blood and urine tests: general, biochemical, and hormone tests.

Determination of genetic disorders or immunological problems is carried out using laboratory blood tests and ultrasound diagnostics.

Based on the results of ultrasound diagnostics, the doctor concludes that it is rational to continue pregnancy

If necessary, the attending physician may prescribe an additional examination of the pregnant woman’s health by specialized specialists: a cardiologist, neurologist, surgeon and others.

Treatment

If the threat of spontaneous abortion is identified in a timely manner, the causes are determined and proper treatment is prescribed, the pregnancy can be saved.

Drug therapy

Treatment is carried out both on an outpatient basis and in a hospital setting - it depends on the degree of threat of interruption.

The main condition for a positive treatment result is to provide the expectant mother with physical and psychological peace, therefore, in some cases, the woman is first prescribed sedatives. For example, Persen or Novopassit - these products consist of natural ingredients and do not harm the fetus (in the absence of intolerance to the components of the drug).

In case of hormonal imbalance, a woman is prescribed special hormonal medications. For a lack of progesterone - Duphaston, Utrozhestan. For high levels of male hormones - Dexamethasone, Digostin, Cyproterone and others.

To eliminate uterine hypertonicity, medications that relax smooth muscles are used. The most common remedy is Magnesia (magnesium sulfate), which is administered into the body in doses determined by the doctor using a dropper. Papaverine suppositories are also often used to reduce uterine hypertonicity.

To relieve pain, pregnant women are prescribed antispasmodics: Drotaverine (injections), No-shpa (tablets).

In the event of a Rh conflict situation between mother and fetus, drugs are used that inhibit the production of antibodies - immunoglobulins. And the method of intrauterine blood transfusion to the fetus through the umbilical vein is also effective. This procedure can be carried out from the 22nd week of pregnancy.

When bleeding occurs, hemostatic drugs are used: Tranexam, Dicinone - administered intravenously, by drip.

If the threat of miscarriage appears due to isthmic-cervical insufficiency, then to preserve the pregnancy, an obstetric pessary is placed on the uterus - a ring that supports the cervix. When used, the gestation period of the baby is extended until the due date of birth. In some similar cases, instead of using a pessary, sutures are placed on the cervix, which prevents premature opening of the uterine pharynx. The method of eliminating isthmic-cervical insufficiency is determined by the attending physician individually for each case.

Treatment of infectious and inflammatory processes, as well as chronic diseases in acute form, is possible only as prescribed and under the supervision of the attending physician.

ethnoscience

The use of traditional medicine when there is a threat of miscarriage is strictly prohibited without consultation with a medical specialist. This method of eliminating the problem can harm health even more, which will lead to an irreversible negative outcome of pregnancy.

The most popular folk remedies are:

1. Dandelion herb decoction. One teaspoon of the herb should be poured into a glass of water and boiled for three minutes. Take one-fourth cup of the decoction in small sips 3 times a day.
2. A decoction of viburnum bark. One teaspoon of crushed young bark is poured into 250 ml of boiling water and boiled for 5 minutes. It is recommended to take 1-2 tablespoons three times a day.
3. Tincture of viburnum flowers. Two tablespoons of flowers are poured into 500 ml of boiling water and infused in a thermos for about two hours. The strained tincture is taken one quarter glass three times a day.
4. A decoction of the medicinal collection: licorice roots, cinquefoil and elecampane, black currant berries, nettle herb. Two tablespoons of the collection should be added to 500 ml of boiling water and simmer for 15 minutes. Strain the resulting broth and cool, take half a glass three times a day.

The use of folk remedies without medications does not have a positive result, and therefore cannot be used as the main treatment.

First aid for threatened miscarriage

If symptoms occur that may indicate a threat of miscarriage, you need to call an ambulance as soon as possible or consult a gynecologist yourself. You should wait for the ambulance to arrive in a motionless position, preferably lying down.

After an examination by a gynecologist, ultrasound diagnostics are performed and the necessary blood tests are done - for the presence of diseases, hormones, etc. All studies are aimed at establishing the reasons that create the threat of spontaneous abortion, as well as to determine the level of danger of the complication that has begun.

If there is a chance of maintaining the pregnancy, the doctor most often places the woman in a hospital for treatment and close monitoring of the patient’s health. Treatment at home is possible only if there are no pronounced symptoms of pregnancy pathology and strict adherence to all doctor’s instructions.

The threat of spontaneous miscarriage cannot disappear on its own; to eliminate it, the help of medical specialists is required. Otherwise, the woman risks losing her unborn child.

Forecasts

The course of pregnancy after the threat of miscarriage in the early stages depends on the reason why this happened, as well as on the effectiveness of the prescribed treatment.

When hormone levels are normalized, infectious or inflammatory processes are cured, and the problem of isthmic-cervical insufficiency is resolved, pregnancy can develop further without pathology.

If the threat of abortion arose for an immunological reason, then the pregnancy will be under close medical supervision, since the likelihood of its failure may arise again at any stage.

In case of genetic failures incompatible with life, the fetus is not preserved. But this is not a guarantee that the problem will recur with the onset of a new pregnancy.

In most cases, after the threat of spontaneous abortion at an early stage of pregnancy, it is subsequently possible to safely give birth to a healthy child on time.

Prevention

Preventive measures against the threat of miscarriage include:

1. Pregnancy planning. At this stage, both parents are recommended to undergo a full medical examination and cure all existing diseases. In particular, it is necessary to visit the office of a geneticist, who will determine the compatibility of the parents and the likelihood of Rh conflict.
2. The right way of life. With the onset of pregnancy, you should give up bad habits, eat right, take regular walks in the fresh air, maintain the correct daily routine - eat on time, do not overwork during the day, sleep at least 9 hours a day.
3. Favorable psychological environment. While carrying a baby, it is recommended to avoid stressful situations and prevent nervous breakdowns and hysterics.

Compliance with preventive measures cannot provide a 100% guarantee of eliminating the threat of spontaneous abortion. But a responsible attitude towards one’s health and a serious approach to pregnancy planning significantly reduce the risks of this pathology.

By undergoing a medical examination before pregnancy, a doctor can identify in advance possible problems after conception. In my case, the use of Duphaston was prescribed from 3 to 18 weeks of pregnancy. Thanks to supportive hormone therapy, I managed to avoid the threat of spontaneous miscarriage.

Spontaneous abortion (miscarriage) is the 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 gestation period of less than 22 weeks.

ICD-10 CODE

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

EPIDEMIOLOGY

Spontaneous abortion is the most common complication of pregnancy. Its frequency ranges from 10 to 20% of all clinically diagnosed pregnancies. About 80% of these losses occur before 12 weeks of pregnancy. When pregnancies are taken into account by determining hCG levels, the loss rate increases to 31%, with 70% of these abortions occurring before the pregnancy can be recognized clinically. In the structure of sporadic early miscarriages, 1/3 of pregnancies are terminated before 8 weeks due to the type of anembryony.

CLASSIFICATION

According to clinical manifestations there are:

· threatened abortion;
· started abortion;
· abortion in progress (complete and incomplete);
· non-developing pregnancy.

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

ETIOLOGY (CAUSES) OF MISCARRIOR

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 trisomies (52%), monosomy X (19%), and polyploidies (22%). Other forms are noted in 7% of cases. In 80% of cases, death and then expulsion of the fertilized egg occurs first.

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 fertilized egg. Chronic productive endometritis, more often of autoimmune origin, was noted in 25% of so-called reproductively healthy women who terminated pregnancy through induced abortion, in 63.3% of women with recurrent miscarriage and in 100% of women with NB.

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

RISK FACTORS

Age is one of the main risk factors in healthy women. According to data obtained from an 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%, in 35 years - 20%, in 40 years - 40%, in 45 years - 80%.

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

History of spontaneous abortion. The risk of miscarriage increases with the number of miscarriages. In women with a history of one spontaneous miscarriage, the risk is 18–20%, after two miscarriages it reaches 30%, after three miscarriages it reaches 43%. For comparison, the risk of miscarriage for 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 when analyzing spontaneous abortions in women with a normal chromosomal complement.

The use of non-steroidal anti-inflammatory drugs in the period preceding conception. Data have been obtained indicating a negative effect of inhibition of PG synthesis on the success of implantation. When using non-steroidal anti-inflammatory drugs in the period preceding conception and in the early stages of pregnancy, the miscarriage rate was 25% compared to 15% in women who did not receive drugs from 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 prenatal diagnostic methods (choriocentesis, amniocentesis, cordocentesis) - the risk is 3–5%.

Caffeine consumption. With daily consumption of more than 100 mg of caffeine (4-5 cups of coffee), the risk of early miscarriages significantly increases, and this trend is valid for a fetus with a normal karyotype.

Exposure to teratogens (infectious agents, toxic substances, drugs with a teratogenic effect) 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 incidence of abnormal fetal karyotype.

Hormonal disorders and thrombophilic conditions are to a greater extent the causes not of sporadic, but of habitual miscarriages, the main cause of which is an inadequate 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

Mostly, patients complain of bloody discharge from the genital tract, pain in the lower abdomen and lower back when menstruation is delayed.

Depending on the clinical symptoms, a distinction is made between a threatened spontaneous abortion, one that has begun, an abortion in progress (incomplete or complete), and a frozen pregnancy.

A threatened abortion is manifested by nagging pain in the lower abdomen and lower back, and there may be scanty bleeding 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 period of pregnancy. Ultrasound records the fetal heartbeat.

When an abortion begins, pain and bloody discharge from the vagina are more pronounced, the cervical canal is slightly open.

During an abortion, regular contractive contractions of the myometrium are detected. The size of the uterus is less than the expected gestational age; in later stages of pregnancy, OB leakage is possible. The internal and external pharynx are open, the elements of the fertilized egg are in the cervical canal or in the vagina. Bloody discharge can be of varying intensity, often abundant.

Incomplete abortion is a condition associated with retention of elements of the fertilized egg in the uterine cavity.

The lack of full contraction of the uterus and closure of its cavity leads to ongoing 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 rupture of OB. With a bimanual examination, the uterus is smaller than the expected gestational age, there is abundant bloody discharge from the cervical canal, with the help of ultrasound, the remains of the fertilized egg are determined in the uterine cavity, and in the second 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 bleeding stops. During bimanual examination, the uterus is well contoured, its size is smaller than the gestational age, and the cervical canal can be closed. In case of a complete miscarriage, the closed uterine cavity is determined using ultrasound. There may be slight bleeding.

Infected abortion is a condition accompanied by fever, chills, malaise, pain in the lower abdomen, and bloody, sometimes purulent, discharge from the genital tract. A physical examination reveals tachycardia, tachypnea, deflation of the muscles of the anterior abdominal wall, and a bimanual examination reveals a painful, soft uterus; The cervical canal is dilated.

In case of infected abortion (in case of mixed bacterial viral infections and autoimmune disorders in women with recurrent miscarriage, aggravated by antenatal fetal death, obstetric history, recurrent course of genital infections), immunoglobulins are prescribed intravenously (50–100 ml of 10% solution of Gamimune©, 50–100 ml of 5% solution octagama©, etc.). Extracorporeal therapy is also carried out (plasmapheresis, cascade plasma filtration), which consists of 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, and septicemia is possible.

Non-developing pregnancy (antenatal fetal death) is 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 fertilized egg from the uterine cavity and often without signs of a threat of miscarriage. An ultrasound is performed to make a diagnosis. The tactics of termination of pregnancy are chosen depending on the gestational age. It should be noted that antenatal fetal death is often accompanied by disturbances in the hemostatic system and infectious complications (see the chapter “Non-developing pregnancy”).

In diagnosing bleeding and developing management tactics in the first trimester of pregnancy, assessing the rate and volume of blood loss plays a decisive role.

When ultrasound shows unfavorable signs in terms of the development of the ovum during intrauterine pregnancy, the following are considered:

· lack of embryonic heartbeat with CTE of more than 5 mm;

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

Additional ultrasound signs indicating an unfavorable pregnancy outcome include:

· abnormal yolk sac, inappropriate for gestational age (more), irregular in shape, displaced to the periphery or calcified;

· Fetal heart rate less than 100 per minute at 5–7 weeks;

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

DIFFERENTIAL DIAGNOSTICS

Spontaneous abortion should be differentiated from benign and malignant diseases of the cervix or vagina. During pregnancy, bloody discharge from the ectropion is possible. To exclude cervical diseases, a careful examination in the speculum is performed, and, if necessary, colposcopy and/or biopsy.

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

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

With hydatidiform mole, 50% of women may have characteristic discharge in the form of bubbles; 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; Fainting (hypovolemia), a feeling of pressure on the rectum or bladder, and a positive bhCG test are common. Bimanual examination reveals pain when moving the cervix. The uterus is smaller than it should be at the expected stage of pregnancy.

You can palpate a thickened fallopian tube, often with bulging vaults. An ultrasound can detect a fertilized egg in the fallopian tube, and if it ruptures, an accumulation of blood in the abdominal cavity can be detected. To clarify the diagnosis, puncture of the abdominal cavity through the posterior vaginal fornix or diagnostic laparoscopy is indicated.

An example of a diagnosis formulation

Pregnancy 6 weeks. Incipient miscarriage.

TREATMENT

TREATMENT GOALS

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

In the USA and Western European countries, threatened miscarriage before 12 weeks is not treated, believing that 80% of such miscarriages are due to “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. For this pathology, bed rest (physical and sexual rest), a nutritious diet, gestagens, vitamin E, methylxanthines are prescribed, and as symptomatic treatment - antispasmodics (drotaverine, suppositories with papaverine), herbal sedatives (motherwort decoction, valerian).

NON-DRUG TREATMENT

Oligopeptides and polyunsaturated fatty acids must be included in a pregnant woman's diet.

DRUG TREATMENT

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

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

Methylxanthines - pentoxifylline (7 mg/kg body weight per day). Papaverine suppositories 20–40 mg twice a day are administered rectally.

Approaches to the treatment of threatened miscarriage differ fundamentally in the Russian Federation and abroad. Most foreign authors insist that it is inappropriate to continue pregnancy for less than 12 weeks.

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

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

Upon admission to the hospital, a blood test should be performed to determine the blood type and Rh affiliation.

With an incomplete abortion, heavy bleeding is often observed, which requires emergency assistance - immediate instrumental removal of the remnants of the fertilized egg and curettage of the walls of the uterine cavity. Emptying the uterus is more gentle (vacuum aspiration is preferable).

Due to the fact that oxytocin may have an antidiuretic effect, large doses of oxytocin should be discontinued after the uterus has emptied and bleeding has stopped.

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

It is advisable to monitor the condition of the uterus using ultrasound.

In case of a complete abortion during a pregnancy of less than 14–16 weeks, it is advisable to perform an ultrasound and, if necessary, curettage of the uterine walls, since there is a high probability of finding parts of the fertilized egg and decidual tissue in the uterine cavity. At a later date, when the uterus has contracted well, curettage is not performed.

It is advisable to prescribe antibacterial therapy, treat anemia as indicated, and administer anti-Rhesus immunoglobulin to women with Rh-negative blood.

SURGERY

Surgical treatment of frozen pregnancy is presented in the chapter “Non-developing pregnancy”.

Postoperative management

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

In Rh-negative women (during pregnancy from a 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 RhA, rhesus immunization is prevented by administering anti-Rhesus immunoglobulin at a dose of 300 mcg (intramuscular).

PREVENTION

There are no specific methods for preventing sporadic miscarriage. 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 in a daily dose of 0.4 mg. If a woman has a history of fetal 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 if they experience pain in the lower abdomen, lower back, or bleeding from the genital tract.

FOLLOW-UP

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

FORECAST

As a rule, the prognosis is favorable. After one spontaneous miscarriage, the risk of losing a subsequent pregnancy increases slightly and reaches 18–20% compared to 15% in the absence of a history of miscarriages. If there are 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.

Ds. Pregnancy 6-7 weeks. Threat of miscarriage. (About 20.0)
The patient is 22 years old.
Complaints for aching (or cramping) pain in the lower abdomen without irradiation.
Anamnesis. The pain started about three hours ago. Last menstrual period September 20 (eight weeks ago). First menstruation at the age of 13, menstruation after 30 days for 5-6 days, regular, less painful, volume 100-150 ml.
She is being registered with a gynecologist for pregnancy. Last visit to the gynecologist 3 days ago. This is the second pregnancy. The first pregnancy ended in spontaneous abortion two years ago at 7 weeks of pregnancy. Denies the presence of gynecological diseases. Stool and urination are normal.
Objectively. The condition is satisfactory, clear consciousness. The skin is of normal color. Breathing is vesicular, no wheezing. RR = 15 per minute. Heart rate = 75 per minute. The rhythm is correct, the heart sounds are sonorous, there is no noise. Blood pressure = 130/80 mm Hg. Neurologically – without any peculiarities.
The abdomen is round, not tense, and there is slight pain in the lower abdomen. Above the womb, during external examination, the fundus of the uterus is not determined. The discharge at the time of examination is mucous and light.
Help. Hospitalization in the gynecological department. Condition during transportation is satisfactory.
***
Ds. Pregnancy 14-15 weeks. Spontaneous miscarriage is common. (About 03.3)
The patient is 25 years old.
Complaints for pain in the lower abdomen, profuse bleeding from the genital tract, weakness, dizziness when standing.
Anamnesis. During the previous 24 hours, my stomach hurt (at first it was a nagging pain, then a cramping pain), but after 24 hours the pain intensified, and I did not see a doctor. During the last hour there has been severe bleeding from the genital tract with clots (I changed eight regular pads). Stool and urination are normal.
She is being registered with a gynecologist for pregnancy with an expected period of 14-15 weeks, her last period was 16 weeks ago. Menstruation from the age of 14, established immediately, irregular, after 21-30 days, lasting 3-5 days. History of chronic adnexitis. This is the second pregnancy, the first three years ago ended in normal birth.
Objectively. Moderate condition. Consciousness is clear. The skin is pale, with normal moisture. Breathing is vesicular, no wheezing. RR = 18 per minute. Heart rate = 100 per minute, the rhythm is correct. Heart sounds are muffled. Blood pressure = 9 0/60 mm Hg. (Usual blood pressure is 120/70 mmHg). The abdomen is round, soft, painful on palpation in the lower parts. The height of the uterine fundus corresponds to 14-15 weeks of pregnancy. The uterus is painful on palpation, the tone is increased. Discharge from the genital tract at the time of examination was profuse and bloody.
Help.
TO atherization of the vein.
Sol. Etamsylati 500 mg, Sol. Natrii chloridi 0.9%-10 ml IV;
Sol. Natrii chloridi 0.9% - 250 ml intravenously.
G hospitalization on a stretcher in the gynecological department.

Pregnancy can be threatened by a very large number of pathological conditions. A woman should be aware of such conditions and possible measures that she can take. Of course, it is hardly possible to do without the participation of doctors in such situations if a woman wants to continue her pregnancy.

Threat of miscarriage: ICD-10 code

What does the international classification of diseases say about this problematic situation? This is code O20.0, which in this classification is called threatened abortion. ICD-10: threat of miscarriage (timing) - what can be said about them? In this case, there is a danger of separation of the fetus from the uterine wall. The eighth to tenth week can be considered the most dangerous in this regard.

Ultrasound: threatened miscarriage (MCD) is a reminder that with appropriate ultrasound diagnostics after a woman becomes pregnant, such a problem can be prevented if problems are suspected in time.

Signs of a threatened miscarriage in the early stages

The first symptom that should alert a woman is the appearance of pain. In the lower abdomen, you can feel a sipping painful sensation, which can also be localized in the lumbar region. In the presence of injury or a stressful situation, severe pain may be observed, which quickly turns into cramping. In this case, you may also experience intense bleeding. If bleeding begins, you need to urgently call an ambulance, as in this case you can lose your own pregnancy.

If there is a threat of interruption of pregnancy, you can also see the presence of bloody discharge. Sometimes such secretions may not exist when there is a threat. If you do not take action after the appearance of small bloody discharge, it may intensify and acquire a scarlet bloody color. Why does such discharge appear when there is a threat of miscarriage? The fact is that the fertilized egg gradually begins to peel off from the uterine wall, as a result of which the blood vessels are damaged.

Other symptoms include a decrease in basal temperature and a drop in the level of human chorionic gonadotropin. The woman's basal temperature should be monitored regularly and only when a verdict is reached about the presence of a threat. If a woman has had problems getting pregnant for a long time or has persistent hormonal imbalances, she will be familiar with the basal temperature monitoring schedule.

Threat of miscarriage in the early stages: treatment

Russian doctors prefer to take an integrated approach to treating women at risk of miscarriage. The sooner treatment is provided, the higher the likelihood that the pregnancy will be saved. The therapy used should be both medicinal and other. You also need to follow a daily routine and proper nutrition.

The first thing that needs to be mentioned is the use of basic therapy. This concept includes adherence to the regime and proper dietary nutrition. Pregnant women should avoid intense physical activity; sometimes it is recommended to remain in bed. It is important to sleep enough hours a day and maintain sexual rest. Moreover, it is important that a woman’s diet contains adequate amounts of proteins, carbohydrates and fats. Sometimes, if a woman is in a nervous state, she will need psychotherapy and auto-training sessions.

As a means of calming, taking valerian or motherwort tincture is indicated.

Treatment of threatened miscarriage with medications

Once the threat of miscarriage and symptoms are known, we can begin to talk about treatment methods with medications.

Threat of abortion: forum - what kind of request is this? Very often, if a woman has been diagnosed with this, she seeks somewhere to find support, both moral and in the form of advice. And very often the source of such support is various kinds of forums.

Threatened miscarriage: what to do in this case? Doctors often decide to prescribe antispasmodics to a woman. They are represented by drotaverine, noshpa, which lead to relaxation of the uterine muscles. However, as a rule, such drugs are administered intramuscularly. An excellent remedy is Magne B6, which contains the vitamin of the same name and magnesium. Rectal suppositories with papaverine are also used. Papaverine is able to quickly cope with pain.

Often, when there is a threat of miscarriage, hormonal agents, namely progesterone, are used. In the early stages, Duphaston is prescribed in a dosage of 40 mg, four tablets at once. After this, you need to take one tablet every eight hours. If it is not possible to stop the threat of miscarriage, then the dosage has to be increased. Another commonly prescribed remedy is Utrozhestan.

Pregnancy after threatened abortion

If a woman does have a miscarriage, she is concerned about what to do next and how long after she can try to conceive a child again. Of course, this is a great tragedy not only for the woman herself, but also for her entire family. That is why the first step on the path to recovery can be considered the normalization of one’s own psycho-emotional state. If a woman is unable to cope with this on her own, then she needs to seek help from a psychologist or psychotherapist. Of course, a woman wants to try to conceive a baby again as soon as possible. But there is no need to rush into this.

Doctors recommend that women wait at least six months before trying to conceive again. During this period, you need to take care of reliable contraception. The fact is that if a subsequent pregnancy occurs immediately after a miscarriage, the likelihood of the situation repeating increases several times. This must be taken into account when planning a subsequent pregnancy if a woman wants to carry it to term.